'My biggest fear is people falling through the cracks': Doctors sound alarm about proposed billing changes

The "severity" of proposed provincial changes to the waydoctors schedule, bill, and interact with their patients has prompted outcry from some Alberta physicians.

The changes would alter rates at which doctors can bill, fees for what are known as complex care plans, and changes to mandatory drivers' medicals for those aged 74 or older.

"I think the first thing that goes through my mind is that this is a blatant and horrible attack on primary care," saidJillian Ratti, a Calgary-based physician. "This appears very much as a cynical attempt to divide physicians right before negotiations, and I'm disgusted by that, frankly."

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The Alberta Medical Association (AMA)was informed of the changes on Nov.14, andgiven untilDec. 20to provide a response to the government.In a letter sent to AMAmembers, president Christine Molnar said the board had "deep concerns" about the changes.

"These proposals have a significant potential for patient harm," Molnar said. "They are directly against the platform that the government ran on."

"Additionally, some of the proposed cuts and ones we're quite concerned about will greatly impact adversely rural care," Molnar said. "These cuts are targeting rural Alberta."

Steve Buick, a spokesperson forHealth Minister Tyler Shandro, wrote in a statement that the proposed changes would help to get costs in line.

"Alberta is a great place for doctors to work and nothing in our proposals will change that," he wrote. "We spend $5.4 billion a year on physicians. Our spending is out of line with other provinces and we need to make some modest reductions."

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"These aren't modest reductions. But the way they've targeted these reductions is going to have an adverse outcome," Molnar said. "We've talked to them about the need for pursuing financial sustainability and quality care. You can do both if we work together."

Billing changes

The Alberta government has proposed changes that willsee doctors paid the same for a 25-minute visit as they are for a 15-minute visit. It is not yet clear what doctors would be paid for sessions lasting more than 25 minutes.

Dr. Kathleen Moncrieff, a family physician who works in northeast Calgary, said this will affect doctor-patient interactions.

"Right now, the way we bill in this province, there's a set amount for a family physician visit that's 15 minutes or less," she said. "But if it's longer than 15 minutes, you essentially bill more for each additional 10 minutes."

This isn't just cutting our salaries. This is cutting what we need to do to run our clinic.- Kathleen Moncrieff, Calgary family physician

Visits that last 15 minutes or lessare fine for addressing straightforward needs, such as diagnosing a urinary tract infection orrefilling a birth control prescription, Moncrieff said.

But many of Moncrieff's patients have multiple health complaints or illnesses, requiring a longer time slot.

"It doesn't make sense for me to say, I have 15 minutes to talk to you about your diabetes, and I have 15 minutes in two weeks to talk to you about your blood pressure or your asthma," she said. "Because you are a person, you're not a collection of illnesses or a collection of body systems."

As doctors at community medical practices are not employees of the government, they essentially function like independent contractors or business owners, Moncrieff said. Doctors have to cover the cost of running a clinic: from paying office assistantsand nurses, to rent, supplies and other overhead.

"This isn't just cutting our salaries. This is cutting what we need to do to run our clinic. The government doesn't pay for these things," Moncrieff said. "So the fact that we have had these billing codes that let us bill for the amount of time we take with a patient is what allows us to bring in the income that keeps our clinic running."

Complex care

The province is also proposing cutting funding for complex care plans, a billing system that supportspatients with complex or chronic conditions.

A person with diagnoses of diabetes, high blood pressure,and chronic pulmonary disease and who ispotentiallyquitting smoking and dealing with depression and anxiety is a typical example of a patient who would fall under this designation, Moncrieff said.

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Moncrieff said such visits allow for doctors to schedule long, involved visits with patients, family members and nurses to develop a plan to improve and maintain health.

"We'll sit together, go through all of their illnesses, go through all of their medications, go through all of their goals and really come up with a plan collaboratively," she said.

Without specific funding for such relationships, Moncrieff said she is concerned patients' needs will not be met.

"As physicians, we'll try to do our best but my concern is, economically, we won't be able to take the time that we have been taking because we need to bill enough to keep our clinics open," she said. "People's concerns will be missed, people's conditions won't be managed as well as they can be.

"Ultimately, it will lead to more complications from illnesses, more emergency visits, more hospital stays, which leads to worse health outcomes and also doesn't lead to any cost savings."

Mandatory drivers' medicals

Under Alberta Transportation guidelines, a drivermust pass a medical exam to keep theirlicence at age 75, age 80, and every two years after age 80.

Those evaluations testvision, hearing, cognitive ability and overall health of these individuals.

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Currently, doctors in Alberta are allowed to bill the government for those exams, but that would change under proposed regulation.

"The government is proposing cutting funding for that entirely, so that senior citizens would have to pay out-of-pocket for those drivers' medicals, which is very concerning to me," Moncrieff said.

Government response

Buick said the proposals would apply to all doctors, not just family practitioners.

"Nothing in our proposals will harm the ability of family doctors to give comprehensive primary care," Buick wrote. "The minister looks foward to working through the issues with the AMA at the bargaining table. We're not going to negotiate in the media."

Moncrieff said that, though she typically doesn't engage in politicson social media, she made an exception in this case out of concern for her patients.

"I think my biggest fear is people falling through the cracks and getting sicker because they aren't getting the care they need," she said.