Since 2018, family medicine in Alberta has been squeezed to the point of asphyxiation.
First, there were radical and unprecedented changes to family practice billing codes – codes that were the difference between economic viability and collapse for many family medicine clinics.
Then came COVID-19. For months, clinics were unable to generate any income, and some had no option but to close. Throughout the crisis, the remaining clinics had to adapt to a constantly changing world of expectations, information and compensation. Once the crisis settled, patients returned to clinics with higher acuity, more complexity and significant mental health challenges.
Right now, many family physicians continue to feel defeated, deflated, denigrated and significantly devalued by their health system. Some have closed their clinics. Some have stopped practicing full-scope family medicine in favour of a more reliable income. Some have moved into acute care facilities, working as hospitalists. Some have retired, some have left the province, and some have soldiered on – continuing, despite all the external pressures, to care for their panels.
We know that family medicine is the foundation of health care in Alberta and we have been part of a collective voice sharing this message. Family physician visits account for the majority of the daily encounters that Albertans have with our health care system, but only represents 8% of the total health budget. The number of family doctors accepting new patients in the province has plummeted from 887 in 2020, to 197 in 2023. PCNs have seen physician member numbers drop over the same time period. Fewer and fewer family medicine residents choose to practice community practice and we cannot currently replace our losses.
However, it now appears that Alberta Health is finally prioritizing primary care in a meaningful way. This is due primarily to the advocacy of multiple champions, including AMA, SFM, SRM, PCNs and ACFP, and with the release of the MAPS report.
What’s up with MAPS?
On October 17, the Government of Alberta released the long-awaited Strategic Advisory Panel final report entitled Modernizing Alberta’s Primary Health Care System or MAPS. This report was the synthesis of a commitment made in the most recent physician agreement between AMA and Alberta Health to address the specific needs of the primary care system. The report was hoped by many primary care physicians to be a beacon of hope in a long dark night.
And in a way, it is. The scope of the report’s 300-plus pages speaks to many areas of the primary health care system. It speaks to reorganizing primary care governance to achieve better accountability. It supports the patient medical home. It supports enabling the primary care workforce. And, critically, it emphasizes the need for investment in primary care.
Specifically, the report addresses some of the pressures that are unique to Alberta family and rural medicine practice. In particular, MAPS emphasized the need to:
- Increase the proportion of family physicians practicing comprehensive family medicine.
- Accelerate efforts to transition to non-fee for service (FFS) compensation models for primary health care providers who are interested by making the process easier while ensuring fair and equitable compensation.
Further, the report was unequivocal that the first priority for government should be stabilization of the current primary care system, including, but not limited to, the allocation of funding for immediate priorities.
What about immediate actions?
The release of the report on October 17 was accompanied by an announcement from AH on their “immediate actions”. These were disappointing to many practicing physicians as there was little that addressed the urgency of the current crisis in family medicine.
AH did commit to the creation of a task force, jointly led by the AMA, to recommend a new payment model for family physicians that “encourages and supports comprehensive primary care, reduces some of the administrative workload for providers, and considers other stabilization measures.” It is hoped this payment model will address the dark night that COVID-19 and fee restructuring helped create.
AH appears committed to link more Albertans to a family physician, improve access to primary care, and help Alberta train, retain and recruit a stable family physician workforce. The AMA, alongside other primary care partners (including the SFM, SRM, PCN Physician Leads Executive and the Alberta College of Family Physicians) all support these priorities.
Together, we are working to advocate with government about the urgent need to act. Without support to make family medicine clinics sustainable, the building blocks for MAPS and the medical home will not exist.
OK, so now what?
The model that is currently under discussion with AMA and AH is called a longitudinal family practice model, or LFP. This practice model is designed to incent longitudinal care or comprehensive care over the lifespan of a patient. Ideally, such a model would make family practice attractive again by several means. First, it would increase remuneration to match the level of commitment and responsibility that family physicians provide. Next, it would recognize and remunerate unpaid work and reduce the administrative burden of comprehensive practice. Finally, it would put Alberta (once more) at the vanguard of primary care in Canada.
More details please …
In theory, the Alberta LFP model would:
- Provide physicians with an annual payment based on their panels (considering the complexity of each patient).
- Provide encounter payments for direct and indirect (or virtual) visits, valued equally.
- Provide time-based payments reflecting the actual physician work.
- Compensate physicians for clinical administration at the same rate as encounter payments.
- Introduce new funding for support for office-based, non-clinical teams (receptionist, medical office assistant, administrative staff, etc.) that are currently excluded from primary care network support.
Such models are already in place in British Columbia, Nova Scotia and Manitoba. The AMA is looking carefully at these models to inform our discussions with AH.
Where’s the catch?
There’s a great deal of work required in the coming months to bring such a model into the landscape of Alberta. It will require a significant new funding investment from the government. Even once implemented, it may take several years to recognize benefits.
Further, there are elements of the primary care system that are working well, and it is foundational for the AMA, SFM and SRM that primary care physicians are allowed to choose the payment model that works best for them. For many physicians, FFS or blended capitation models may be working well. It is not the intent of the new model to create a one-size-fits-all payment model for all Alberta family physicians. Instead, the model aims to encourage providers to practice community-based primary care.
Currently, Alberta is facing a growing shortage of health human resources. Many of the physicians that could practice longitudinal family practice are working as hospitalists, supporting acute care, working in urgent care clinics, providing care for unattached patients in walk-in clinics, or focusing on much-needed areas such as maternity care, care of the elderly, addictions and mental health, etc. The creation of a new payment model could pull physician resources away from these very necessary contributions. This is another important reason why, as we move forward, we need to engage with physicians at every level of the health system.
Keeping you informed and asking for your perspective
As the AMA moves forward with discussions with AH, we recognize that it will be critical to keep physicians informed. We will do exactly that, within the constraints of good-faith negotiations. Transparency is key to trust.
As the new acting president of the Section of Family Medicine, I want to hear your perspectives and experiences. I also encourage you to consider reaching out to your local MLA or to the Minister of Health. They need to hear directly from you regarding how the challenges impacting primary care are changing how you care for patients.
Banner image credit: Jake Parkinson, Pixabay.com