Most physicians know a colleague who's pulled up stakes,
lured to practise medicine in the greener pastures of
Alberta. Newspaper reports go so far as to dub this phenomenon
an 'exodus' of doctors to the west. Perhaps it's because
Alberta is booming. There's money to be made. But not
everyone is lured by the prospect of cash.
The Capital Health region in Edmonton
is blazing a trail, much like the pioneers of yesteryear,
and delivering healthcare in new innovative ways. They're
essentially redesigning models of care and giving doctors
the chance to do research, making Edmonton a magnet
for the brightest minds. Even the British-based Economist
is taking notice, and calls the health region "a model
of excellence throughout North America." So what's the
big deal with Alberta?
THE
SECRET TO SUCCESS
Much of Alberta's ability to recruit the best of the
best and keep them comes from their Academic Alternate
Relationship Plan (ARP) — known more commonly as
an alternate funding plan (AFP) in the rest of the country.
"There is no question that since we started the ARP
the amount of time doctors spend teaching has gone up
and the productivity on the research side has increased,"
says Dr Ken Gardener, the vice-president of medical
affairs at Capital Health.
"I think that Edmonton has one
of the best alternate funding programs in Canada," says
Dr Allan Purdy, chief of medicine at the QEII and a
professor at Dalhousie. And he would know — Dalhousie
is struggling to perfect its own AFP. They're looking
to Alberta as a model to follow. "Capital Health in
Alberta is the gold standard," says Dr Purdy.
Like Alberta and Nova Scotia, most
other provinces have some sort of alternate funding
plan that offers financial arrangements to physicians
who want to teach or do research along with clinical
practice. But none are as organized as the one in Edmonton.
"The attitude of the physicians has been instrumental
to the success of the ARP," says Laura Querengesser,
project manager of the ARP. "They place equal value
on clinical and academic work; accept that they forfeit
some control; and are collectively willing to be held
accountable for outcomes."
A key premise of the Alberta ARP
is that the value of an hour of clinical work is equal
to an hour of teaching, is equal to an hour of research
and is equal to an hour of administration. This lets
physicians devise their own unique job description that
recognizes their individual interests and expertise.
Under an ARP, physicians cannot
influence their income. They're paid a contractual amount
determined by an income grid. But incentives are rewarded
for outstanding performance, just as money is withheld
if doctors don't live up to their end of the deal. Physicians
who participate in the ARP are expected to achieve specific
outcomes and their success is assessed through an accountability
framework, which is an important factor in determining
funding. ARP payments to the department from the government
depend upon the collective performance of all physicians
in the group.
By not locking doctors in to a
fee-for-service (FFS) pay scheme governments can start
exploring different models of delivering care: telehealth,
phone consults, interdisciplinary clinics. "The ARP
allows us to design clinical programs that are better
aligned with new ways of delivering healthcare, unlike
fee-for-service," explains Dr Gardener.
He uses the following example.
"There was a long wait list for patients to get in to
see an endocrinologist. When the ARP came in we said
'we can deliver this care differently.' We had a doctor
call the referring FP. We found out that we could give
the FP advice on how to handle the patient without them
coming in to see an endocrinologist. Wait times were
cut in half." He explains that in a FFS model this wouldn't
have been possible because the doctor making the call
wouldn't get paid for that service.
Sceptics contend this kind of arrangement
wouldn't fly in a 'have not' province. But those on
the front lines disagree. "I think that's a conclusion
that everybody jumps to," says Dr Jon Meddings, chair
of the department of medicine at the University of Alberta.
"The ARP only represents a small amount of spending.
I think it's rather a question of priorities."
PARING
DOWN THE BUREACRACY
The U of A wasn't the first university to implement
an alternative funding arrangement. The University of
Toronto's department of pediatrics was the first back
in 1990 and Queen's instated the only faculty-wide program
in 1994. "As with most things, somebody else had the
idea first," recalls Dr Thomas Marrie, the dean of the
faculty of medicine and dentistry at the University
of Alberta and one of the founders of the Alberta ARP.
"Queen's had one for a long time and a lot had been
written about it — most of it negative. I took
the concept and thought 'yes, there's a different way
to do this.'"
Alberta picked up where others
failed and turned the idea into an 'alternate relationship'
rather than 'an alternate funding plan'. The core difference
has to do with attitude. "One of the reasons why we
changed the name from AFP to ARP — and we knew
it would confuse people — is the outstanding relationship
we have going [between the University of Alberta, the
Alberta Medical Association and the Ministry of Health],"
explains Dr Gardener.
"The reason why [the ARP] works
so well is that it's a partnership with the government,"
remarks Dr Meddings. How exactly does this integration
work? Essentially all the groups involved work together.
"It facilitates the way you deliver care," explains
Dr Gardener. "It takes away the individual barriers
to working together. We are all at the table together
— the physicians, the university faculty, the region
— and we're working together." In many ways this
integration has streamlined the bureaucracy. "We're
able to pull together all the requisite people and it
does allow us to respond a little more quickly than
we could have before."
HAPPY,
PRODUCTIVE DOCS
"There is working proof that physicians are more committed
to the workplace," says Dr Marrie. "The response has
been overwhelmingly favourable."
If it's all sounding a little too
perfect, it only takes one look at the most recent Accountability
Report of the University of Alberta Department of Medicine
— which the department is required to do. The results
show that 80% of physicians surveyed found that the
ARP had a positive effect on their personal career and
clinical practice and 92% would recommend similar positions
to their colleagues.
If imitation is the highest form
of flattery then the ARP would be blushing. Dr Meddings
says that other provinces have approached him for help
setting up a new ARP or helping existing ones get back
on track.
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