PANDEMIC BUDGETING
UCP plan to cut doctors’ pay was already contentious. Then the pandemic hit. Here, Dylan Short examines how the government aims to control health spending while coping with the financial pressure of the pandemic.
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.
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.
“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.
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 healthcare 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 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.
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.
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.
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, 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.
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.
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,” he said.
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.
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.
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.
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.
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.
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.
David 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.
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.
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.