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Associate Clinic doctors make tough call

Tuesday, 21 April 2020. Posted in Shootin' the Breeze

Associate Clinic doctors make tough call

By Shannon Robison

Physicians of Pincher Creek’s Associate Clinic will discontinue hospital-based services once the community gets through the COVID-19 pandemic.

Consideration of local impact was given to the difficult decision announced this week by Dr. Cathy Scrimshaw, Dr. Tobias Gelber, Dr. Gavin Parker, Dr. Bev Burton, Dr. Tracy Burton, Dr. Jared Van Bussel, Dr. Ashley Rommens, Dr. Daniel Ruttle and Dr. Samantha Myhr.

Dr. Myhr says changes imposed by the provincial government make it financially unsustainable to keep the clinic running in the same capacity and to provide extended services such as emergency duties, inpatient treatment and obstetrical care under the new physician funding model.

Details have not yet been finalized, but it is likely that most, if not all, of the clinic’s nine physicians will discontinue extended services in July unless the government reverses the changes implemented April 1.

A number of physicians from Stettler, Sundre, Lac La Biche and Rocky Mountain House have recently resigned emergency room practising privileges for the same reason.

The Rural Sustainability Group, of which Dr. Myhr is a member, says 41 more communities will be impacted by July as announcements such as this continue to be made. 

The grassroots organization issued a press release Monday asking the provincial government to suspend its new funding framework during the COVID-19 crisis and to work with the Alberta Medical Association on an agreement that considers the unique needs of rural communities.

In a press conference Tuesday, Rachel Notley, leader of the Official Opposition, encouraged rural United Conservative Party MLAs to weigh partisan loyalties against the needs of their constituents, and to enact a solution within their caucus. 

Ms. Notley proposed a three-part solution similar to what many Alberta physicians have been asking for — to restore the previous contract with doctors on a temporary basis; to enter into third-party binding arbitration with doctors to develop a new contract; and to repeal elements of Bill 21 that allowed the province to void contracts with doctors “on a whim.”

“What we are asking for is an honest and open attempt at negotiation as opposed to a rollback,” says Dr. Jared Van Bussel. “By first legislating Bill 21 to allow the government to renege on their contract, any further negotiations were clearly in bad faith.”

“The changes made were so tone deaf because they were made without discussion about what the province’s needs are and what the impact of unilateral changes would be on rural practice, and without any recognition of the steps the Alberta Medical Association has been making towards fee equity,” he adds.

“However, it is not because this was not communicated to them, as it was, through many different routes. This only goes to show that these decisions were made with intent, in keeping with the recommendations made in the Ernst & Young report. Pushed through under the cover of a pandemic.”

In the process, trust and communication were lost.

Local physicians shared concerns about how changes to the physician funding model could impact local medical care, and the community as a whole, at a standing-room-only town hall meeting held March 2.

Within a week, the community rallied with more than 350 written letters of support, which were presented to Health Minister Tyler Shandro and his principal advisor, Ivan Bernardo, at a March 11 meeting arranged by Livingstone-Macleod MLA Roger Reid. 

The Pincher Creek contingency at this meeting included Mayor Don Anderberg, Coun. Scott Korbett on behalf of the Pincher Creek Health Professions Attraction and Retention Committee, Dr. Tobias Gelber and Dr. Myhr. They were joined by MLA Reid.

Mayor Anderberg was disappointed the group had the health minister’s ear for only about 10 minutes of the allotted 30 after Minister Shandro took a call and left the room. Mr. Bernardo finished out the meeting and listened to suggestions presented by the group.

“They directly stated that physicians could have offered [the government] a ‘10 per cent cut across the board and they still wouldn’t have taken it,’ ” Dr. Myhr says in reference to the outcome of the meeting. “This statement solidified fears that it was never just about money and that the government was not going to listen to our input on where cuts could be made safely.”

Coun. Korbett adds, “It seems they had an agenda before they started negotiations, and are working hard to keep that agenda without collaborating with important parties that are affected by everything we work on.”

Mayor Anderberg agrees that there is more going on because, for him, things don’t add up.

“We keep hearing that they are not cutting pay for doctors, but we know they are cutting pay because we’re talking to our docs here and they’re not going to make as much money, so that’s a cut in pay,” he says.

“There’s more to this than doctors’ pay and it’s absolutely mind-boggling,” he adds. “If you’ve got the same budget as before and you’re going to pay that much money out, and you’re paying these doctors less money, where’s the rest of the money going? What’s really going on here?”

In the initial announcement of the changes and in response to subsequent inquiries, Minister Shandro and Premier Jason Kenney have both stressed that the previous $5.4 billion of spending on physicians is being maintained. The budget for physicians has remained unchanged since 2018-19.

Some critics of the funding model change have pointed out that an unchanged budget allocation means no allowance for increases in overhead and cost of living and, in effect, amounts to a cut even though it hasn’t been called one.

Dr. Van Bussel notes the statement that there is no pay decrease, overall, has become a frequent talking point. 

“Physician fees staying at $5.4 billion budget means that any growth in population and increase in need in a population that is aging and becoming more complex requires more overall work at less pay,” he says. 

“This is without considering inflation or cost of living increases to staff, higher staff wages in Alberta, or that physician fee reduction results in a much larger reduction in percentage of take-home income. And if due to pay cuts or physicians leaving, the cost is lower than budgeted, this will not be returned to physicians.”

Alberta physicians have been grappling with financial uncertainty in the months leading up to the April 1 implementation of the new funding framework.

As the initial impact of COVID-19 was felt across Alberta, Minister Shandro announced on March 17 that changes to physicians’ payments for complex modifiers would not go ahead as planned at the month’s end. “During these unprecedented times, we want to ensure physicians on the front lines can focus solely on providing patient care,” he said. 

“Up until March 30 we had no idea what we would be paid to work in emergency March 31. It turns out it is now about 20 per cent less to do the same job as down the hall in our clinic,” Dr. Myhr says.

“They say we are double-dipping because we don’t pay overhead in the hospital,” she adds. “That may be true for someone who practises only in the hospital, but rural doctors still pay overhead in their clinics, no matter if they happen to be in emergency for a day. It was just another disguised cut that will have unintended consequences.”

Overhead for physicians includes staff wages and benefits, building rent and utilities, equipment, insurance and licensing fees. Like every business, the clinic must earn enough revenue to cover its costs.

“Our visiting specialists have already said they will rethink even coming out to Pincher Creek, or at the very least consider only doing surgery here and making our patients all travel to their clinic for consults,” Dr. Myhr states. “How could we expect them to work for less in our hospital when they are still paying the same bills for their clinic?”

As doctors around the world are dealing with the COVID-19 crisis, Alberta physicians are dealing with the additional burden of determining whether or not they can continue providing extended services to their local hospitals when the dust settles.

The Rural Sustainability Group announced Monday that preliminary results of its recent Alberta physician survey are alarming. Roughly 47 per cent of the over 300 doctors who responded have already been forced to decrease their hospital-based services by July, and more have indicated they will likely have no choice but to do so at a later date. 

Dr. Myhr says rural doctors account for about seven per cent of all Alberta physicians and the group estimates the survey reached 500 of them.

“These announcements are the canary in the coal mine and this government should treat them seriously,” Dr. Myhr adds. “It is difficult to attract and retain rural physicians at the best of times, and I fear that if these changes are not reversed soon, the damage to rural communities will be long-standing.”

Mayor Anderberg is proud of the high level of health care Pincher Creek residents enjoy but says it took many years and the hard work of many people to develop a system that works here.

While it will be business as usual in Pincher Creek for the short term, he is afraid of losing what has been built over the past 20 years and says other municipal officials share that fear.

Even in the current atmosphere, it is difficult to attract physicians to rural locations, and to retain the current status under the new funding model may prove challenging as well.

“This crisis is going unnoticed because it is happening site by site,” says Dr. Vicci Fourie of Westlock. “Rural MLAs have been strangely silent on this issue and seem forced to toe the party line. I hope our findings encourage them to speak up publicly for their constituents.”

Mayor Anderberg says interactions with MLA Reid have been positive and believes the MLA has some of the same questions the doctors, their community and their local government have.

“I work very hard to keep dialogue open with physicians in the riding in terms of bringing their concerns to the minister,” says MLA Reid. “I know it’s a tough time for them and I know the changes have been challenging, so we try to make sure that I hear how those changes have truly impacted our rural health care and their ability to operate a clinic.”

Based on a “great” rural caucus meeting last Friday, MLA Reid believes Health Minister Shandro is taking time to listen to rural concerns. 

“I think the points that we’ve raised with looking at the billing changes have to do with the nuances of rural practice,” he adds, noting that similar implications arise in terms of education, economic development, trade and tourism. 

“Myself and my rural colleagues do try to speak to that every time we look at a piece of legislation. We can’t paint everyone with the exact same brush … and legislation needs to be as equitable across the board as possible.” 

“I know the mandate of the minister of health and completely support the message that we need to bring our health-care spending under control,” says MLA Reid. “I’m adamant about that because the reality is, if we don’t, the first casualty will be rural health care.”

“Concerns raised are twofold, in terms of quality of patient care and from a business standpoint in terms of impact to their practices,” he says of commentary coming from clinics across the constituency. 

“There’s an intimate level of care that we benefit from in our smaller communities — our docs and our front-line staff are fantastic, the level of care is personal and sincere, and patients aren’t lost in the shuffle like they can be in the city,” he adds. As a rural resident, this is something he appreciates.

MLA Reid says he will continue to communicate with Livingstone-Macleod physicians and take their concerns to the health minister.

The Town of Pincher Creek is actively supporting its physicians. A resolution was passed at town council’s April 14 regular meeting to request that the Alberta Urban Municipalities Association board engage member municipalities in developing an advocacy strategy.

The call is for AUMA to advocate for the immediate reversal of wage cuts that came into effect in the fall of 2019 and on April 1, 2020, “to ensure the continued and proactive health care for our rural communities, and to support the physical and mental well-being of our local physicians and health-care workers who may be concerned with potential layoffs, while simultaneously putting their own health and the health of their families at risk to save lives of Alberta residents.”

Mayor Anderberg says AUMA president Barry Morishita is fully in support of this action as the same thing is happening in his community of Brooks.

“This isn’t good for rural health care,” Mayor Anderberg adds. “It’s not right and we deserve in rural Alberta the same health care as people who are in larger centres.”

“Rural doctors do not want to be faced with these choices in the midst of a global pandemic,” says Dr. Ed Aasman, president of the Alberta Medical Association Section of Rural Medicine. 

“Unfortunately, the government changes have created a completely avoidable health crisis that makes the way we currently practice unsustainable. We can no longer do it all and, when the pandemic has passed and we return to regular practice, many rural doctors have to modify their services to keep their clinic lights on and doors open.”

The nine doctors of the Associate Clinic serve a population of about 10,000 from Pincher Creek and surrounding area — community members are relying on their expertise and personalized care during the COVID-19 pandemic.

“Now is not the time to be attacking front-line physicians,” Dr. Myhr says. 

Doctors here are immersed in the community and have felt demoralized by the provincial government’s decision to put through changes that have significant negative impact on their practice during such a challenging time.

Dr. Myhr is hopeful today’s announcement will draw attention to the impact of these changes on rural communities like Pincher Creek, and will make the government see the importance of pausing these funding changes and going back to the table for further meaningful negotiation once the COVID-19 crisis has passed.

To date, there are no confirmed cases of the novel coronavirus in Pincher Creek and doctors have put considerable effort and time into planning their local response and educating staff and patients. The majority of regular appointments are being managed through telephone calls and the emergency department is open as usual.

Dr. Myhr is hopeful her community will understand these are difficult but necessary decisions to ensure high-quality care continues to be provided to patients through the Associate Clinic doctors.

The Government of Alberta has indicated it will find replacement physicians to fill the gaps in hospital-based services in other communities where doctors have announced similar changes, so the 90-day notice provides time to arrange for this.

Both Dr. Myhr and Mayor Anderberg stress there is still an opportunity for intervention by the provincial government, through a reversal of the changes implemented April 1, before the discontinuation notice comes into effect. 

This is their hope.

A letter to local residents from the Associate Clinic physicians was published in the April 22 issue of Shootin’ the Breeze.   https://bit.ly/3eIhPiA (See pages 3 & 4)

For more local news and features, check our home page www.shootinthebreeze.ca

April 22 issue https://bit.ly/3eIhPiA

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