No decisions made on physician supply mechanisms

January 13, 2017

Dr Padraic E. Carr, AMA President

Dear Member:

  • A needs-based physician resource plan will be developed by a multi-stakeholder Physician Resource Planning Committee (PRPC).
  • Any decisions about how to manage physician supply must consider the evolving plan.
  • No decisions regarding billing number conditions have been made.

As noted in my last President’s Letter, the AMA Amending Agreement commits the parties to establishing a needs-based physician resource plan. Using best evidence, the plan will be developed by a multi-stakeholder Physician Resource Planning Committee (PRPC). I am pleased to announce that Dr. Ruth Collins-Nakai, past AMA and CMA President, will be our representative to this important committee. (Thank you to all the individuals who applied to serve on this committee. We are fortunate to have an abundance of talented physician leaders to help us with the work of the association.)

I have heard from a number of physicians about the future direction of this initiative. Specifically, there is a concern that restrictions to billing numbers are imminent. Before saying anything else in this letter, let me emphasize that no decisions have been made with respect to application of billing number conditions.

The plan must inform decisions and actions

The increase in the net new number of physicians entering Alberta is significant and unsustainable. The number of physicians in Alberta has been increasing at a rate of around 5% per year on average since 2010. The overall trend is an important consideration, particularly when coupled with Alberta’s difficult financial state.

It makes sense for the parties to consider management of entry, exit and physician distribution as a contributor to sustainability. However, for sustainability as we have defined it, the all-important aspects of patient access and quality of care must be addressed. Additionally, the AMA, AH and AHS believe that we must continually renew the profession by incorporating new graduates into Alberta as practicing physicians.

This is why any decisions about how to manage physician supply must consider the evolving needs-based plan to be developed by PRPC. The committee stakeholders, including future PRPC members, first met in October to receive information on physician resources in Alberta, including trends in physician supply, distribution of physicians in Alberta, and the costs of physician services. For purposes of gaining insight and feedback, AH and AHS also presented a draft proposed regulatory approach, giving AH the authority to issue new billing numbers only to new physicians who practice in positions identified in the needs-based plan.

Since that first meeting, AH has held several individual and small group meetings with stakeholders to further discuss the draft proposal. Any eventually proposed changes must be approved through the regulatory process, which includes consultation with stakeholders. AH is consulting and listening to feedback. This engagement will continue; AH has indicated they are very open to further input. This includes the PRPC, which involves community-based physicians, primary care networks, resident physicians, medical students and international medical graduates. The necessary representation and channels are built into the design of the PRPC. (See page 16 of the Amending Agreement.)

No decisions on future actions have been made

Again, no decisions regarding billing number conditions have been made. There are a number of existing tools that could be applied as needed. Government is naturally looking at all options as part of its own diligence. They are clear, however, that the PRPC owns the task of developing a needs-based plan, based on the best current evidence and involving all the appropriate groups. This evolving plan must be – and will be – considered as we move forward.

As I have said before: The timing is fortuitous. We are working to meet an identified need, but we are not under pressure of a crisis. Today, for the most part, the natural attrition of physicians in the province is being resupplied by the output of our medical schools. We have the time and the ability to do things right. We have the knowledge and expertise to develop a highly refined and effective needs-based physician resource plan.

Let’s also think about this: We have a significant opportunity with this new Amending Agreement, because we have a real voice and influence in all aspects from the fee schedule to clinical appropriateness to physician supply to informatics and beyond. That kind of influence, though, comes with a price: we must take on some risk, some responsibility, and willingness to lead by doing things differently. We need a plan, and that is what the agreement calls for.

There is a great deal of work ahead for the PRPC. All the necessary parties will be there, and our Agreement ensures this. We have an unprecedented commitment for everyone to be guided by the outcome of the committee’s work – based on best evidence and consultation with those most affected. This is a unique collaborative effort, and will set the stage for our future endeavours with government.

I will keep the profession informed as we move forward, including principles set forward by the Board which will guide our deliberations. As always, please let me know what you think. Email president@albertadoctors.org.

I look forward to working with you in 2017.

Yours truly,

Padraic E. Carr, BMedSc, MD, FRCPC, DABPN
President

P.S. Physician supply and related issues are topics of interest across the country. The CMA launches a new workforce study today. Click here to access it. I encourage you to participate to assist with data collection at the national level.

5 comments

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  • #1

    H Clifford Yanover

    Physician

    12:24 PM on January 14, 2017

    The issue of restricting billing numbers was a bone of contention in British Columbia in the 1980's. The Province tried to limit billing numbers by denying new physicians a number or by trying to limit a billing number to a specific geographical location.
    The issue was taken before the courts and the provincial legislation was deemed to contravene the Charter of Right and Freedoms. Pleased review the following document entitled Liberty to Practise Medicine: The Charter and B.C. Billing Numbers-https://www.google.com/search?q=british+columbia+and+limiting+physician+billing+numbers&ie=utf-8&oe=utf-8#q=british+columbia+and+limiting+physician+billing+numbers&start=10
    Please do not try to reinvent the wheel with respect to this issue. The Supreme Court of Canada refused leave to appeal the ruling of the B.C. Court of Appeal.

  • #2

    Ed Papp

    Physician

    2:19 PM on January 14, 2017

    These omnibus letters do nothing to reduce the sense of terror among our Residents and Students regarding the prospect of limited billing numbers. The very fact that the AMA is accepting this as an approach to the control of the healthcare budget and is ignoring our Mission and Values which includes "stands as an advocate for its physician members" is disappointing to say the least. We live in frightening times when our advocate organization is ready to throw some of us to the proverbial wolves as has and continues to happen with the SOMB rule change process already. We do now live in troubling times.

  • #3

    Ahmed R Docrat

    Physician

    7:41 PM on January 17, 2017

    Manage Physician Supply.
    I suggest instead of limiting billing numbers the AMA/AHS should offer Physicians over 65years to retire by offering them compensation for the investment they made when we where encouraged to remain in practice when there was a shortage of physicians .An offer off approx.$70000.00/year for 3 years.This will cost the system $210,000.00. Most physicians bill the system on average approx. $240,000.00/year. This will amount to a saving of $ 510,000.00 over a3 year period for every physician that accepts the offer.
    Over the years we have worked very hard to encourage young residents to specialize in Family Practices by limiting billing numbers we will loose all the gains we have make in last 10years.

  • #4

    John Julyan-Gudgeon

    Physician

    11:26 PM on January 17, 2017

    This email concerns me.

    "No decisions have been made yet." This really means nothing. When trust starts to break down, then this statement means "we have not concretely put a policy in place as the sending of this email." It does not address what options are being immediately bandied about on the table, it also does not address that certain options are likely already top contenders for the decision and that likely it is already known what decision will be made. Further, a decision could be made in 5 minutes after sending this email, the timing of the email being technically truthful, but not in the spirit of the intended representation. That is what a break down in trust does, it makes all these possibilities seem much more likely.

    There is a communicated intent of inclusion. I am supposed to feel like I have a say. What exactly is the conduit, the vehicle, by which my voice can be heard? I feel that if this is vaguely alluded to, but not explicitly stated, it is safe to assume it will not be utilized nearly to the extent that physicians would want to use it. With the state of the medical community, which is to be ever increasingly burdened with greater workloads and responsibility, it can be relied upon that the one's juggling the increasing medical needs of the population will not have a chance to search out these options. Is this not some form of intentful neglect?

    The more I think of these ideas of salaries, practice location restrictions, penalties etc...that starts sounding less than an employment paradigm of "professional independent contractor", which doctors have been placed in with respect for at least 60 years if not much longer...and changing that to a paradigm of either a) government employee or b) indentured servant. Now, "government employee", that would likely imply a right to unionize, and benefits packages and retirement funds. On the other hand "indentured servant", well we know what that really is. In a modern progressive society that does model itself largely on free market concepts, human rights and the right to deliver your services as best as you see fit, providing the market demand accepts your expectations, this seems so far from anything that resembles dignified that I can't imagine that these concepts are being considered, let alone that we will have them forced upon us.

    This is all shrouded in concepts of "duty to patient care". We have all been indoctrinated to believe that "duty to patient care" is tantamount. That is good, that is appropriate, that is professional medicine. However, this concept is being used against us, this is being manipulated into something it is now. This is being twisted into weapon against us, in the belief that none of us will dare speak out against the gospel of patient-oriented medicine.

    Finally, my understanding is that with the latest contract ratifications, the AMA was finally accepted by Alberta Health and the Alberta Government as the official representation of the physician body within Alberta. Yet, I find myself having to write this letter to ask clarity on the above points. Should these concepts that I raise above not have already been vetted and contended with? I am not politically savvy in the least, and yet these immediately come to my mind. In the process of the AMA becoming our "official representation" it would seem that they have developed a relationship with the government that seems more to facilitate a galvanized strategic implementation of the government's political will against doctors, and infinitely less about representing physician needs, opinions, expectation to the government.

  • #5

    Kirstin Derdall

    Physician

    10:46 AM on January 18, 2017

    I am quite concerned by the benign and yielding language of this letter with regards to the draft proposal giving AH the authority to restrict billing numbers. Also, if the statement regarding physician growth in Alberta is intended to be alarmist, it simply serves to illustrate how ill-conceived the AMA's response to this issue is. From 2000-2010, Alberta's population grew by almost 25%. From 2010-2015, Alberta's population grew by anywhere from 1.6% to 3% per year, or roughly 12% in a 5 year period. An increasing population requires and increase in the number of health-care workers, unless the AMA is again siding with the government and simply expects already overburdened physicians to carry a greater patient load and accept unacceptably long wait-times. Finally, as Dr. Yanover astutely pointed out below, an attempt to implement such restrictive practices on physicians was found to be in violation of the Canadian Charter of Rights and Freedoms. Why is the AMA taking such a conciliatory approach to such threats to our liberties as physicians when the very mission of the AMA is to "stand as an advocate of for its physician members".

 

The Alberta Medical Association stands as an advocate for its physician members, providing leadership & support for their role in the provision of quality health care.