miss the days, you showed us your neighbourhood, your land tour photos, your wife's cooking, your time with your little girl.
I don't think you are in-debted, so maybe reduce your number of patients every day (and charge higher per pax).
Fee to charge is not set by me.
Is set by Health Minister.
And the current one is a fucking asshole.
Nobody talks about the new fees for telemedicine which are pathetic. But with telemedicine here to stay now most patients would rather just do telephone call and not want to go in person. Also to see in person you need to justify why the need for in person. And in our practice most do not need physical examination.
So dont play play. Asking patient to come in person for the sake of earning more money is a no no. Also competition. Other cannabis clinic also all go telemedicine.
The family practice clinics also suffering. In fact even worse. Cos most consults go around 15 to 30 min. But the fee is one amount for <10min and one amount for >10 min.
If 30 min also same as the one for 11 min.
They have saved a lot of money on health care during covid. And patients have it more convenient now too. So this is here to stay.
https://edmontonjournal.com/news/po...-healthcare-how-healthy-is-our-medical-system
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Alberta doctors and the UCP government have battled for months over fees. Here's how and why it happened
Author of the article:
David Staples • Edmonton Journal
Publishing date:
Sep 09, 2020 • Last Updated September 10, 2020 • 14 minute read
Physicians and the Alberta government have been in a dispute over fees for months, but talks resumed in mid August. PHOTO BY ED KAISER /Postmedia
Will there soon be an agreement between Health Minister Tyler Shandro and the Alberta Medical Association over physician’s pay?
That’s looked unlikely for months. Indeed this summer relations hit a low point with 98 per cent of Alberta physicians in an AMA survey saying they had lost confidence in Shandro.
AMA president Christine Molnar was withering in her critique. “Over the past year, Mr. Shandro’s words and actions have created a chaotic state in health care and have alienated most of the people responsible for actually delivering the care in the system,” she told reporters. “It’s a toxic situation and physicians have clearly had enough of it.”
But seven weeks later the rhetoric has cooled.
“I’m an optimist,” Molnar now says, “And I know our members have expressed the non-confidence, but I still think there’s an opportunity here.”
Since mid-August the AMA and the government have been quietly negotiating. Shandro and Molnar say they have personally talked. A breakthrough appears to have happened, with the AMA and Shandro agreeing on the basic outline of a solution, a hard cap on payments to doctors, though several difficult side issues — especially in relation to the payment of new physicians in a hard cap system — are still being negotiated and could derail any agreement.
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While rhetoric has cooled off, the dispute has been bitter and negotiations could easily fall apart again. NDP health critic David Shepherd warns in regards to the UCP’s hardline approach to the doctors: “There is no way that we build a more effective healthcare system with lower costs if they’re alienating the very people who understand that system best and are the ones who deliver care.”
The AMA has shown a willingness to work with Shandro, but not the other way around, Shepherd says. “He has utterly demonstrated an inability to work with them collaboratively and in good faith and in trust.”
Many governments, little cost control
Over the past 25 years, Alberta has slowly but surely become Canada’s top spender on physician pay.
After the Ralph Klein cuts of the mid-1990s, Alberta’s per capita spending on physicians was $297 in 1996, compared to the Canadian average of $379, with B.C. at $412, Ontario at $410 and Quebec at $309, according to data from the Canadian Institute for Health Information.
But twelve years later in 2008, Alberta’s per person spending on physicians surpassed the Canadian average of $688, hitting $717 per person, still behind B.C. at $728 and Ontario at $775. In 2009 Alberta’s per capita spending overtook B.C. and in 2011 it overtook Ontario.
The most recent national numbers have Alberta at $1176 per person, the Canadian average at $984, with B.C. at $897, Ontario at $991, and Quebec at $963.
The high cost of healthcare workers is a major cost driver, leading to Alberta having the highest per capital healthcare costs in the country, says Dr. Tom Noseworthy, a University of Calgary healthcare policy professor, who started to practice as an Alberta critical care physician in 1980, was CEO of Edmonton’s Royal Alex in the early 1990s and worked for four years as an executive for Alberta Health Services, 2011 to 2015.
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“The doctors have always done well … I’m not necessarily saying they are over paid but we do have a tendency to be on the high end on the wage levels,” he said.
While costs grow ever higher, Alberta’s results didn’t always stack up well compared to B.C. Ontario and Quebec, as the Alberta government’s 2019 spending study led by Janice MacKinnon
reported.
Alberta has lower life expectancy, higher infant mortality and more suicides and cardiovascular deaths per capita. Alberta also has longer wait times for hip and knee replacements and cataract surgery than in Ontario and Quebec.
A major issue is a lack of accountability in the system, says Dr. Colum Smith, a fellow at the U of C’s School of Public Policy, who practiced for 35 years as a radiation oncologist in Ireland, Canada and Australia and is a former dean of medicine at the University of Saskatchewan. Smith was on a UCP riding board in the 2019 election.
There’s no systematic follow up on whether or not various procedures have met the needs of patients, Smith says. “There’s really no information on outcomes, minimal information on outcomes. We don’t know what we’re getting for the investment that we’re giving.”
All this could be accomplished with a follow up survey with patients after their procedure, Smith says. But physicians often fight against this kind of accountability, arguing such measurements aren’t fair. Doctors will argue, Smith says, their patient population is much sicker than the average so they’re going to have poorer outcomes, or that the data is out of date. “It’s a battle that physicians can wear you down on.”
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Molnar, who has worked as a radiologist and nuclear medicine physician in Calgary since 1985, says the AMA is working to better chart patient experiences and outcomes. “We are moving in the right direction. Yes, we can improve,” she said.
Speaking directly to Health Minister Tyler Shandro, the Alberta Medical Association’s took out ads in newspapers in July stated: “Minister, we still believe there is a way forward. Let’s not waste any more time. The health care system desperately needs the stability that only working together can bring. This is what patients deserve.” PHOTO BY IAN KUCERAK /Postmedia
The sticky issue: physician pay
Payments to physicians have continued to shoot up despite a 2013 agreement that was hammered out after a previous bitter negotiation, a deal the Alison Redford government of the day hoped would greatly slow any increases.
Things got so heated during that lengthy dispute, which saw the doctors without a contract for two years from 2011 to 2013, that Dr. Lloyd Maybaum of the Calgary and Area Medical Staff Society said of doctor/government relations: “We’ve plumbed new depths of low — as rock bottom as anyone can ever remember the relationship being.”
But a new seven-year agreement was eventually reached. Redford was proud of the agreement, which had three years of zero fee increases, followed by two years of 2.5 per cent increases and two years of cost of living adjustments. “She was so giddily happy you’d think she just received a phone call from President Barack Obama approving the Keystone pipeline project,” The Journal’s Graham Thomson said of Redford
But the agreement failed to control Alberta’s payment to doctors, especially in comparison to other Canadian provinces.
In 2013-14, the Alberta government paid an average of $354,492 to Alberta doctors in gross clinical payments (with their net pay less that amount due to office, equipment and staffing costs),
reports CIHI. That was six per cent above the Canadian average of $334,693, with payments to doctors in Ontario, Manitoba and Saskatchewan all higher than in Alberta.
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By 2017-18, however, payments to Alberta doctors on average had shot up to $385,174, the highest in Canada, and 12 per cent above the Canadian average of $344,978.
So what drove up costs?
While the government and doctors agreed that fees would not increase for three years, they did not agree to any limit on the number of services performed.
At that time, a Physician Compensation Committee was created with both government and AMA representation to set prices for various fees. The PCC had ministerial authority to set fees, but it never took on the job of limiting overall procedures. And any savings found by the PCC had to go back into the pool compensating doctors in some other way.
The big driver for increases in payments to doctors was utilization of the system by Alberta patients, Molnar says, with more people getting more medical services, and sometimes getting more complex and expensive procedures, which have grown out of innovation and new technology.
“Doctors were not paid more,” Molnar says. “Were they doing more work for more patients? Yes ,they were. But their fees didn’t go up. They weren’t paid more for an individual service.”
Some point their finger at this fee-for-service model, more popular in Alberta than elsewhere in the world, as the major culprit in escalating doctors costs.
In 2017-18, 13 per cent of all payments to Alberta doctors was done by alternative means, as opposed to 27 per cent in Canada. In Alberta, 83 per cent of doctors were paid entirely through fee for service, compared to just 31 per cent nationally. Alternative payments include a physician that is paid a salary, or paid to look after a large pool of patients, being paid not for each procedure done, but for each patient in the group.
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Alberta has too much of fee-for-service overall, Noseworthy argues. “To have it as the exclusive payment system for 70 to 80 per cent of the doctors simply makes no sense.”
Doctors are fiercely independent, Noseworthy says. They aren’t salaried employees, but work as independent contractors, small business people, who pay the rent and staff and supplies, then provide service on fee-for-service bases. They have to use Alberta Health Services for diagnosis and treatment services. “But they definitely don’t work for AHS.”
Doctors like fee-for-service because it gives them independence, Smith says. “Salary means you’re an employee and physicians generally do not like being an employee.”
Fee-for-service can also be a great motivator for doctors to work hard and cut down on wait lists, Smith says. He points to Ontario about 20 years ago where radiation oncologists were on salary and wait lists were shockingly long. Each physician was asked to take on about 215 new patients per year for their salary, but wait lists got so long patients had to be sent to Buffalo, New York for treatment, Smith says. In the end, the Ontario government decided to go with fee-for-service for radiation treatment. Within 18 months there was no wait list and physicians were taking on 400 to 500 new patients per year.
But the fee-for-service dynamic is not always beneficial Noseworthy says.
Most family doctors take home $200,000 to $225,000 per year but some earn over $1 million. “I know exactly what they’re doing to make a million bucks. I used to be a family doctor too. Do I want that kind of medical practice? No. Do I want to be a patient in that kind of medical practice? No,” he said.
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The AMA has systems and training in place to help physicians gauge what services and tests are appropriate for patients, and which are unnecessary, Molnar says. “There is always room for improvement,” she says. “But are we on the right track? I think so. I think we are. Could we step it up? Absolutely.”
Noseworthy says the new generation of physicians he’s teaching would be satisfied to work in an alternative payment model. “The new doctor is not looking to work 60 hours weeks, is not looking to bust their ass on fee for service day and night. They want a life. They want some orderliness and predictability … My sense is we need to capitalize on that,” he said.
There is no perfect single payment model for physicians, Molnar says, with some payment models such as fee-for-service suited more for specialists, and others such as salaries or per-patient pay suited more for primary care and family doctors. She defends fee-for-service noting it’s a good way to get productivity. “Alberta physicians work longer and harder than most other physicians in Canada. Are they providing more services for more Albertans? Yes, they are. Is that wrong? Well, I don’t think so.”
In the end, it all adds up to Albertans paying more for healthcare. For example, the average cost of a hospital stay is $5,500 in Ontario, $5,800 in Quebec, $6,500 in B.C., but $8,000 in Alberta, CIHI reports for 2017-18.
Kenney’s cost-cutting
In May 2019, Jason Kenney’s United Conservative Party was elected, pushing hard a message to bring Alberta’s debt and deficits under control. Kenney appointed Calgary lawyer Tyler Shandro as health minister. Shandro is critical of the Physicians Compensation Committee put in place in during the last round of negotiations with doctors. This system, Shandro says, “ended up essentially giving the AMA a veto on their budget and so it kind of gave physicians for almost a decade kind of a blank cheque.”
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The ever increasing volume of services brings about inflation in physician pay, as does doctors choosing more expensive procedures, Shandro says. “There was essentially no oversight,” he said.
The government wants to cap physician expenses at $5.4 billion per year for the next three years, but under this old system there was going to be cost overruns of $2 billion over those three years, Shandro says.
He says he told the AMA such a hard cap was necessary last November, when negotiations on a new deal commenced
“I can appreciate that gave the AMA anxiety,” he says. “At the same time, if we were middle of the pack in terms of physician compensation I could appreciate that anxiety. But this is the highest in the history of this province, $5.4 billion, it’s the highest in the country on a per capita. Our physicians are the most generously paid here as anywhere in this country.”
Along with a hard cap on payments, Shandro also proposed a new advisory committee with AMA representation to set fees, but under this plan the government and health minister would have ultimate say on payments and overall costs.
In negotiations last fall and early winter, the AMA offered to cut all fees by five per cent but the government rejected that, believing it would not contain costs.
Negotiations broke down. Mediation failed. The old agreement was set to run out at the end of March 2020, but in late February the Kenney government decided to bring in its own plan, but without agreement from the doctors. Along with imposing a hard cap, the government brought in other billing restrictions, including cutting what doctors could bill for patient visits over 15 minutes in length, removing overhead costs from billing outside a physician’s clinic, and capping the number of patients a doctor could bill for in a day at 65.
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This was a major blunder, Noseworthy says of axing the expiring deal. “They just tore up the collective agreement — that’s mean spirited.
“Civility has been lost, trust has been lost. I don’t know Tyler Shandro but he certainly doesn’t understand doctors very well and he doesn’t appear to want to care about that. So it’s time to change the channel here if you want to fix this problem.”
Enter COVID-19
A few weeks after the government imposed a new agreement, the coronavirus pandemic erupted, putting the Kenney government in a major fight with doctors at the same time as physicians faced an unprecedented unknown public health challenge, and just as the public was turning to physicians for both care and leadership.
“I think it was incredibly reckless, frankly,” says the NDP’s Shepherd.
At the same time Shepherd says Shandro was picking fights with doctors on Twitter and refusing to back off his plan, which forced physicians to go to seminars to learn new billing codes even as they were scrambling with pandemic preparation. “It was just unconscionable that this government decided that the middle of the pandemic was the time to force through their own idealogical changes.”
David Shepherd, NDP Opposition critic for health, says the government is alienating doctors, making it more difficult to improve the health system or contain costs. PHOTO BY SUPPLIED /Dave DeGagne
Negotiations go from bad to worse
In early April, the AMA filed a lawsuit to try and force the province to restart negotiations. At the end of that month, the government reversed the plan to prevent billing for overhead costs outside a doctor’s clinic, making the reversal permanent for rural doctors, but only delayed for urban ones
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The dispute boiled over into summer. In mid-July, the AMA bought full-page newspaper ads setting out its position, essentially that the AMA would agree to a three-year hard cap on physician costs, with any cost overruns covered off by bringing in a fee reduction. At the same time, the government would have to cover the cost of any new doctors in the system.
The AMA’s non-confidence survey came out soon after the newspaper ads.
Shandro’s reaction?
“I get that the AMA needs to continue to advocate for their members and all power to them,” he says. “But we campaigned and we had over a million Albertans vote for us on a campaign to be able to hold our spending in line, to make our system more efficient and to make our system more patient focused and that’s exactly what we’re going to continue to do regardless of a survey the AMA is going to have with their members.”
In the face of the AMA’s non-confidence vote, Kenney stood by Shandro, telling the AMA that the health minister’s position was the government’s position. “He has my 100 per cent confidence,” the Premier said of Shandro recently.
Shandro says the government has tried to meet concerns raised by the AMA and on August 11 presented a new proposal to the physician’s group, followed up by a meeting between Shandro and the AMA on Aug. 19.
Shandro wants the AMA to take a red pen to the government’s proposal and cross out anything that doesn’t work for doctors. “I keep on saying to the AMA, ‘Tell me specifically what you would propose to change. It can’t just be go back to the old agreement. But what would you want to change in this new framework?’ ”
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As for the government paying for new physicians outside of the proposed hard cap, that’s not viable, Shandro says, as it will push costs over $5.4 billion. “We’re not going to go beyond $5.4 billion.”
Some physicians have claimed worse outcomes will result from the government’s hard line, but Smith says it’s not possible to prove such claims, pointing to the lack of solid reporting on patient outcomes in the system. “They can say these things but there’s not a shred of evidence behind it. How do you know if it’s going to be worse if we don’t know what it is today?”
Noseworthy is not at all keen about Shandro’s tactics, but he is onside with making it clear to doctors that no one is getting paid more money, that the pay envelope is not going to change, even if new doctors come to Alberta. “You have to put a lid on the total size of the pot and Alberta has never done a good job at that. … That has to stop in Alberta and it really has to stop in Canada at large.”
On the sticky issue of whether new physicians should be paid within or outside the hard cap, Molnar says the AMA is willing to work with the government on a plan to get the right number and type of physicians in the right places in Alberta.
Molnar has reservations about Shandro’s approach when it comes to patient care. “What they’re really asking is they want Alberta doctors to provide more services for less money.”
Nonetheless, the AMA is now digging into this conceptual framework for a deal.
“What the government wants is budget certainty,” she says. “So our latest offer to them is a budget management offer, a co-management.
“We’ve accepted that the government doesn’t want a rate based budget, that they want a hard cap budget, so we’re working towards a position that we accept that, and how could we manage that with them. I’m cautiously optimistic.”
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