COST CONTROL VS. COVID-19
What is the future of health care?
Alberta is in a very tough, tough situation where there are going to be many different demands that we want to support with public dollars.
This is the fourth and final part of our series on how COVID-19 has affected politics in Alberta. Here, Dylan Short examines how the government aims to control health spending while coping with the financial pressure of the pandemic.
In late March, a man walked up to two boys playing basketball outside their southwest Calgary house on a cool, cloudy Saturday evening and asked if he could speak to their father. They went inside and got their dad, who was then berated by the man and his wife over a critical Facebook meme the father had posted on social media.
It was a squabble between neighbours that could happen in any neighbourhood, however this particular confrontation took place between Alberta Health Minister Tyler Shandro and his neighbour, Dr. Mukarram Zaidi. Shandro and Zaidi had previously worked together on the constituency association for UCP MLA Mike Ellis.
The confrontation came after months of heightened tensions between the province and doctors that saw negotiations between the two sides break down when they couldn’t come to an agreement on a new funding formula.
“The majority of physicians believe there is bad intentions behind what the minister of health and this government wants to do,” said Zaidi in an interview in early June. “Since the beginning, they haven’t been negotiating in good faith. And they have left the table.”
Requests to interview Shandro for this story were declined.
The battle with doctors played out as the government was diverting much of its health resources to fight the COVID-19 pandemic. The week before the health minister accosted Zaidi, the province had declared a public health emergency, in-school classes were cancelled indefinitely, businesses began shutting down, and Alberta recorded its first death from the novel coronavirus.
The UCP government is now left to reconcile its plan to control health spending with the ongoing financial pressures brought on by COVID -19.
Fiona Clement, an associate professor and health economist with the O’brien Institute of Public Health at the University of Calgary, said that reconciliation could take years.
“It’s going to be tough fiscally as we look forward, probably for the next decade,” she said. “Alberta is in a very tough, tough situation where there are going to be many different demands that we want to support with public dollars.”
Arto Ohinmaa, a professor and program director at the University of Alberta’s school of public health, said the government has a relatively low debt they can still tap into but right now they may have difficulties generating the revenue to cover those costs.
“It’s a revenue problem for the government, how to get funds to seek health care and other public services,” he said. “So we can probably cut some of the health-care costs in the future but there’s a limit to how much we can do it.”
After contract negotiations between the government and the Alberta Medical Association (AMA) fell through in February, Shandro unilaterally implemented his latest offer to doctors. That included cutting what doctors could bill the government for patient visits over 15 minutes, 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.
When Shandro announced the changes at a Calgary news conference in late February, he said they were intended to stop cost overruns.
“This compensation model is broken and so we’re fixing it. Another $2 billion in spending increases is not sustainable,” he said.
Dr. Kate Bisby, a family physician in Calgary, says the move to rip up the funding model and unilaterally replace it has destroyed the relationship between the government and its health-care workers.
“I have run out of adjectives to try and meaningfully describe how absent the trust is between physicians and this government,” she said.
BUDGET UNDONE
The 2020 provincial fiscal plan, released eight days after Shandro imposed billing changes on doctors, budgeted $20.616 billion for the Ministry of Health, a relatively flat amount compared to 2019 and 2018 where spending came in at $20.611 billion and $20.409 billion, respectively. The $5.4 billion dedicated to physician pay is the largest expense within the health budget.
It was a budget that was touted by the UCP as one that would rein in spending from previous years while the government worked to find efficiencies and other cost-saving measures. The budget pointed out that Alberta physicians were being paid an average of $90,000 more per year than their counterparts in Ontario and overall the province was spending $997 more on health care per person than other provinces.
“We remain committed to paying physicians at some of the highest levels in Canada, but we have to be realistic,” Shandro’s press secretary Steve Buick wrote in an emailed statement.
David Shepherd, the opposition NDP’S health critic, said the health budget needed at least an additional $500 million before the pandemic hit the province to avoid potential job cuts and to maintain services.
“I think in the view of anybody looking at the 2020 budget that we got from (Premier) Jason Kenney and the UCP government is pretty much a worthless document,” he said. “I think they knew that when they brought it forward and jammed it through the legislature.”
However, Clement, the health economist, says controlling health spending is necessary to ensure there are resources for other government priorities.
“I believe the health-care system had enough money and we should not have been giving them budget increases, PRE-COVID,” she said. “They had taken up 43 per cent of the provincial budget, which means that every other social program and public investment within the province was working with 57 per cent of the budget.”
Revenue challenges brought on by the collapse in oil prices emerged as the province was facing spending pressures to control the spread of COVID -19. The budgeted $6.8-billion deficit for this year is now widely expected to grow to $20 billion.
PIVOTING FOR THE PANDEMIC
Combating the pandemic meant the government had to make a series of changes to ensure the health-care system wouldn’t buckle under the pressure of COVID -19. The province reallocated funds to the health-care system, diverted procedures away from hospitals and implemented some of the most aggressive testing policies in the western world.
“In the 10-year plan for any health-care system, the pandemic was not included, obviously. So I think the system and not just the health-care system, but you know, governments and people have had to pivot very, very rapidly,” Clement said.
Health-care spending was topped up to the tune of $500 million and hundreds of millions of dollars were given to long-term care centres. All non-emergency and elective surgeries were postponed to help free up hospital beds and equipment in anticipation of a surge of COVID-19 patients requiring hospitalization.
Public gatherings were limited to 250 people, then 50 and finally 15. Non-essential businesses and services were ordered closed, and people were advised to only leave their homes when necessary.
Those health measures have paid off, Clement says.
“I think while of course we can criticize those decisions, in hindsight, because the public-health measures have done such a great job at limiting the cases and flattening the curve out, it could have very easily gone the other way,” she said.
Hospitalization rates remained well below their maximum threshold, hovering around 90 people in care at one time at the height of the pandemic.
Sabrina Atwal, a spokeswoman for AHS, said the most in-patient beds they had available in hospital at one time was 2,749, during the week of April 15. In mid-june, there were fewer than 400 active cases of COVID-19, with around 50 in hospital.
The province heavily emphasized testing as a way to stop transmission of the virus. More than 325,000 tests had been completed by June 12 at provincial labs, accounting for one test for every 13 people in Alberta. By comparison, British Columbia with close to a million more residents than Alberta had conducted just over 165,000 tests. Ontario conducted one test for every 15 people, Quebec one for every 16.
Ohinmaa said if he was to criticize the province’s response it would be that they could have acted faster responding to outbreaks sweeping through long-term care homes.
“One of the problems seemed to be helping the long-term care facilities, they kind of delayed their response and extra funding. Probably, that was partly because it is not fully in control of Alberta Health Services,” he said.
“Looking backward, I think we did relatively well considering that our outcomes have been very good. If you think about the COVID indicators here in Alberta, they are one of the best in Canada.”
The government did, however, attempt to address outbreaks at care homes by limiting workers from being in multiple homes and topping up front-line workers in the facility with a two dollars an hour pay increase.
DOCTORS GO VIRTUAL
Many doctors moved their clinics online with virtual care to comply with physical-distancing recommendations during the pandemic. Originally, doctors said billing for virtual visits was 30 per cent less compared to billing for an in-person appointment, another source of tension with the government.
The province also launched a virtual care app alongside Telus called Babylon to encourage Albertans to seek online consultations with doctors, prompting further criticism from some physicians who claimed it would undercut overhead costs that clinics have to pay.
Physicians would later be permitted to bill virtual appointments at the same rate as physical ones, but Bisby, the doctor in Calgary, says there is still a cost discrepancy between virtual and in-person visits.
“Had I been in person with this patient? I would have probably billed around $200 for that 90 minutes. Because it’s all been done by phone, I believe I’ll be able to bill about $65,” she said of an appointment she conducted in May.
Bisby said that while the government has allowed for physicians to differentiate between calls lasting less than 10 minutes against those that last longer than 10 minutes, physicians will get paid the same amount for a 30-minute virtual appointment that they will for an hour long visit.
She said doctors are now having to lay-off support staff, which is forcing health-care providers to spend more time doing administrative work and less time with patients. In one instance, Bisby said, an appointment that should have taken an hour ended up eating four hours of her day.
Zaidi, the doctor who was yelled at by Shandro, announced in a public letter last month that he laid off two of his four staff members after billing changes and the shift to virtual appointments made his practice unsustainable.
He said he has had to charge for services he usually did not, such as doctor’s notes. Now he’s worried the system will become inaccessible to vulnerable populations in the future.
“People are desperate because they haven’t seen a doctor or gone to a clinic in three months. Now when they say I have three issues, you can’t just say well we only deal with one issue today,” he said.
Clement said despite its problems in Alberta, virtual care has been considered best practice in other jurisdictions and has been in place for years.
“It’s certainly not right for everyone, but I think in many of the systems we would look at as high-performing systems, there has been virtual care for close to a decade, if not longer. It’s working well and it’s liked by the patient but again it’s not exclusively virtual care,” she said.
Shandro said in early June that virtual care will continue past the pandemic.
FUNDING FRAMEWORK STILL NEEDED
As doctors continue to fight the pandemic, tensions with the government remain. Though some of the imposed billing changes have been paused or rolled back, Shandro hasn’t backed down.
“Our government is moving forward through the new funding framework for physicians that we announced in February,” Buick, Shandro’s press secretary, said in June.
Kenney said in early May that once the pandemic is over doctors’ pay will need to be addressed.
“While we continue to maintain and in some cases increase physician compensation, we must manage it in the future,” he said during question period in the legislature.
At the end of March, more than 800 physicians signed a letter demanding the changes to their compensation that were to come into effect in April be put on hold until the threat of COVID-19 passes.
The province had already cancelled changes to how much doctors could charge for longer visits on March 17, the same day a public-health emergency was declared. The health minister said at the time this was so physicians could focus on patient care during the pandemic.
Then in late April, the government reversed a plan to prevent billing for overhead costs outside a doctor’s clinic, a change that would be permanent for rural physicians, but only delayed for urban ones. Liability insurance was also frozen for rural doctors.
In early April, the AMA filed a lawsuit to try and force the province to restart negotiations.
Dr. Christine Molnar, president of the AMA, said her side has already made offers that included a five-per-cent cut in physician compensation but the government declined those.
She said the government making changes, then rolling changes back and imposing rates unilaterally, has deepened the lack of trust between the two parties.
“Forging ahead without proper consultation, and then pulling back on ideas here or there when it’s obvious that the warnings that they were given and didn’t listen to were true ... I honestly find that more frustrating, not less,” she said.
Buick said the government will consider any credible proposal from the doctors’ association as long as it allows them to keep physician spending at $5.4 billion.
Complicating negotiations further, Shandro said in early June in the legislature that he will be reviewing whether there are ways to negotiate with physicians without the AMA.
MEDICAL FLIGHT
A number of doctors across the province have announced they intended to leave Alberta.
Dr. Will White from Calgary, who authored the letter signed by 800 doctors protesting billing changes, recently told Postmedia he is now planning on leaving the province to practice elsewhere.
Ten doctors in Lac La Biche said in April they could no longer afford to provide obstetrics services at the community’s hospital because of billing changes.
Then in May, Dr. Melanie Young, a physician in Fort Mcmurray, said she would be leaving the province over instability in the health care system.
Nine doctors in Athabasca and eight in Sundre have followed suit, making announcements of their intentions to leave the province or withdraw services once the pandemic has ended. At least 20 communities have seen doctors announce they will be reducing or cutting their services.
Bisby in Calgary said the most pressing issue between doctors and their employer isn’t money, but a lack of trust in the workplace from the government implementing their own funding formula when a mutually agreed upon one couldn’t be found.
“I think that the government actions are actually more worrisome from kind of a long term uncertainty perspective,” she said.
FUTURE COSTS
With cost-cutting measures expected in the future, medical professionals are worried the government should be providing additional support as they attempt to clear up the backlog of postponed procedures.
AHS has begun to reschedule surgeries as physical distancing restrictions are loosened, with 26,000 to 30,000 urgent and non-urgent surgeries expected to be performed between the beginning of May and mid-june. The numbers account for between 70 and 81 per cent of the typical volume of surgeries in Alberta compared to rates from before COVID -19.
Atwal, the AHS spokeswoman, said between 20,000 and 25,000 procedures were postponed and approximately 76,000 people were waiting for surgeries as of May 25. She did not say how long AHS expects for the backlog of procedures to clear.
Buick, Shandro’s press secretary, said the government remains committed to maintaining or increasing health spending while reducing surgical wait times and continuing to find efficiencies within the health-care system.
“As we begin the economic recovery post-pandemic, we must continue to manage taxpayer dollars in a responsible manner and maximize value for taxpayers wherever possible,” he said.
He did not expand on the government’s plans when asked how they will find efficiencies while the pandemic applies added pressure on the health-care system.
The government paused negotiations with the Alberta Union of Provincial Employees and the United Nurses of Alberta at the end of March and extended job protections for nearly 6,000 employees, including 750 nurses, that were potentially going to be cut, the CBC reported.
Bisby said on top of the delays in hospitals, the public has been reluctant to visit their doctors for checkups or non-urgent issues during COVID-19.
“There’s going to be a flood of patients now who have put off seeking care and probably need it more urgently and doctors are kind of in a weaker spot to manage so how is that going to play out,” she said.
Bisby also said family physicians have to pay out of pocket for the additional personal protective equipment that is needed to treat people with COVID -19 symptoms.
Dr. Natalie Forbes, a pediatrician in Calgary, said she has seen a backlog of patients that she cannot fully assess over the phone.
“We have a whole slew of kids waiting to be seen as new patients and I can’t really do a good assessment on them over the phone so that you know in terms of COVID it has significant impacts with delaying kids getting diagnosed with things like speech-language delay or other developmental problems, because we can’t see them in person,” she said.
Forbes said many of the kids she sees come from underprivileged neighbourhoods.
“I’m asking families who can afford it, and that’s not most of my patient population, to look at private services because weirdly, weirdly, the private services are still somehow doing their work and they’re doing it remotely,” she said.
Shepherd, the NDP’S health critic, is calling for further increases in funding to help offset these costs.
“We were calling early on for surge funding for long-term care. We were calling for ensuring that the funding was there to support people on the front lines,” he said.
He also said he remains worried about further cuts to the government’s budget once the pandemic is over, to deal with lost oil revenue.
Ohinmaa said these forthcoming costs are all the unfortunate consequences of policy that needed to be made. While he couldn’t put a dollar figure to what the backlogs and increased funding would cost the government, he did predict they would be “quite substantial.”
“That happens everywhere in every province, every country. So every government needs to know, just take those costs and do their best to protect their population and economy,” he said.
People … haven’t seen a doctor or gone to a clinic in three months. Now when they say I have three issues, you can’t just say well we only deal with one issue today.