It is unsurprising that Albertan physicians rejected a tentative compensation agreement reached by the Alberta Medical Association (AMA) and the government after lengthy and acrimonious negotiations given the actions of Health Minister Tyler Shandro and the terms of the proposal. As the parties announced on March 30, of the 59 per cent of physicians who voted on the agreement, 53 per cent voted against ratification.
Since late 2019, the government has implemented a number of policies that target and alienate physicians. These policies include billing number restrictions, fee code changes (to complex modifiers, clinical stipends, daily volume caps, etc.), termination of the previous compensation agreement prior to its expiry, and directing the College of Physicians and Surgeons of Alberta to strengthen rules on the closing of medical practices in response to physicians leaving the province. The government also introduced Telus Babylon, a virtual-care platform that competes for patients with family physicians. Many of these policies were implemented without appropriate consultation with the AMA.
Shandro fostered a climate of distrust and disrespect by accosting a physician outside his home, blocking dozens of doctors on Twitter, and making inflammatory public statements about physicians. For example, to garner public support for his aggressive cuts, Shandro publicly announced that Alberta doctors make 35 per cent more than their peers in other provinces. When the AMA pushed back against his flawed numbers, he responded with sunshine list legislation intended to inflame public sentiments about physician pay.
Another reason for the rejection of the agreement was that the terms were largely unfavourable to physicians. For example, the agreement provided for non-binding mediation rather than binding arbitration as a dispute-resolution mechanism. Furthermore, if ratified, the AMA would have had to discontinue its legal claim against the government seeking binding arbitration pursuant to the Charter right to freedom of association.
The agreement also capped the Physician Services Budget (PSB) at $4.571 billion for the next two years. This would have been a relatively hard cap that allowed for increases only in limited situations. Furthermore, the agreement permitted reductions to the PSB and empowered the minister to shift expenses between the Alberta Health Services budget and the PSB, for example, by “bundl(ing) related services through a competitive contract.” It also provided that the PSB would be monitored and, where projections showed that billings would exceed the budget, physician payments or portions of payments could be withheld, for example, on the basis of geography or specialty.
The PSB encompasses both traditional fee-for-service billings and other funding arrangements, including payments for physician services delivered by corporate-run virtual platforms and in privately operated surgical facilities (which will perform 90,000 surgeries per year by 2023). The latter funding arrangements raise concerns of unnecessary care and supplier-induced demand, for example, through aggressive advertising campaigns by Babylon, and allow these providers to draw from the same finite PSB. This might unfairly disadvantage physicians who rely on traditional fee-for-service billings.
The concessions to physicians in the proposal were comparatively minor. For example, they would receive approximately $200 million in one-time funding for physician grant programs such as virtual codes. This figure purportedly represents the amount of money saved when billings were down due to COVID-19. Physicians would also be given a seat at the table in discussions on issues such as budget management, physician supply and physician compensation. The value of this concession depends, of course, on the extent to which the minister would be willing to collaborate and consider their views. Finally, the agreement would have been exempted from legislation that permits the government to terminate an agreement with the AMA. It is unlikely, however, that the government would have applied this power to an agreement that favoured its bargaining position.
Although 47 per cent voted to ratify, it is likely that some of the yes votes were cast reluctantly, due to fatigue from fighting with the government, wanting the potential stability of an agreement, and/or concerns with punitive actions following a no vote. For physicians whose practices took a financial hit during COVID-19, funding for physician programs might have been influential.
Those who voted against the agreement likely were influenced by the minister’s combative behaviour and the patient-care and financial implications of the agreement. Some may have also been concerned that ratification could imply approval of the government’s corporatization and privatization agenda for the health-care system or about the uphill battle they would face in future negotiations trying to regain things they negotiated away, like an uncapped budget and arbitration. Physicians may have also been concerned about losing the political capital to push back against budgetary decisions if they voted yes, as the government could dismiss criticisms by noting that the changes were in accordance with what they had agreed to.
In the days leading up to the vote, the minister announced funding for rural recruitment, acknowledged he made a mistake by cancelling complex modifiers, and expressed regret about statements that trivialized physicians’ concerns. It is unclear whether this newfound contrite attitude is sincere and whether he will bring it back to the bargaining table.