RF’s direction to Board and work with sections ahead

March 22, 2017

Dr. Padraic E. Carr, AMA President

Dear Member:

The Representative Forum recently held its spring meeting on March 10-11 in Edmonton.

A number of important subjects were addressed including an interactive session on future directions of the AMA, an update on Physician Resource Planning, a session on Health Information Exchange, and a session on Negotiations 2018 among others. The two day meeting was also significant in that both the Minister and Deputy Minister of Health addressed the RF on separate days. I will send members an update about these other topics in more depth, but wanted to write you today about an issue which has been generating a lot of discussion, and that is income equity.

As I wrote to you March 1, this meeting sought guidance for the Board of Directors regarding three questions:

1. Is it time to address income equity among sections?
2. Should equity be achieved using regular, negotiated increases/allocation, or should some reallocation between sections occur?
3. Do the RF and sections want to further explore and examine high billers within sections?

The RF has provided clear direction. They have advised the Board to proceed with income equity in a timely fashion, while ensuring that full consultation occurs with the profession. The RF also directed that reallocation will be a mechanism applied toward intersectional income equity. They have asked the Board to present an overall plan of action for the Fall RF. We will need to be absolutely transparent in our process and communicate clearly about the methodology and the data that will be applied.

Why now?

For as long as I have been a member of the RF, there has not been a clear and common consensus of what fee and income relativity mean. However, resolutions have been passed over the years in an attempt to evolve toward them. Some progress has been made with the advent of the Physician Compensation Committee. Generally, though, the profession has been reluctant to take on these issues on a large scale; likely in part due to difficult past experiences with developing relative value guides, fear of creating rifts in the profession, and concerns over impacts on patient care.

The topics of income equity (which does not mean “income equality”) and the Adjusted Net Daily Income (ANDI) model appeared on the Spring RF agenda because of a request from the Forum itself. In September 2016, a motion was referred to the Board to adopt the ANDI model as an additional tool in the context of seeking long-term intersectional income equity.

The intent for this spring meeting was to address the big picture, and not to seek the RF’s approval of any one particular ANDI model specifically. (Click here for the example that was provided to RF for discussion that members also received with my last President’s Letter.) An ANDI type model can be implemented any number of ways and is only one strategy towards income equity.

Today’s Schedule of Medical Benefits (SOMB) and billing practices reflect historical input from sections and genuine attempts to value patient services using a very complex schedule. However, the nature of these services and how they are provided has changed over time. The historic focus on complexity of the schedule to value individual services (or fees) has not been ideally linked to the effect that fees (and changing practice patterns) have had on incomes. As a result, income inequities can become exacerbated over time. We have heard from many members for many years that this needs to be addressed.

The difficulty is: change is complicated, too. While doctors may be reluctant to admit it, change can induce fear. How do we foresee all unintended consequences? Are we sure our proposals will have the desired effect? How quickly can we or should we move? How will this affect patient care?

Other provinces have adopted ANDI variants to address equity concerns. Many of the requisite components are either known or are under development, including better ways to accurately measure overhead or how to measure and apply factors such as work hours, years of training, and work conditions. At the same time, the actual effects of our recent SOMB Rules Initiative need to be considered. Finally, while we did not receive specific direction with respect to addressing high billers within sections, there are opportunities to do so in exploring income equity. Foundational work for all these things is already underway.

Many readers of this letter will wish that we had reached this stage years ago. Others will likely not want to go down this road at all. Still others won’t be sure. Your governing body, the RF, has given a clear mandate to the Board of Directors. On that basis, we will explore income equity with a tempered and measured approach. Our discussions will be thoughtful, and our actions will be careful. We will work through the RF and with sections, and you will be kept informed of what develops at every stage.

As we are taking ownership of this initiative, we are not under the same time constraints as our negotiated Amending Agreement. Much of the information we require won’t be known until June 2018 – once our overhead and hours-of-work study is complete and the second reconciliation under the Amending Agreement is completed.

What happens next

The Board meets March 23-24 and will consider all the motions passed at the RF. There are many, including a large set submitted in the last hour of the meeting when there was no time left to debate them. The motions, debated or not, have been provided to the RF delegates. Following the Board meeting we will make them available as usual to the membership. The Board will also be considering its consultation process with sections, and what are the best ways to carry this out.

I am proud of the RF and the work that was done at the spring meeting. The subject matter was contentious and debate could have become acrimonious. Yet, even delegates who showed unmistakable emotion went out of their way to acknowledge and respect different viewpoints. The overwhelming theme was that we must work together and we must remain united. The Board will respond accordingly.

A plan for moving forward will be brought to the fall meeting for the RF’s further direction. We will act, and we intend to do what is best for the profession and the patients we serve.

We will work closely with your section leaders. Please stay in touch with your executive and RF delegates over the next six months. As always, your comments to me are welcome. Email president@albertadoctors.org or leave a comment below.

Yours truly,

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

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