2022-23 Mid-Year Update: New Activities

Implementing the Agreement

• Working with AHS to improve the relationship with physicians while leveraging AHS managed programs towards improving/stabilizing physician practice in AHS facilities.
• Stipends - Through the joint working group, develop and implement a process to review the current stipends paid by AHS and make recommendations to the management committee on the disposition of each group, based on the principles outlined in the agreement. This work is likely to extend beyond the current year and must be completed no later than March 2025.
• Overhead arrangements - Develop and conduct a review process to determine the amount of overhead fees in agreements between AHS and physicians. This work is likely to extend beyond the current year and must be completed no later than April 2024.

• Stipends - The newly ratified AMA Agreement extends stipends to March 31, 2025. Schedule 6 provides for a Stipend Working Group to develop a process to review current stipends paid by AHS to physicians and allows for an independent chair to make a decision, should the parties fail to reach consensus. A recommendation is made by the working group to the Management Committee and subsequently to the Minister. 
• AHS has asked the AMA to think about a side process, outside of Schedule 6, for physician groups already in the process of exploring a clinical ARP. The stated intent of the side process is to allow for willing physicians to transition towards new arrangements without having to wait six to twelve months for the working group to come together. AMA has sought a legal opinion on this. The established process involves first determining which stipends provide payment for non-insured services and which are a double payment (i.e., covered by the SOMB). The legitimate stipends will continue until replaced by another payment arrangement. Those physicians who wish to move to an ARP can do so and their stipends will end. Those who do not, or who are not happy with the ARP being offered will continue on stipends until replaced or the deadline of March 31, 2025 is met or another arrangement is arrived at. It is unclear if AHS or AH share this view.
• A MOU between AMA and AHS outlines an AHS-AMA Engagement Framework on Physician Compensation Related Matters within AHS Facilities to address issues through a process of engagement (negotiating, renewing, extending) within the best interests of patients and the health system. The parties may, through mutual agreement, appoint mediation and/or arbitration to help resolve the issue.

• Complete the IEI measure - In preparation for the rate review beginning in 2024-25 we will complete the following this year:
• Bring together information from all studies (Hours of Work, Overhead, Training, etc.) and calculate the complete IEI measure.
• Complete the physician panel review and external technical review.
• Prepare the dispute resolution process.
• Deliver the complete measure to RF in September for preliminary endorsement.
• The remaining steps to be completed before the end of 2024 are resolving any disputes and member ratification.

• AMACC continues to develop the full Income Equity Measure for fall 2023 RF. AMACC recently discussed proposals to enhance overhead measurement and expand compensation elements to include Business Cost Program payments and clinical ARP/AMHSP compensation. AMACC monitored the analysis of the Hours of Work study log data and made recommendations related to incorporating these data into the full Income Equity measure. AMACC’s near-term focus is on ensuring that all factors (compensation, overhead, hours of work and training career length) are aligned in the full Income Equity measure. 
• The Institute of Health Economics presented an overview of the final Market Report at the December AMACC meeting. The report shows the analytical relationship between Alberta fees and service provision. The study provides contextual information required to address the 2017 RF motion calling for any income equity adjustment based on ANDI model or variant to factor in physician supply and patient access. This report is included in the Spring 2023 RF package.
• The two key messages from the IHE report are:
  • As compensation rises in the fee‐for‐service environment, physicians tend to work more. 
  • No difference in the magnitude of the response between fee increases and fee decreases was found but the report noted there were limited instances of fee decreases in the dataset.

• Market/rate review - Develop and move forward with a strategy to properly prepare for and undertake inter-provincial review of SOMB, ARP and AMHSP rates in preparation for the rate review beginning in 2024-25.

• Senior AMA staff have initiated development of a framework to ensure there is alignment between the various aspects of the AMA Agreement: market/rate review, global reopener negotiation, Income Equity Initiative, other system initiatives (recruitment and retention of physicians, primary care initiatives, ASI, etc.). This will include the following:
  • Development of a set of principles to guide the strategy (e.g., various components should work together to support system goals and not work against each other).
  • Description of the alignment between various components of the agreement and initiatives underway. As an example, how does the results of the fee review and Income Equity Initiative feed into allocation? 
  • Determination of how the AMA will support sections in the market rate review (fee and ARP/AMHSP comparisons, overhead differences, differences in service delivery, etc.).
  • Development of a common information strategy with government. What sources of information will be used to inform the market rate review, reopener negotiation and allocation, where are the gaps and who will they be addressed?
  • Plan for advancing these concepts with Alberta Health at the Rates Committee and Management Committee.
  • Communication plan to socialize concepts among sections, RF, AMA membership.
• Immediate priorities are to implement the 2022-23 and 2023-24 allocations (currently underway) and to work with sections on their 2024-25 allocation priorities in advance of the market rate review.

• Other specified AMA Agreement deliverables include:
• Daily visit caps
  • Temporary removal of caps
  • Complete an evidence-based assessment of future rules for implementation April 1, 2023. 
• Business Cost Program - Implement rate increases November
• Rural Remote Northern Program review - Identify critical communities and recommend strategies for addressing supply issues by January 2023.
• Secure access to benefits for Medical Examiners.
• Virtual care codes
  • Mental Health implemented January 2023
  • Review of remaining items by March 2023
• IMIT funding
  • Develop program parameters to support physicians with IMT-related change management by December 2022.
• One-time COVID payment
  • Issue the one-time payment to physicians by December 2022.
• Benefit programs
  • Launch the 2022-23 Continuing Medical Education program.
  • Launch Medical Liability program.
  • Launch General Practitioner special skills locum program.

• Daily visit caps: Parties agreed with the approach and was announced on November 21, 2022. Ministerial Order was signed with change effective December 1.
• Business Cost Program: Process and timing for retroactive payments is being discussed. AH will share a bulletin when ready and AMA will send a PL out to its members on this issue.
• RRNP: AH and AMA are proceeding with identifying communities and developing parameters.
• Secure access to benefits for Medical Examiners: Both parties have reviewed this issue and provided input for consideration by Management Committee at its March 3 meeting.
• Virtual Care Codes: Under the terms of the new AMA Agreement, AH and AMA have committed to a joint review of virtual care to be completed by March 31, 2023. As part of this, a review will be undertaken of mental health virtual care codes. This portion was to be completed by November 30, 2022, with a ministerial decision by January 1, 2023. AH is currently analyzing the costs and implications of implementing the various priorities and will be preparing a Rates Committee proposal for consideration.
• IM/IT Funding: IM/IT Working Group met on January 31 and will provide a report to Management Committee in March.
• One-Time Payment (COVID): Grant executed December 15, 2022, funding provided December 20, payments issued to physicians December 23.
• CME Program: 2021-22 CME program administered by government is completed. Approximately, 8,500 applications were received by government. The 2022-23 program, administered by the AMA will be launched in March as soon as the grant agreement is signed with government.
• MLR Program: Alberta Health expects to make top up payments for the 2022 Canadian Medical Protective Association year in March, for those that were paid based on a higher deductible (the deductible was reduced to $1,000 for all physicians under the AMA Agreement). The 2023 MLR program will be administered by the AMA and will launch in April as soon as the grant agreement is signed with government.
• GP Special Skills Locum Program: Locum grants are being finalized and the program is expected to formally launch in March.

Policy Initiatives and Opportunities

• Modernizing Alberta’s Primary Health Care System - We will provide coordination and support to physician leaders advancing short and long-term proposals under government's MAPS initiative, encouraging alignment across stakeholder groups and with the AMA Agreement (e.g., use of targeted funding).

• Since September 2022, the AMA has participated with others in Modernizing (M) Alberta’s (A) Primary Care (P) System(S), initiated by the minister with core support from Alberta Health
• AMA participation has largely been through:
  • The Board approved budget and staff (ACTT plus others) resources to support physician leader participation, including support for research and a coordinating group chaired by Dr. Brad Bahler and the AED, ACTT.
  • AMA sections have provided input: Primary Care: SFM and SRM Other sections: SCA.
  • Other groups that have strong AMA connections and which have provided input to MAPS include: PCN Physician leads executive; Provincial PCN Committee (PPCNC); medical student representatives.
  • At this stage (February 2023) AMA input and collaboration is largely reflected in four MAPS proposals:
    • Seven short-term proposals submitted by various members of the coordination group set up within AMA.
    • An SFM, SRM, PCNLE proposal, “Team-Based Funding.”
    • An SCA proposal, “Linkages Between Primary Care and Specialty Care in the Health Neighbourhood.”
    • Provincial PCN Committee Proposal.
• Physicians have been well-served by the physician leaders involved. The review process now underway includes significant physician leader input.
• There is much in common between the AMA-led proposals in assessing challenges and recommending improvements to the primary health care system. Differences relate mostly to the priority and timing of some of the steps or the degree to which they should implemented. 
• We believe that there is more than enough of a consensus to begin acting. Significant steps should be taken now with the intent to monitor and adjust as needed. MAPS needs to become about strategic action and not just strategic planning.
• The alliance between primary medical practices and PCNs needs to be strengthened, by enhancing the support to each and improving the relationship between them:
  • There is an urgent need to provide additional support to physician practices given the financial and service delivery challenges they are facing and the increased national competition for primary care physicians. Ensuring Albertans have access to the primary care physician resources within viable and sustainable practices should be a principal focus for MAPS: all other aspects are dependent on this for their success. 
  • PCN one-time funding and the funding review should be priority in ensuring they have the resources to meet demands, explore new opportunities and initiate approaches to expanding the medical home.
  • Means to strengthen the relationship between the primary medical home and PCNs should be explored.
• The physician – PCN alliance needs to broaden so that it can serve as the foundation for a health home for all Albertans. 
• New investments and relationships within primary care will impact on the roles, responsibilities and accountabilities of physicians. Support for these changes will be essential.
  • Performance measurement and management.
  • Accountability of PCNs to physicians and vice versa.
  • Physician roles and responsibilities within team settings.
• Primary governance will need to evolve and mature. Initial steps should be taken now to strengthen individual players and partnerships with an eye to developing a new model of overall governance.

• Primary Care Network Funding Review – We will provide coordination and support to physician leaders participating in the minister's PCN review working group, encouraging alignment with proposals developed as part of the MAPS project, and mechanisms available under the AMA Agreement (e.g., targeted funding, allocation, etc.).

• There are two groups active on PCN funding, as per the agreement commitment letters.
• Short-term group to review and recommend on the $40 million for PCNs in the next two years.
  • The group is recommending the first $20 million be allocated for the April 1, 2023-March 31, 2024 fiscal year for PCN grants. This will allow the PCNs to plan now and use the money in the coming fiscal. This group is reporting to the Provincial Primary Care Network Committee (PPCNC). 
  • An extension for the additional $20 million in year two is being requested so that it can be allocated in the fiscal year April 1, 2024- March 31, 2025.
• The long-term working group is working toward recommendations to be submitted to the minister by March 31, 2023. PCN physician lead executive and Section of Family Medicine physician representatives are members of this group. 
• A technical task group has been created to support the work and the deadline of March 31. This group has AH, AHS and AMA ACTT staff as members.

• Alberta Surgical Initiative – We will provide coordination and support to AMA physician leaders involved in the governance structures of the Alberta Surgical Initiative, encouraging alignment with activities advanced through other initiatives (e.g., MAPS project).

ASI Governance: 

• ASI governance 2.0 has ended. Discussion is ongoing with Alberta Health and Alberta Health Services on evolving the governance structure as well as an operational oversight model for some of the program services and AMA is advocating to ensure physician input at all levels of the governance structure. 

Specialty Access Physician Leads: 

• AH supported the use of AMA ACTT grant funds to hire Specialty Access Physician Leads for each zone and are supporting them in their work on the ASI bundle projects (Electronic Referral Solution, FAST, Pathways, Advice, Pre/Post Care). Each lead is developing subject matter expertise on a project and will be representing Primary Care at respective Coordinating Committees.
• The leads are building relationships in the zones (PPACs, PLE, PCNs) and with PMH Physician Champions to coordinate change management activities.
• The funding for these positions ends on March 31, 2023; AH and AMA ACTT are considering the use of surplus funds to extend the Specialty Access Lead funding for the next year. 

Specialty Access Bundle Work:

• AHS is looking to launch the next round of working groups in March which includes General Surgery, Gynecology, Thoracic Surgery, and Vascular Surgery; Specialty Access Physician Leads are taking on recruitment efforts on behalf of Zones.
• Co-Design Sessions are being held March 22-23 to support the ASI Specialty Access Bundle work (specifically around advice, clinical pathways and referral pathways). 
• The ACTT team is developing supports for clinic-level change management.

Government Relations and Advocacy

• With an Agreement in place, we have an opportunity to work collaboratively with government to improve the system, while continuing to hold them accountable. We will create opportunities for members to engage in government relations and advocacy in several areas including:
  • Agreement and Implementation: Members who engage to advance physician financial viability (their own and that of their colleagues) and support patient care.
  • Governance and Leadership: Members who engage to be part of building up the profession and their roles in society.
  • Advocacy: Members who engage and are motivate by active advocacy for patient care.
  • Government Relations: Members who engage because they want to affect their local environments and communities.

• Much of the government relations activity has been at the staff-to-staff relationship level. 
• The President has spoken regularly with the minister and helped to convene important meetings with sections of emergency medicine and pediatrics to discuss the untenable situation in patient care.
• We have continued to engage in social media advocacy on topics relating to the agreement and health care, building on existing momentum. We have had a major push to promote awareness of physician burnout and the extreme pressures on our emergency departments and hospitals due to backlog and an unprecedented respiratory tridemic virus season. We have strongly encouraged Albertans to do their part to follow public health and safety guidelines for immunization, handwashing, masking in close spaces and staying home when ill. We have had extensive social media engagement and traditional media coverage. 
• A strategy for the provincial election has been developed and will be shared with the Spring RF.

Rebuild and Reconnect

• In addition to the activities already listed in the healthy AMA portion of the business plan, we will be looking at opportunities to strengthen section governance, improve the diversity of our physician leadership and enhance transparency across all levels of the organization.
• We will also be strengthening our connection with members by enhancing some of our existing touchpoints and creating new opportunities for members. Some examples include:
  • Reviewing how we use social media to keep members and the public informed and advocate for physicians and patients.
  • Reviewing the content and format for the Annual General Meeting and other events throughout the year, to provide opportunities for members to ask questions of leadership and celebrate milestones.
  • Investigating mechanisms for improving transparency with members from all levels of leadership.
  • Reinvesting in our member tracker surveys to monitor member sentiment and connection to the AMA. 
  • Being timelier with information disseminated to members through President’s Letters and direct email. 
  • Supporting members directly on the broad range of activities outlined above.

• A panel presentation, outlining activities planned to strengthen members' connection with leadership including work being undertaken by the Governance Oversight Group to assess what governance best practices are in place and what additional supports may be needed. 
• A Transparency Working Group is being established to investigate opportunities for improving transparency with members from all levels of AMA Leadership. The terms of reference will be presented to the RF in March.
• The Annual General Meeting working group has met several times to review options to improve the effectiveness of the AMA AGM and will make its final report to the Board in April.
• The member tracker survey was relaunched in January 2023, which will provide important insight into the interests, concerns and sentiment of members.
• Equity, diversity and inclusiveness training is now mandatory for all AMA hiring committees.