Last week the need for a public inquiry into the 322 ER cases and 250 deaths on the waiting list boiled over as doctors came forward with proof of the culture of intimidation that stifles patient advocacy. But it’s not just individual doctors who have experienced harsh treatment at the hands of the government or healthcare administrators. The Alberta Medical Association (AMA) is renegotiating its 8 year trilateral master agreement, which expires on Mar 31, 2011, with Alberta Health Services and Alberta Health & Wellness (let’s call them the Government for the sake of simplicity). The negotiations took a nasty turn last month when the Government told the AMA that unless it signed a new 3 year master agreement by Apr 1, 2011, nine key programs would vapourize. The AMA reacted with shock and anger. In a show of magnanimity the Government granted a 90 day reprieve.
The Government’s display of brinksmanship is more than a ham fisted negotiation tactic. It’s a breach of faith. First, it is unprecedented to chop existing programs while a contract is under negotiation. Second, these 9 programs were established in lieu of fee increases as a way to reduce overhead costs and help offset the fee freeze. Third, axing these programs flies in the face of the Government’s 5 Year Health Action Plan, which is continually trotted out by the Premier and Minister Zwozdesky in response to any criticisms of their management of healthcare.
What are these 9 programs and why is their termination so controversial? Three programs are financial and the remaining 6 are value-added. The financial programs are the Business Costs Program (BCP) which sets the value of office visits—the elimination of the BCP will decrease a physician’s income by approximately $25,000/year; the Continuing Medical Education program which provides a $2,500/year reimbursement for mandatory continuing education and the Retention Benefit which ranges from $4,840 to $12,100 depending on years of service. The elimination of these 3 programs will reduce a doctor’s income by approximately $35,000/year.
The 6 value-added programs fall into three categories. First, programs that provide counselling support and referrals to physicians and their families, including a program that The Lancet* recognized as a leading example of quality and innovation in physician health. Second, programs that underpin the 5 Year Health Action Plan. These include programs to support system changes, programs to improve access to primary care and the Practice Management Program which is key to setting up primary care networks (PCNs). In addition there is a parental leave program which provides 17 weeks of support at $1000/week.
The AMA worked hard to ensure that Minister Zwozdesky understood the criticality of these programs. Dr White, President of the AMA, met with the health minister to review his concerns. Initially the health minister distanced himself from the controversy with vague statements like “They’re at the table, I think, even as we speak, possibly. I’m not sure. They are negotiating, and the process, from what I understand, is working”.** The Minister makes it sound like he’s not part of the process. Perhaps he’s forgotten the meaning of the word “tripartite” and the fact that his department is a party to the agreement. A week later the Premier said “Yesterday—good news—the AMA reached an agreement with government in terms of a three-year funding agreement.”*** Apparently he thinks the negotiations are over. Nothing could be further from the truth.
The very next day Dr White set out the AMA’s position: “We do not have an agreement, we’re far apart, we’ve got a lot of work to do. This is the first time the profession has been broadsided by government and it’s really pissed us off. We’re very angry. We’re very disappointed, and I can tell you the relationship between mainstream medicine and government is at it lowest ebb in a long, long time”.**** Does that sound like a deal to you?
So stepping back for a moment, why are the doctors so outraged? The dollar value of the programs is only $35,000/year, they make buckets of money and drive around in Ferraris, don’t they? Well, no, they don’t. Most doctors fresh out of medical school start their careers in debt (average debt in the US is $150,000). Their incomes don’t increase as their experience increases. In fact if the government continues to freeze fees, their net incomes will plummet. One way to offset this decreased revenue is to pack in more patients. Most doctors see 30 to 40 patients a day already—it boggles the mind to think that they could squeeze in more patients and still have time to complete their charting and billing work. Overhead costs continue to rise. The cost of leasing space, employing staff and purchasing medical supplies can easily chew up 40% of a doctor’s income. All in all, a physician’s net income can be in the $100,000/year range—significantly less than one would expect for 10 years of education—so the elimination of programs valued at $35,000/year is a major financial hit.
In addition to the personal financial impact, the loss of these programs undermines the doctors’ ability to deliver on the promises made on their behalf by the Government in the 5 Year Health Action Plan. The AMA attempts to address this gap by setting out key expectations in the “agreement in principle” (still to be finalized). In addition to freezing rates for 2 years and then increasing rates in year 3 by the cost of living, current programs and benefits will continue for 3 years and some programs will be guaranteed to continue beyond that.
More importantly, the AMA wants the Government to specify exactly how it will achieve the lofty goals and targets set out in the 5 Year Health Action Plan and identify the funding, resources and timelines required to get there—a brilliant move that will make the Government accountable for its promises at long last. The AMA expects clarity on physician engagement in decision-making process (this could be a bit tricky considering the reluctance of physicians to speak up for fear of losing their jobs). Lastly, the AMA requires the new master agreement to be functionally and fairly managed, as opposed to bureaucratically or unilaterally managed. The President of the AMA put it this way: “The concept of ministerial responsibility, which is paramount in democracy, must be clarified and enshrined in the agreement.”***** Reading between the lines this means that the master agreement should not be administered by a politician—a novel concept.
The AMA is to be applauded for standing up to a Government that has demonstrated a “no holds barred” approach to dealing with the medical profession. The new master agreement will benefit not just the doctors but all Albertans. We must show our support for the AMA and our doctors by writing to the Premier, the health minister and our MLAs to urge the Government to accept the terms requested by the AMA. If we don’t our doctors will do what any reasonable person would do in the circumstances—pack up their medical bags and drive their VW’s somewhere else.
*The Lancet, Nov 14, 2009
**Hansard, Mar 2, 2011, p 151
***Hansard, Mar 15, 2011, p 355
****Calgary Herald Mar 16, 2011, p A8
*****AMA President’s Letter March 14, 2011, p 2