SOMB savings: Keeping you informed

November 15, 2016

Dr. Padraic E. Carr, AMA President

Dear Member:

We have had an impressive response from physicians to our call for suggestions toward the Schedule of Medical Benefits (SOMB) Rules Savings Initiative.

With the help of sections and hundreds of individual members, we were able to identify a first batch of SOMB rule changes in the first phase of the initiative that ended November 15. I would estimate that we received over 700 individual emails before we were able to post the online forms and begin collecting feedback that way.

We will need much more input for phase two, beginning now. In this letter I want to provide you with some updated information about the whole process, but even more than that, I want to encourage you to participate!

This is your opportunity to have some direct input into modernizing the SOMB while improving the quality of care our patients will receive as a result. We welcome submissions coordinated through the sections or from individual members. Please see below for how to get involved or to stay involved if you are already participating.

What and why

To recap briefly, the Amending Agreement contains provisions to work with government and attempt to identify some savings in the SOMB, slowing the growth rate of health expenditures. The amount identified is $100 million in annualized savings. (In 2016-17, this amount has been reduced to $85 million due to a mutually agreed to and one-time extraordinary application of funds through the Physician Compensation Committee fee review process.)

The SOMB Rules Savings Initiative is designed to allow the profession to identify things that we do for patients that are of low clinical value and could be eliminated without negatively impacting quality care – and quite possibly improving it.

Timelines and board direction

The timelines established by the Amending Agreement for this initiative are extremely short. The first phase was due for recommendation for implementation by the Management Committee to the Minister of Health as follows:

  • By November 15, 2016 – for implementation on January 1, 2017 and/or April 1, 2017.
  • By February 3, 2017 – for implementation on April 1, 2017.

The ratification vote was finalized on October 14. On October 17, I emailed section presidents and members to invite your input into the first phase of the savings initiative. I emailed again October 31 with an update and provided links to the online forms we have developed to gather input (and where you can see comments and suggestions posted by your colleagues). We have received SOMB suggestions covering the full gamut including rule changes to individual codes, changes to ways codes are billed together, and even a request that we do not alter the SOMB at all (which is obviously not an option considering the ratification vote and our binding contract). I really do want to thank everyone who has taken the time to contribute to this endeavor.

Listed below are the principles that were applied in selecting items to go forward. Rules savings options should:

  • Where applicable, be informed by one or more of the Choosing Wisely Canada recommendations.
  • Be driven by best available evidence and national guidelines for high quality patient care.
  • Consider the need to reduce inappropriate variation in physician practices.
  • Be objective, transparent, and driven by peer reviewed literature, other reliable data or necessary consultations with field experts.
  • Improve alignment of incentives driving high quality patient care practices across different modes of payment.
  • Simplify existing complexity and modernize the SOMB.
  • Be easily and quickly implemented.
  • Not impact quality of care.
  • Impact the broad range of sections as equitably as possible.
  • Be clear and easy to interpret.

The Board of Directors has been closely monitoring this work and spent our last meeting discussing implementation issues across the Amending Agreement. With respect to SOMB savings specifically, the board discussed the issue of equity – both in our approach and in the eventual results of the initiative. Accordingly, all sections have been asked to contribute by submitting suggestions to the working group. When decisions are made, however, we recognize that the impact will still vary across the sections and may have an impact on equity. Accordingly, the AMA will make it a priority to seek opportunities in the annual Reconciliation Process (under the Amending Agreement) and in future allocations to recognize the degree that sections have been impacted and the contributions they have made. We will work through the Representative Forum and with sections to develop a process to achieve this goal.

Phase one completed

I am pleased to report that, with the help of sections and members, the AMA working group was able to submit a list of items for the phase one November 15 deadline. From that list, the joint AMA-Alberta Health working group found 40 ideas and suggestions that met the criteria and were relatively straightforward to assess, project cost savings and plan to implement. These rules changes will come into effect January 1, 2017.

This phase one results list can be found HERE.

Phase two and what happens next

Thank you again to everyone who has participated so far. The thoughtful submissions were well received. It’s very encouraging that we were able to reach agreement with government on the phase one list without triggering the arbitration provisions that exist under the Amending Agreement. Working with this degree of cooperation and collaboration so early and so effectively bodes well for the work ahead.

Today AMA staff and I met with all the section presidents to discuss phase two and gather further feedback on what has happened so far. We also explored concepts of budget management and section input and accountability.

Here is the link to the evolving phase two list. Many of the items on this list were carried forward from phase one because they are more complex to assess or are simply more controversial and require much more discussion and input from sections and members. As members and sections make new suggestions, we will add to the list.

This initiative will succeed in direct proportion to its ownership by the profession. You know what works and doesn’t in your particular area of practice. Please let us know what could be eliminated to find savings while not negatively affecting patient care.

To best meet the timelines of the working group, ideally we would like to receive as many submissions as possible by November 30 so that there is sufficient time for consultation with the profession as well as information systems work at Alberta Health needed for implementation April 1, 2017. We will, however, continue to accept submissions until the list is agreed to, which is expected to be in the first week of January 2017.

We will keep you informed and will do our best to answer any questions you may have. It is the board’s wish that our tasks be undertaken with the utmost openness and transparency.

Please let me know how you think we are doing. I welcome your thoughts on this or any other subject. Please email or leave a comment below.

Yours truly,

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


Commenting on this page is closed.

  • #1

    Dr John Pasternak


    4:23 PM on November 15, 2016

    I was a Family Doc in BC when the 45 patient / day/ Family Physician was institututed ( I believe it was 1998). There is a reduced fee after the first 45, and I believe further reductions at 60+. There was a huge out-cry by those who had a pattern of practice that would speed patients through and exceed those numbers routinely, referred to as High Volume Low Intensity ( could be known as no proper history or examination performed)The rule however has stood the test of time and in response, there are greater incentives in place to manage more complex patients. With the concept of a Medical Home evolving that should result in closer relationships between patients and their doctor, this limit would fit in logically with that concept. I know this concept was thought of about a year ago and there was even a survey taken which likely put the whole thing down. But at this juncture, with more desperate action being taken on all fronts, I believe this offering, truly and obviously in our patient's best interest would be a great suggestion.

  • #2

    Fayaz Bharwani


    1:23 PM on November 17, 2016

    It is an insult to anesthesiologists to simply be reimbursed for the time spent in the OR. As anesthesiologists we spend much of our time dealing with patient care in addition to the time in the O.R. That time includes preoperative assessments of patients (researching old charts, Netcare, etc.), talking to patients including a full history and physical exam as well as discussions regarding anesthetic options, risks and benefits, etc. Unlike other specialists, we do not bill a consult fee prior for each one of these assessments. In addition, much of our time can be spent managing patients in the recovery room after their surgery is over. This can include management for acute pain, postoperative nausea, management of hypertension and hypotension, and many other complications that can arise postoperatively. To disallow any billing outside of the the time spent in the O.R. is taking advantage or our specialists and expecting a high quality of care without compensation. This to me is unacceptable. Perhaps then care in the post anesthetic care unit (PACU) should be handled by non-anesthesiologists, although the quality of care will suffer.

The AMA advances patient-centered, quality care by advocating for and supporting physician leadership and wellness.