OPINION | During a pandemic, Alberta imposes a needless burden on doctors

This column is an opinion from Juliet Guichon and Ian Mitchell,faculty members in the Cumming School of Medicine at theUniversity of Calgary.

A recently filed statement of claim by the Alberta Medical Association argues that the Alberta government did not negotiate meaningfully and in good faith about the terms and conditions under which Alberta physicians practise.

There has been much focus on terms (payment) for medical practice, but conditions are important, too.

Some altered conditions have been well described in media reports.

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These include changes affecting the Rural Remote Northern Program, which has been very important in helping to recruit and retain physicians in Alberta's rural and northern communities, where so many people want and deserve medical care. That program is threatened.

Another change involves the assistance that Alberta Health gave in paying part of medical insurance costs, which vary by type of practice. For example, family physicians pay fees related to what kind of medical work they do; if they deliver babies or work in the emergency department, they now must contend with less financial support for high insurance premiums.

As a result, some physicians have now decided not to deliver babies or to work in emergency. Such changes in terms of medical practice directly affect patient care.

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But there have been other changes in the conditions of medical practice that will affect patient care.

These changes have been mainly discussed in terms of income, but they have multiple implications on working conditions that have not been well described.

Changes to billing codes

The minister of health has made medical practice conditions more onerous by ridiculously changing the billing codes that reimburse physicians.

Complex and developed over time, medical fee codes recognize the physician's skill, training, difficulty of the procedure and time taken, among other matters. The codes are a short form way of describing the service and attaching value to it.

Fee codes are somewhat like the codes used in grocery stores for fruit and vegetables, but the medical fee codes are more complicated and the changes onerous to learn.

The new fee codes are described in a government document that is almost 300 pages long! Can you even imagine a grocery store chain changing the produce codes in the midst of a pandemic?

The medical fee code changes were imposed on April 1, as COVID-19 cases mounted, creating a workplace nightmare. The changes require doctors to use radically different codes to describe their work, and even to attend webinars to understand these codes.

A Byzantine world

Many codes used for a particular patient service can now depend,not on the service provided, but on where the activity takes place.

For example, if a physician sees a patient in a private office, then one fee code is used. If the same physician sees the same patient in a hospital to provide the same service, then a different code is used.

But wait, there's more. If the second encounter takes place in a hospital where the physician pays overhead by agreement, then the physician must return to the first code.

In this Byzantine world, we hear that the same bureaucrats and politicians who designed and imposed this plan do not understand it themselves.

Physicians who submit fees with the new correct code, (e.g. a physician in a hospital with an overhead agreement) have found that the submission has nevertheless been rejected. Round and round we go: resubmit, letter of explanation and possible acceptance.

A needless burden

Physicians know the existing codes; learning new ones takes a lot of time. Dealing with bureaucratic rejections is also time consuming.

These changes are a needless burden during a pandemic. Most physicians would likely take a percentage pay cut rather than cope with fee code changes when they are already using their leisure time for coronavirus education and to refresh their skills and knowledge on preventing infection transmission.

Forcing these changes during a pandemic is unethical, potentially dangerousand an avoidable managerial error.

Under Alberta's own ethics rules, it is unethical for the health minister to change the codes.

Alberta's Ethical Framework for Responding to Pandemic Influenza(2016)states that in a pandemic, "the health system is obliged to respond to the needs of the affected individuals, societyand health-care providers who put themselves at risk for the good of others."

In doing so, the system must abide by principles, including "working together," "reciprocity," "flexibility" and "good decision-making."

Let's look at each of those in turn.

If the health minister worked together with his partners Alberta's doctors then they would tell him that fee code changes are a major distraction during this public health crisis.

Reciprocity requires burden sharing. As the framework states, "health-care workers may face very heavy burdens in trying to help us through pandemic influenza; it is important to think about how to minimize those burdens." The health minister should actually reduce burdens, not impose new ones.

Flexibility means that, "plans should be adapted to consider new information and changing circumstances." Yet the pandemic, which obviously requires flexibility in dealing with the burden imposed on physicians, has not stopped the fee code changes.

And finally, good decision-making involves being open, inclusive, accountable and reasonable. Yet these attributes are difficult to find. In fact, this is not good decision-making, the consequences of which are only partially obvious now.

The consequences are many

Medical students and residents, who are currently seeking a hospital environment in which to practise, are observing the dedicated care provided by their mentors. But they are also observing a minister who is choosing this moment to impose a new burden on physicians.

These young people ought to form the future backbone of our health system, but might leave in disgust.

The consequences of the imposed fee code changes are many. They will likely encourage medical trainees to leave Alberta once qualified, they will take physicians away from patients and families, and, sadly, they will probably result in increased medical error which rises when physicians are tired and stressed.

What's more, this imposed burden is a managerial bungle.

According to management scholars, when headquarters personnel make decisions without the information held by people who actually interact with the customers, they can engage in the "tyranny of the head office."

Such a bungle can be remedied when decision-makers choose to dialogue with the front-line people and to change their orders accordingly.

Physicians, who are risking themselves and their families by tending to the sick during this outbreak, know how to do their jobs effectively and efficiently. Don't make them inefficient in a pandemic by changing fee codes.

Imposing such changes in the conditions of medical practice right now is unethical, potentially dangerous and managerial folly.

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