By Lethbridge Herald on March 4, 2020.
March 3, 2020
Premier Jason Kenney
Health Minister Tyler Shandro
Mr. Nathan Neudorf
Ms. Michaela Glasgo
Mr. Drew Barnes
c.c. Ms. Shannon Phillips
We write to you today as a united voice of southern Alberta Emergency physicians in the cities of Lethbridge and Medicine Hat to add our voices to those of physicians across Alberta in response to the imminent changes coming to our healthcare system. We are deeply concerned that as early as April 2020 our emergency departments will begin to be overwhelmed due to reductions in local primary and specialist care. We also warn that any decision that degrades access to community based primary care medicine will inevitably result in increasing, unsustainable health care expenditures that will rapidly reverse any budget savings anticipated by these measures.
The emergency department has often been called the “canary in the coal mine” for problems in any healthcare system. When patients are unable to obtain or visit a family doctor, they come to the ER for routine care. When referral visits to specialists or for elective surgeries are delayed, patients come to the ER in crisis. When community long term care beds and accessible home care is unavailable, patients who no longer need hospital care have nowhere to go and languish in expensive hospital beds. When hospital beds are full, new patients requiring admission cannot be accommodated and remain in the emergency department. Elective surgeries are cancelled because there is no postoperative recovery space available.
All these factors combine to grind the efficiency of the emergency department to a halt, impairing its ability to accept and treat new patients. Wait times soar, ambulances pile up and become unavailable to respond to new emergencies. These causes of emergency department crowding are well documented and understood by health care professionals. There is abundant evidence that emergency department crowding increases costs to the health care system and has a cost in patient lives. There is also abundant evidence and consensus from health care experts here and around the world that investing in primary care, long term care and home care is the most effective and affordable way to reduce the burden of expensive hospital-based care.
We recognize and applaud this government’s stated intention to increase the availability of community long-term care and await details as to how this will be implemented. Nonetheless, we are concerned that the current government either does not fully understand the above relationship, or does not understand how the unilaterally imposed changes that were vehemently resisted by the Alberta Medical Association will rapidly decrease access to quality community health care, resulting in poorer health for Albertans, and a rapid increase in the utilization of expensive emergency and hospital based care.
Southern Alberta currently enjoys some of the best emergency department wait time indicators in the country. The average wait to see a physician in a south zone regional hospital is about 55 minutes. Our zone has been identified in the past as one of the most cost efficient in the province. This is in large part due to an excellent primary care system that is accessible to patients, and a network of specialists available to provide timely consultation, admission and follow-up for emergency department patients.
Currently, a simple visit to the family doctor costs Alberta Health $38-$56, from which clinics pay their operating expenses and employ their support staff. An equivalent simple visit to the emergency department costs $359 in hospital overhead + $29 in doctor fees. If additional time, complexity, consultation or testing is required, that expense rises significantly. There is a similar disparity in cost to the system between community and hospital care in other areas of medicine. The ER is generally busiest on weekends, holidays and Mondays – all related to times when community care is less readily available. As community care decreases and more people become reliant on the ER for their care, it is easy to see how health costs rapidly rise.
The following are specific ways in which we anticipate our emergency departments will be immediately affected by these changes beginning April 1:
· The reduction and loss of complex care modifiers will make it difficult for family medicine and specialist clinics to remain financially viable unless visit lengths are significantly reduced. Less time translates into poorer care, making it more likely complex patients will experience a health crisis requiring a trip to the ER and/or hospital admission.
· Daily visit caps on community physicians will shorten or eliminate evening walk-in clinics. These patients will come to the ER instead.
· Daily visit caps will disproportionately affect high volume orthopedic, surgery and cast follow-up clinics, meaning more patients will come to the ER as they cannot see their surgeon.
· Yet to be clarified changes to specialist in-hospital visits and the loss of on-call stipends have our consulting specialist colleagues already notifying us of decreased future availability to rapidly see and admit patients in the ER, as they will need to book additional time in clinics to continue covering their overhead expenses. This will dramatically increase the amount of time patients will be held in the ER before moving into the hospital or receiving an urgent procedure.
· Of particular concern is the potential loss of the stipend supporting the Acute Trauma on-call service, which provides general surgeon coverage in hospital to respond to trauma team activations. This 7-year program has decreased adult and pediatric trauma death in Lethbridge by 65%. In 2018 there were 107 major trauma patients treated in Lethbridge, and 63 in Medicine Hat. Time is critical in these instances, and an increase in preventable traumatic deaths is highly likely should it be lost. The status of this program is unclear due to governments’ lack of response to requests for clarification and is expected to be lost on April 1.
· Palliative care is losing the stipend needed to cover the travel cost of home visits to vulnerable and dying patients. Home visits may no longer be possible requiring more palliative patients to be admitted to hospital and preventing us from discharging them back home into palliative care.
· We provide emergency referral care to all community hospitals in southern Alberta. Rural physicians across the province have been speaking up loudly about their impending inability to provide the same level of care under the new framework. We anticipate unplanned intermittent rural ER closures due to a shortage of physician coverage, similar to those experienced elsewhere in Canada. This will mean more visits from rural communities by patients seeking emergency care.
· The elimination of “good faith billing” means that disadvantaged patients with addictions, mental illness or homelessness are likely to face significant barriers to obtaining care in the community, as many of them are unable to produce proof of provincial health insurance.
· Already we are hearing established community physicians and soon to be graduating medical residents making plans to work outside Alberta due to the instability and acrimony of the relationship between physicians and government. The government’s plan to dictate where future doctors will be allowed to practice will drive many graduates from Albertan medical schools to other provinces. There is abundant work elsewhere. This will mean fewer community providers, and higher reliance on the ER.
Alberta has developed its current model of “the medical home” in primary care over two decades of thoughtfully structured changes to all levels of health care funding. World leaders in health economics and comprehensive patient care have helped build a primary care system that is the best in Canada. It is currently used as an example by other provinces to improve their health services and recruit physicians into similar models providing the best value per dollar in health care. To be frank, the currently planned changes on April 1 risk rapidly destroying 20 years of health delivery progress in this province.
We recognize that the fiscal reality of Alberta means savings must be found in all areas of the budget. Physicians have been willing partners, voting to accept decreases in fees in our last round of negotiations, and had again proposed global cuts to their own fees in the recent negotiations terminated by your government. The Alberta Medical Association has repeatedly expressed its willingness to return to the negotiating table to find sustainable decreases in health spending that will not have draconian and devastating effects on the foundation of Albertan’s medical care. If the AMA was “not willing to consider” your proposals this is why; they will immediately harm patients, and they will not save money.
It is not too late to put a hold on these changes and return to the negotiating table to repair this government’s relationship with physicians and find actual savings in health care. We urge a similar cooperative rather than adversarial approach to ongoing negotiations with other public sectors. The experts in each field are the best positioned to identify potential cost savings and avoid the unintended consequences of indiscriminate cuts. Use their knowledge and experience. A financially secure Alberta is in everyone’s best interest.
The elephant in the room right now is the inevitability that health care workers in Alberta may soon be overwhelmed by the response to a coming pandemic. As always, we will rise to the occasion and provide the best care we are able. Please Premier Kenney, Minister Shandro – can we deal with one freight train crashing into our health care system at a time?
Chinook Regional Hospital (Lethbridge) Emergency Physicians:
Dr Stephanie Brass
Dr Richard Buck
Dr Nathan Coxford
Dr Ryan Derman
Dr Chrisjan deWaal
Dr Sharon Fehr
Dr Kevin Foster
Dr Nic Hamilton
Dr Mervyn Hiebert
Dr Ehi Iyayi
Dr Matthew Kriese
Dr Peter Kwan
Dr Magdalena Lisztwan
Dr Duncan Mackey
Dr Kevin Martin
Dr Nicholas McPhail
Dr Adrian Millman
Dr Bilal Mir
Dr Wes Orr
Dr Braden Teitge
Dr Alan Wilde
Dr Sean Wilde
Medicine Hat Regional Hospital Emergency Physicians:
Dr Ryan Currah
Dr Hendri Faul
Dr Chris Ghazal
Dr Dan Girgis
Dr Geoffrey Harris
Dr Joe Hawkwood
Dr Ash Jaffer
Dr Jan Joubert
Dr Michael Lee
Dr Tyler van Mulligen
Dr Edwin Orellanna-Jordan
Dr Paul Parks
Dr David Sameshima
Dr Chris Stewart