Physician and University of Calgary professor Braden Manns speaks with Alberta Primetime host Michael Higgins about changes to the acute care funding model.
This interview has been edited for clarity and length.
Michael Higgins: From a front lines perspective, what kind of shift does this represent in the delivery of health care?
Braden Manns: It’s not as much as you might think. The premier had that nice seven-minute description of what activity-based funding is, and Alberta Health Services (AHS) was already doing some of that. She talked about three parts to it, and that you get a clear price for the service.
For knee surgery, I need two nurses in the operating room, I need one nurse for every four patients in the recovery room, you need the hardware for the surgery, you need some supplies. So you agree on what resources are needed and you set the benchmark.
AHS was already doing benchmarking against other hospitals within Alberta, similar hospitals, hospital wards, surgery, and across other provinces as well. They were already doing the benchmarking.
The premier talks about competition, every hospital is going to have to do the procedure for less than the price. Problem is that the competition is all going to be for the easy cases, the ones you can do really quickly, people that don’t have a lot of complexity to them, the ones that can be done in the chartered surgical facilities (CSFs), the ones that don’t need an overnight stay.
The competition is not going to be for the harder cases, those are going to still be left in Alberta Health Services and if you need the support of a hospital, then you do need to be operated on in the hospital. Then she talked about accountability, and, again, we really struggle in the health care system, but you can get accountability with a global budget.
The government just needs to hold the hospital system doctors accountable, and it’s not just accountability for doing volumes, it’s accountability for getting a good surgery, a safe surgery. Are we going to have more accountability in this? I guess we’ll see. Are we actually going to monitor that the cases are being done safely? We’ll see.
MH: How about that service-based funding, payment by results, payment by volume? What impact do you expect this to have on quality of care?
BM: We don’t measure quality of care in chartered surgical facilities. We were measuring quality of the surgical care across hospitals, but that program in Alberta Health Services actually closed a year ago, so we don’t have as good a sense as we used to about what quality of surgery looks like.
In fact, a lot of the human resources and the infrastructure that we had for measuring quality in Alberta Health Services has been lost over the last couple of years with cuts to funding and with the changes that have happened, the restructuring.
MH: On your point about hospitals, if it is that the results are to be rewarded, how do you see hospitals adapting to a competitive environment? What does that look like?
BM: I’m not against activity-based funding, and I’m not against pulling surgeries out of the global budget. Ontario and Quebec did it. Alberta did it during the pandemic, actually, when the government provided extra funding for surgery, catch up, and providing hospitals extra funding specifically for surgery increased, significantly, the number of surgeries being done because it’s no longer competing with an emergency room that is stacked with patients who aren’t able to get up to the hospital.
So you actually protect that funding for surgery. The problem is it doesn’t deal with our critical shortage of humans, anesthetists, operating room nurses, and so simply changing the funding formula, it’s going to have a limited impact if we can’t get more anesthetists.
There’s been a program piloting the use of respiratory therapists who were supervised to do anesthesia by an anesthesiologist who looks after three to four rooms with really highly-trained respiratory therapists, but it has been really difficult to scale that program because there hasn’t been a billing code for the anesthesiologist. They run into some issues with using those respiratory therapists in the chartered surgical facilities, and the government’s not willing to put their foot down and push some of these solutions that we actually need which will get us more humans to actually do surgery safely.
MH: How do you see this playing out at a time when there are investigations and reviews underway into allegations of government interference in surgical contracts?
BM: There’s challenges associated with chartered surgical facilities charging twice as much as the cost in AHS for similar cases. When you compare the easier cases, we’re paying the chartered facilities, or some of them, twice as much. They tend to do milder cases because you can get those through faster.
Some of those cases actually probably don’t need to be done. So, we actually need to do a much better job of managing surgical wait lists. They create more variation in care. There is not one wait list for knee surgeries in Alberta, every surgeon has a wait list for knee surgeries, and they manage it separately. Now, they’re going to have two wait lists for knee surgeries, the ones that can be done in hospitals and the ones that can be done in chartered surgical facilities.
Would you rather work in a chartered surgical facility from seven to five during the day and not on the weekends, or would you rather work in the hospital where you’re going to be on call and you might get called at 3 a.m.?
The hospitals have to ensure that there’s a surgeon available if you get appendicitis or your grandma breaks her hip. You’re going to expect that the hospital is staffing their call schedule, and then we’ve seen that the CSFs are ripe for financial abuse.
The additional facilities were pushed through very quickly and I don’t think there’s enough staff to audit what actually happens there. There’s no assessment of quality and, essentially, AHS just pays the bills that CSFs send over.
After just saying that and this scandal, they’re pushing more surgeries to be done in CSFs because activity-based funding is going to increase the number of surgeries that are done there.
So we’ve just gotten badly burned, and before any reviews have been completed, we’re doubling down.
