What is up with these cuts?
The Alberta conservative government is proposing a number of changes to healthcare delivery. The Alberta Medical Association (AMA) has been negotiating insured services, and has highlighted significant concerns in response to proposals from the government. We all knew that this government would propose funding cuts, and now many are left scratching their heads as to why particular ones are being proposed. This is definitely a puzzle to figure out. Here are some of the pieces of that puzzle as I see it:
Puzzle Piece One: Changes to the Schedule of Medical Benefits – and System Impacts
Most of the cuts on the table are aimed at primary care – approximately 85% of them. To note are the impacts to the complex care fee codes – eliminating 25-minute appointments and complex care planning. Smaller issues raising concerns include the requirement for non-funded driving assessments. At a clinic level this means about a 25% reduction in payments for some, depending on the clinic-level operations and panel make-up. A physician with a relatively young panel, or specialty practices like OB might be less impacted than panels with older or more complex care needs. The impact of these cuts are likely to be felt more rurally as primary care providers just have fewer options - and thus end up doing more.
There are several unintended consequences to eliminating longer appointments. The antiquated “one issue per visit” mantra will likely re-emerge like a zombie from the graveyard. Three or four issues that might have been covered in one appointment of 25 minutes might now take two to three 15-minute appointments. Not only does this have a negative impact on patients, but it is also almost impossible to achieve when you consider that people are not diagnoses. A person who has COPD may also have depression and diabetes, and all of their conditions may be impacted by current life circumstances. How do you parcel that into several conversations? The need for multiple appointments means that patients will have reduced access to care and appointment slots will likely fill up quickly.
While specialists may not have been named, further impacts are likely to be felt by them. When dealing with complex patients and limited time, one option family doctors may have is to refer more often. Many specialty practices have been working with primary care to support chronic condition management within the “medical home”*. However, without the appropriate time, the number of referrals are likely to increase, resulting in longer wait lists.
Further unraveling the system impacts: without the support of a family doctor spending time with patients who have complex needs, the quality of care could decrease with the result being downstream increases in emergency department visits and hospitalisation rates.
So will this actually result in a cost savings? Unlikely. Considering all of the system impacts the downstream costs are likely to result in a higher cost of care. This is not a surprise as evidence from leading health systems around the world are built on strong and integrated primary care systems.
What these changes do achieve are twofold: 1) it makes fee for service unattractive; and 2) it promotes that the government is "addressing" the higher pay Alberta family doctors receive as compared to other provinces.
Puzzle Piece Two: Bill 21
While the funding cuts are top of mind, Bill 21, otherwise known as the Ensuring Fiscal Sustainability Act (2019) was introduced at the end of October and should not be ignored. This is a bill that proposes a number of changes to health and social services, police and energy regulation. There are significant changes proposed to the Alberta Health Care Insurance Act (2000) that impact providers. The changes lay out additional powers to the Minister to manage physician complements in the province based on “geographic area of practice, practice type or specialty; or any other category as prescribed in the regulation”. The Lieutenant Governor may by order cancel the AMA Agreement or any other negotiated agreement between the government and the AMA. Additionally, the government has made changes to the public service placing limits on terminations to a maximum of 78 weeks calculated at a week per year of continuous service regardless of years worked.
Puzzle Piece Three: HQCA Report
The Health Quality Council of Alberta (HQCA) just released its report on the Taber Clinic and Crowfoot Village Family Practice. These are two primary care organizations in the province that are paid under alternative funding models – mainly a combination of capitation and fee for service. While the funding alone is not indicative of system savings, it is a necessary lever to allow doctors and teams the time to build a “medical home”.
High quality primary care requires leadership capability, quality improvement, collaborative team-based care and shared information (like an EMR) to achieve cost and quality outcomes. That comes at a price – it costs more to deliver primary care in this model ($12 per person more in Taber versus usual rural primary care and $50 more per person in Crowfoot when comparing to urban cost of primary care). But the cost savings to the system are significant. When “downstream” costs are studied, there is a cost savings of $449 per person in Taber and $182 per person in Crowfoot. This is the result of fewer specialist referrals, fewer visits to the emergency department and fewer hospitalisations.
So let’s play with numbers a bit. Using “cowboy analytics” if we could achieve the same cost savings that Taber and Crowfoot achieved – let’s use $300 as an easy average, and we did that for 4 million Albertans, we would save $1.2 billion per year. That’s not bad.
Putting It All Together
I am no fortune teller, but I have been around. Do bear in mind these are my musings, and only based on my opinion. Based on what I am seeing here are my “predictions”:
Prediction 1: Payment reform is coming to primary care. Previous attempts to make changes were not supported by providers for many reasons. The government is making fee for service unattractive and cutting the very areas that are needed to support strong primary care: chronic condition support. Step one is making the current state unattractive, step two is to paint the future state as more attractive. The government will use the HQCA report as their support. Classic change management theory.
Prediction 2: Cuts to others parts of the system are coming. We all know that is the case, and some have already started. Even if primary care costs more to deliver, the cost savings are still positive. A “bolus” of funding to get it started is needed, which the savings from terminations may come in. Long-term funding can be managed with the cost savings to the system with stronger primary care.
Prediction 3: Alberta Health will be much more involved in physician management. The veto power on negotiations and health service planning is interesting and one that likely can’t be ignored. That may come in the form of tighter controls over Primary Care Networks.
One thing that is certain, is that change is coming, and adaptation is necessary. Hiring the right people is more important than ever – the cost of turnover is too high when other cuts are coming. Maximizing your efficiencies in practice is needed, and focusing on physician leadership skill is an imperative. Only time will tell if “Margie’s Predictions” are even in the ballpark!
*The medical home, or Patient’s Medical Home or Patient Centred Medical Home is a framework and philosophy of care where a clinic is built to support patients throughout their life and changing health circumstances; and reciprocally a patient is able to access a long-standing relationship to get health advice in managing their own care. Care is team-based, patient-centred, continuous, comprehensive, and accessible.
Margie is the Senior Director at Thought Architects – a values-driven company that builds capacity in practices to be able to take on whatever changes are thrown at them. Thought Architects is designed to be a temporary support for your team in the areas of HR strategy and operations, improvement and patient engagement activities and leadership and team development. You can learn more about them at thoughtarchitects.ca
Margie has worked at all levels of the health system over the past 25 years and brings expertise in clinical and process improvement, facilitation support, leadership & team development, human-centred design and coaching. She is also the Education Program Officer at the University of Alberta in the Faculty of Medicine and Dentistry supporting coaching development in physicians.