The COVID-19 pandemic is undeniably here. Most of Alberta is currently in the calm before the storm. We are doing the right things to prepare our hospitals, our medical staff and our province. Social distancing started early compared to elsewhere. If it is adequately embraced, we will hopefully be spared the worst effects other parts of the world are already experiencing. It is a stressful time for everyone, and we in healthcare are feeling it all day every day.

Yet while we prepare to be part of the front line against the coming storm, our stress is amplified by the persistent need to look over our shoulders. As we’ve been looking to the fight to come, we have little trust or confidence in our political generals, and are still bleeding from wounds they inflicted, and unsure how to deal with the bigger ones still to come. The Alberta government has not relented in their attack on physicians, despite the bluster of unity in political press conferences. You may have read otherwise in the media, and yes, as of this writing, after months of physician outcry, they have relented on one proposed change; delaying the reduction of complex modifiers (despite still claiming they should not be a problem). See this previous post for an understanding of why this will be so bad for primary care. A step in the right direction, but this is only one of many ill conceived changes that are still scheduled to come into effect on April 1, leaving many physicians unclear on how they will manage their businesses beyond that date. This coincides almost exactly with the period when we expect to see our health system beginning to strain under the load of Covid-19 pandemic patients. Physicians are far from the only ones facing significant economic uncertainty right now, but we are the ones being asked to put our own safety on the line for Albertans. Health care workers around the world have a higher infection rate than the general population due to our risk of multiple exposures (see here and here).

I’m busy with plans for how our local ER is going to cope, so I do not have time for details, but in brief these pending changes still include:

The loss of clinical stipends to support palliative care, trauma and other critical programs (note AHS has announced it will delay until August some of these cancellations given the pandemic. I suspect this was an AHS rather than direct government initiative and it does not include all stipend losses).

Daily “encounter caps” still mean many after hours walk-in clinics will need to close

Still undisclosed cuts to in hospital consultation fees that may make hospital work unsustainable for some specialists and rural physicians

More specific concerns as addressed in recent communications to government can be read here.

Even in the midst of pandemic planning, further stress has been put on Alberta physicians through the following developments:

On March 13, the Minister of health gave 1 year notice of termination of the contract with provincial radiologists, with the apparent intention of putting out a tender to have the province’s medical scans in the future read by the lowest bidder. This is a contract that was recently renewed in binding arbitration with a 12% fee cut. The full implications of this are not entirely clear, but one possibility is that the reading of diagnostic tests in Alberta could soon be filled by a cheaper overseas radiology “call center” of sorts. Would you rather have your MRIs, mammograms and CT scans read by Canadian trained and regulated radiologists, or the lowest worldwide bidder? As an ER doctor who relies on those reports to care for you, I know who I would rather have reading them, and who my lawyer would.

Social distancing is beginning to be achieved in health care throughout the country by the roll-out of “virtual care” fee codes. These allow your doctor to be paid when communicating with you through email, phone or video call to minimize face to face contact, and avoid clinic visits for at risk patients during the pandemic. It has been recognized throughout Canada as a key pandemic response. The fees need to be high enough to allow the doctor’s office to use them, and still pay overhead. Premier Kenney is fond of comparing Alberta physician billing to the rest of the country, so let’s do that here:

BC: $31 -$35 per visit

Manitoba: $38 – $44

New Brunswick: $45

Quebec: $49

Yukon: $51

Saskatchewan: $35

Ontario: $37 (> 10min), $68 per half hour of counseling

Health minister Shandro proudly re-introduced the old H1N1 pandemic virtual medicine fee, at the same old fashioned rate of $20, regardless of time spent. That’s 30-70% lower than anywhere else in the country. We have a few other pre-existing telephone fees that also pay about $20, but are limited to 14 uses per week. There are many Alberta family doctors on social media who are trying to protect their vulnerable patients during a pandemic by keeping them at home, and are right now operating at a loss to do so. Remember this money is used to pay clinic rent, utilities, staff and equipment.

This is completely unsustainable, especially in a pandemic. There are already clinics in Alberta that have announced or are planning a closure. We (speaking from the soon to be overwhelmed hospital front) need our community physicians to be able to stay in business and keep caring for Albertans! All your chronic diseases and usual day to day health problems are not going to be put on pause as easily as a Florida vacation. If family doctors, palliative care doctors and other specialists cannot provide good, comprehensive primary care – from their patient’s own homes when needed – we will further burden the acute health care system at the worst possible time in our provincial history.

[Update March 23: Today the Alberta government announced some additional temporary virtual medicine codes that are similar to regular office visits fees for both family physicians and specialists. There are a few significant restrictions including that the patient, not the physician must initiate the call, no time modifiers will be paid for longer visits, visits must last a certain minimum number of minutes to be paid, and there is no remuneration for additional administrative time including chart review, charting, prescription or consult letter preparation. They will not be subject to daily caps. This represents a definite improvement, and time will tell how clinics will adapt to survive a potentially prolonged period of “socially-distant” medicine with newly restructured rules governing their income.]

This is an unprecedented time. Everyone is suddenly either out of work or overworked, depending on what they do. Financial times are suddenly stark for many, and are going to get even harder – but is this the time to carry on with draconian and frankly completely uninformed tinkering of the health care system? By politicians who have shown no interest in listening to the experts about how that system works? Nurses have been told their layoffs will be delayed until after the pandemic. I’m sure they are grateful for the message that while they are needed to shield the province from harm they are at least temporarily of more value.

The Alberta government wants to renovate the house of health care. Instead of working with the architects who built that house, and the people who maintain it, they have come in and started unilaterally demolishing the foundation – primary care. We have spoken up loudly about it, insisting we can fix the house together, but that they are going about it the wrong way. They have persisted, and now a hurricane is coming – we are rushing to hold up the walls, leak proof the roof and make room to shelter more people. Meanwhile the government continues to dismantle the structure behind us.

It’s becoming clear that the UCP does not want this pandemic to delay their plan to reshape health care into an as yet unknown image. Have you seen the ads suddenly popping up in your social media feeds for virtual online health care in Alberta? Is that where the health care budget is going now – to these private companies? As I am writing this, Premier Kenney happily announced (on twitter) new partnerships with online health delivery companies to take care of your health needs over the phone or an app. Don’t be fooled – they are paying discount doctors a cheaper rate to do incomplete electronic medicals while a private company is pocketing the difference. Do you think that service will be an adequate replacement for your family doctor? What kind of health care relationship will you develop with this app while your GP who knows your health history and can actually physically examine you is being undercut and going out of business? This is one more thing that looks like it will save money in the short term, but will cost much more in the mid and long term because it destroys the patient’s medical home- the most health and cost effective tool in Alberta’s public health system. This government has proven itself incapable of understanding the basic principles of health care and health economics. They are dangerous.

We no longer have time to continue this asinine fight, but perhaps you are finding yourself with more time than you used to have. Perhaps you can take up the battle to defend our backs while we face the storm.

If you can,

Contact your MLA. There is growing feedback coming to physicians from some back-bench UCP MLAs that they are not happy with their own government’s approach to health care, especially once they understand the facts – that the system is going to suffer and health care is going to cost more. This is not ideological, it is math and basic health economics. We have been encouraged by some to continue our advocacy to THEIR bosses – the Minister of Health, Premier Kenney and whatever small room of yes men is setting provincial policy. Don’t accept willful ignorance or cowardice from your elected MLAs. It is their government, and its power rests in their votes. Their future jobs rest in ours. The UCP recently passed a bill limiting their own member’s ability to debate or comment on some legislation- the Premier does not want his own MLAs to speak up. Demand that they do.

Find your member of the Legislature and their contact information here.

Contact the Premier and the Minister of Health. Tell them you see through the propaganda, and insist that they acknowledge the problems that have been identified by so many physicians. Their response is always the same: “We are holding the line on health care funding.” “Alberta doctors are paid more than anyone else.” These are deflecting answers that ignore the problems in the details of their actions. Do you care what the total budget for your new house will be if the builder refuses to properly pay for the pouring of the foundation? It doesn’t matter how much you spend on the roof tiles, the house is going to collapse.

Premier Jason Kenny contact information

Minister Tyler Shandro contact information

Demand at the least that these changes be put on hold until after the worst of the pandemic is past. Invite them to then take that opportunity to collaborate with doctors and other healthcare providers who can help find the inefficiency and waste in the system, and who will continue to offer sustainable cuts to their own income in hard economic times – later, when there is time.

Demand our province raise virtual medicine fees to a level commensurate with other provinces, so clinics can stay open and avoid further layoffs while caring for patients in isolation.

Consider signing this petition, asking the government to see sense and delay the changes.

While you’re at it, please sign this petition, asking provincial and federal governments to please immediately implement a national plan to ramp up production of protective medical equipment. We will need it badly and the entire world is headed into an immediate severe shortage. What a great way to create some jobs in a crisis! Please consider speaking out about this.

If you want to get out of the house, please consider donating blood. It will be sorely needed for many, and is safe to go and do.

Please continue to follow the excellent advice and leadership of Dr. Deena Hinshaw, our chief medical officer of health. Thanks to her, and thanks to the blessedly wise decision of our Premier to follow her advice, Alberta has a chance to be more prepared, further in advance than much of the world. We hope it is enough, and we hope you will have our backs, while we do our best to protect the health of every Albertan.