Good Surgeons Plan Before They Cut, Minister Shandro

J. Edward Les, MD
Dec 18, 2019 · 7 min read

The Minister of Health acted in haste; he will repent at leisure. But the patients of Alberta will suffer.

December 18, 2019

Attention: Tyler Shandro, Alberta Minister of Health

Dear Minister Shandro,

I’ve writing to you today from my vantage point as a 15-year veteran of emergency medicine at Alberta Children’s Hospital.

When you were sworn in last spring as the new Minister of Health for Alberta, I was optimistic that this challenging and complex portfolio would be handled with skill and sensitivity.

You are an accomplished lawyer, not a physician. But you are the scion of a medical family: I knew you would be endowed with insights beyond those displayed by many of your predecessors.

Hence I was dismayed by your ministry’s sudden broadside against doctors.

The public had every reason to be confident that your government would be astute guardians of public health care. In the run-up to the election, with great fanfare, Jason Kenney signed a Public Health Guarantee — on a giant whiteboard — pledging to “maintain or increase health care spending” and to “maintain a universally accessible, publicly funded health care system”.

And indeed, your government’s maiden budget included a $200 million increase to health care funding. Promise kept.

But it was nothing more than smoke and mirrors, it would seem.

On November 14, away from the glare of television cameras, Alberta Health quietly dropped a lump of coal into the Alberta Medical Association’s pre-Christmas stocking, labeled “Insured Services Consultation”.

Your government intends to significantly cut the pay of family doctors and pediatricians by slashing compensation for complex and comprehensive care. By the AMA’s estimation, this change — along with others outlined in the briefing document — will reduce outlays to doctors by some $360 million, of which more than 70% will be borne by primary care physicians. Family doctors will, on average, take an annual $60,000 hit to their billings.

It is the patients of Alberta, however, who will suffer the most. Seniors, the medically complex, and those most in need of comprehensive care will be left stranded, forced to seek care in high-volume walk-in clinics that serve no one particularly well.

Given a severe cut to their pay but no cut to their overhead costs, conscientious family doctors will have little choice but to turn away from comprehensive care delivery for complex patients and toward a “turnstile” model of practice. Either that, or they will board up their practices and head for greener pastures more conducive to quality medical care.

Decreased access to skilled family doctors will ratchet up demand for emergency services, as patients turn to us for assistance. Aside from the fact that the ED is an extraordinarily expensive venue in which to deliver primary care, the pressure on emergency departments is already at fever-pitch. In my own sandbox of pediatric emergency care, visits have increased 26% over the past seven years — more than double the rate of population growth. I invite you to drop by my hospital’s waiting room one evening to fully appreciate the atmosphere.

The new cuts are set to take effect on February 1, 2020, barely six weeks from today. The AMA was given all of four weeks — in the run-up to Christmas — to offer a response via “consultation sessions”.

This is less “consultation” than rule by decree; it’s of a piece with Bill 21, which will allow your government to unilaterally terminate the AMA’s agreement with the Alberta government if we don’t limply take what we’re given.

These actions are disrespectful toward an honourable profession; they are careless of the public’s health; and they are unworthy of a mature and healthy democracy.

“Patient First” is the guiding mantra of Alberta Health Services. The AHS mission statement declares: “Our goal (is) to provide the best possible healthcare experience. What matters to you and your family drives everything we do. Every interaction. Every initiative. Every investment.”

But this ham-fisted strike against family doctors leaves patients dead last.

It’s fair to say, in light of all this, that Premier Kenney’s flamboyant Public Health Guarantee rings rather false, no matter how strenuously you sell it.

As the inimitable Judge Judy, an American member of your own profession, might put it: “Don’t pee on my leg and tell me it’s raining.”

I am well aware of the financial constraints with which your government is grappling.

I am — rather, was — squarely on your side. I voted for the UCP.

I’m aware that healthcare hoovers up almost 40% of governmental operating expenses.

I’m aware that we spend more per capita on healthcare than comparable provinces.

I’m aware that we get middling bang for all those bucks: health care outcomes in Alberta lag behind other jurisdictions in a number of ways, despite our province hosting the youngest population in Canada.

I’m aware that transformational change to our health care system is far overdue, that as part of that process, cuts in some areas must be made. Surgery is required.

But surgeons plan before they cut.

They don’t slice into patients without a clear understanding of the problem at hand and with no knowledge of the relevant anatomy. That would be butchery, not surgery.

You are operating, I know, based on the conclusions provided by Premier Kenney’s “blue ribbon” panel, which analyzed the state of provincial finances with a view to bringing the budget back to balance.

Given the enormous bite that health care takes from the provincial budget, one might have expected the inclusion of an experienced physician or two on that roster of experts.

Unbelievably, no physicians were recruited, let alone wise and seasoned doctors who have served on the front lines of patient care. Janice MacKinnon and the other panel members boast an impressive array of credentials in finance, business, public policy, and politics; but not one brought meaningful healthcare expertise to the table.

Consider, as analogy: After the space shuttle Columbia disintegrated during atmospheric re-entry in 2003, the space program was put on hold as an autopsy of the disaster was carried out. The panel that oversaw that forensic analysis was stuffed to the gills with experts in aerospace engineering. It had to be, or there would have been scant confidence in the inquiry’s conclusions, nor any reasonable expectation that future catastrophe could be avoided.

It’s no surprise, then, that the McKinnon Report’s foundation for “transformational change” in health care is wobblier than a two-legged stool. Making drastic policy changes based on this document is akin to surgeons attempting an appendectomy based on an accounting textbook: they’d be apt to remove the patient’s liver instead — if not his life.

The MacKinnon Report claims that physicians in Alberta are compensated at a rate 35% higher than the average of comparator provinces, but neglects to take into account higher payments physicians in those provinces receive via Alternate Remuneration Plans. With these properly included, the difference between Alberta and elsewhere shrinks to roughly 11%. Thirty-five percent makes for a splashy headline, but it’s a 200% error.

Add in the unique economic environment in Alberta, including higher overhead costs, and the remaining 11% gap melts away faster than snow in a Calgary chinook. And it’s worth emphasizing that remuneration in Alberta has consistently tracked below the province’s Consumer Price Index, going all the way back to 1971.

Are doctors overpaid? Certainly not from my vantage point.

Not hard on the heels of a hectic emergency department shift that ended with bringing an infant back from the brink of respiratory failure at 2 o’clock in the morning.

Not after fourteen years of university education and training and after erecting a skyscraper of debt in order to be granted the license to do what I do.

Not after paying back that debt, funding my own extended sick leave and trying to save adequately for retirement with after-tax income while raising four children (physicians pay a lot of tax: after all that schooling most of us are in the top tax bracket for the duration of our careers).

Doctors work, in the main, as independent contractors. Contrary to public perception, and in stark contrast to public employees, physicians are not vested with pension plans, dental benefits, drug plans, or paid maternity, vacation and sick leave.

The MacKinnon Report gets at least one thing right: “Hospitals are the biggest expense in the health care system and the costliest place to treat and care for patients.”

Surely, then, one of our main goals should be to keep patients out of those hospitals by investing in effective, comprehensive primary care, rather than taking a hatchet to the practices of good family doctors and community pediatricians.

As justification for removing fee modifiers for complex care, the “Insured Services Consultation” posits that such patients would be better served by Alternative Relationship Plans (ARPs). That may be so, but beyond vague lip service to the notion of ARPs, no strategies are offered and no metrics are provided as to how we get there from here — this with cuts to physician pay slated to take effect in six short weeks. Cut first, ask questions later — it’s like surgeons boldly opening patients without the foggiest idea as to how to close.

The only “Alternative Relationship” that is forming at the moment is one of fear and mistrust of this government by doctors. Which is deeply unfortunate, and wholly unnecessary.

The MacKinnon Report offers robust praise for “comparator” provinces: “The government should empower strong, strategic leadership to reform the current health system, using other provinces as models (emphasis added).”

Mimicking mediocrity is hardly “transformational”, I must say — the entire Canadian health care system, across all jurisdictions, can be summed up with four words, sadly: “Hurry up and wait.”

I urge you to take a breather, Mr. Shandro. Put the scalpel down for now. Your task is enormous, complex, and difficult. Take time to properly consult with doctors on the front lines and elsewhere before you proceed. Many of us have very good ideas.

Let’s get serious — together — about transformational change.

Let’s work to establish a Medical Home for each and every citizen of this province.

Let’s empower doctors to provide the comprehensive care that Albertans deserve.

And rather than emulating broken systems elsewhere, let’s do as we Albertans have always done: let’s build a model of innovation and ingenuity for the rest of this country to admire.

Respectfully,

J. Edward Les, MD, FRCPC

Emergency Physician

Alberta Children’s Hospital


Originally published at https://dredles.com on December 18, 2019.

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