‘Time for war’ in doctor pay debate
Some specialists rejecting push for ‘income equity’ among profession
Rivalries and rancour are rising among Alberta’s physicians as leaders of the profession meet in Edmonton this weekend to decide the prickly question of how to more fairly distribute $5.2 billion in provincial funding.
The complex “income equity” concept, which could provide lower-paid physicians such as family doctors a bigger slice at the expense of higher-paid professionals, has been touted as necessary to achieve important reforms in the health system. Yet it also carries the threat of dividing the profession.
The effort is being led by the Alberta Medical Association, which has been working with the province to better control physician compensation costs. The government has said there is little new money to pay doctors, meaning any increase for certain groups will have to come from rebalancing existing funds.
While AMA leaders say they expect doctors to remain united as they vote on a path forward, it’s clear some groups remain adamantly opposed to the initiative and have been gearing up for a fight with their colleagues.
Documents obtained by Postmedia show the section of ophthalmology, for one, has canvassed each of its members for a $5,000 donation to build up a legal war chest. The documents indicate roughly half of the province’s 127 ophthalmologists, including the section chiefs in Calgary and Edmonton, have so far contributed to the fund — adding up to more than $300,000.
“I would urge you to speak to any of your colleagues to contribute to this fund, as it is seen … as the only way to stop or significantly mitigate the catastrophic effect the proposed re-allocation of earnings WILL HAVE on all ophthalmologists,” Ian Macleod of the Eye Physicians and Surgeons Association of Alberta, told members in an email last August.
The money has apparently been put to use. Last month, a law firm hired jointly by the ophthalmologists and dermatologists hit the AMA with a letter challenging the association’s authority to proceed with the income equity initiative.
The Feb. 28 letter from Dentons LLP promised a further response that would illustrate the AMA’s “breach of mandate,” “overt bias” and “predetermined disposition” in the matter.
The missive was sent to oppose a legal position the AMA sought recently from its own lawyers, who concluded: “We don’t see a risk of a successful claim being made by dissident members/sections.”
Ophthalmologist and dermatologist leaders did not respond to Postmedia’s requests for comment.
HIGH BILLINGS, BUT ALSO HIGH OVERHEAD
The two specialties are among the highest-earning groups in the medical profession.
Provincial statistics show Alberta ophthalmologists received average gross payments of $1.12 million in 2015-16, while dermatologists collected average payments of $737,000. In contrast, gross payments earned by family doctors averaged $298,000, while psychiatrists earned $347,000.
High-earning specialists such as ophthalmologists have argued their billings are justified due to the extra schooling they require and overhead costs they must bear for high-tech equipment and trained staff.
It’s unclear how much ophthalmologists might stand to lose through the income rebalancing process, though the documents show section leaders were worried at one point that average net earnings of $611,000 could instantly decline by $120,000 or more, with further cuts in subsequent years.
In a submission to the AMA last year, those leaders argued such revenue losses would make it impossible for many eye doctors to cover overhead expenses.
“Many Albertans will lose vision,” the document said.
‘ADJUSTED DAILY NET INCOME’ CHOSEN MODEL
AMA delegates decided last fall that income equity should be built around a model known as “adjusted daily net income,” which has been used in Ontario and B.C.
In basic terms, the model collects data on average gross billings for each section of medicine, and then applies adjustments for factors such as overhead costs, additional training and daily hours worked. In theory, comparisons can then be made among the sections to determine if some groups are receiving a fair share of funding.
The model requires the AMA to conduct detailed studies on overhead costs and hours of work for each section, but those won’t be finished until the fall.
As such, a key question facing delegates this weekend is whether they have enough information already to approve a plan for implementing income equity, or whether the vote should wait until the studies are ready.
A delay in approval would mean that any reallocations of income wouldn’t start until the fall of 2019 at the earliest.
Dr. Rob Davies, who leads the section of radiology — another high-earning specialty — has been among those calling for a delay to ensure the process is fair.
In an interview, he said an important aspect of the exercise is that disagreements are resolved in a “professional and principled” way, and that his section is committed to working within the AMA.
“Things may look messy to outsiders as we progress, but we have a vigorous democratic process ... and what you are seeing is a healthy level of debate,” he said.
SCARE TACTICS ALLEGED
However, others insist that physicians calling for the vote to be put off are simply engaging in fear mongering and stall tactics designed to ensure income equity never proceeds.
Dr. Phillip van der Merwe, a family physician leader in Calgary, said such tactics have derailed past attempts to resolve inequities, so it’s important that not be allowed to happen again.
“It’s time for war and it’s enough waiting,” he said. “It’s time for everybody to do the right thing.”
Van der Merwe said a number of lower-earning specialties have been long undervalued for the impact they have on patients and the health system in general.
In the case of family doctors, one of the province’s key policy goals is to deliver more care outside of hospitals. Accomplishing that will require primary care teams to provide more comprehensive services, which will, in turn, require family physicians to be given more resources.
But as long as certain specialists continue to suck up an excessive share of funding, that goal can never be fulfilled, said van der Merwe, who recently ran in a byelection for the NDP. He said he is particularly incensed at specialty groups threatening the unity of the AMA, claiming they have no room to tighten costs, or insisting that specialists will leave Alberta.
“If you want to go live in the U.S., I will show you a road map to the 49th parallel,” he said.
In the middle of the dispute is AMA president Dr. Neil Cooper, who said he hopes the “angst” can be resolved when delegates debate the issue this weekend.
He said it will be important for physician leaders to remember the ultimate aim is to produce better care for patients. As for those physicians seeking to push back the implementation vote, Cooper said he hopes it is simply about ensuring due diligence.
“I’m hopeful we have people who are professionals and realize you can’t have a system that is not fair go on forever,” he said.
It’s enough waiting. It’s time for everybody to do the right thing. If you want to go live in the U.S., I will show you a road map to the 49th parallel.