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1 juin 2005
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Wednesday, June 1, 2005


Physician Alternative Funding

Printed and Published by Nova Scotia Hansard Reporting Services


Mr. Graham Steele (Chairman)

Mr. James DeWolfe (Vice-Chairman)

Mr. Mark Parent

Mr. Gary Hines

Ms. Maureen MacDonald

Mr. David Wilson (Sackville-Cobequid)

Mr. Daniel Graham

Mr. David Wilson (Glace Bay)

Mr. Michel Samson

In Attendance:

Ms. Mora Stevens

Legislative Committee Coordinator

Ms. Elaine Morash

Assistant Auditor General


Department of Health

Ms. Cheryl Doiron

Deputy Minister

Ms. Jane Breckenridge

Director, Physician Services

Ms. Angela Purcell

Acting Manager, Alternative Funding

[Page 1]



9:00 A.M.


Mr. Graham Steele


Mr. James DeWolfe

MR. CHAIRMAN: Good morning ladies and gentlemen. Welcome to the Public Accounts Committee. We are very pleased to have with us today representatives of the Department of Health to address the topic of physician alternative funding. I would like to recognize Ms. Cheryl Doiron, the Deputy Minister of Health, and ask Ms. Doiron to introduce the colleagues she has brought with her today.

MS. CHERYL DOIRON: Mr. Chairman, today I have with me Jane Breckenridge to my right. Jane is the Director of Physician Services in the department and to my left I have Angela Purcell who is the Acting Manager of Alternative Funding, which is a reasonably new position in the department during the past few months.

MR. CHAIRMAN: I would now like to ask the members to introduce themselves, starting with the member for Halifax Needham.

[The committee members introduced themselves.]

MR. CHAIRMAN: As is our custom, Ms. Doiron, I would now like to invite you to take up to 15 minutes for an opening statement.


[Page 2]

MS. DOIRON: Mr. Chairman, thank you, members of the committee, for this opportunity to appear before you on the topic of alternative funding plans for physicians. There is usually a general lack of understanding around this method of paying doctors so it's a good opportunity for us, I think, to educate not just yourselves but others who may listen to this dialogue. This reaction is understandable and it's seen right across the country. AFPs are a relatively new approach to paying doctors in Canada and actually Nova Scotia has been very much in the lead on this approach.

This comes with a very steep learning curve for the health system and for the people who just want access to a doctor when and where they need one. We discussed this topic at the Public Accounts Committee a bit in February and today I hope to provide additional clarity around Nova Scotia's use of these contracts and how we are working to improve them over the next while.

Over the past seven years we have seen a significant shift toward alternative funding. In 1997-98 fiscal year, about 9 per cent of our doctors were paid solely through alternative funding. Today it's approximately 30 per cent or 600 full-time equivalents. We have 25 contracts which cover a range of work settings, including academic, regional specialties, family practice and collaborative practice arrangements. We have a range of contracts because they are used to accomplish different goals.

I will share three quick examples. First, we have contracts for family doctors who practice in rural areas to ensure we have stability in those communities and an opportunity to work with nurse practitioners. The population may not offer the chance to make comparable money as compared to larger centres so the contract is used to help with recruitment and retention and to ensure that these important health providers are in the communities where they are needed. Secondly, we also offer contracts to specialty physicians who work in smaller communities where we have the need for their services but not adequate volume to sustain a fee-for-service practice. Thirdly, academic contracts ensure that groups of specialists can make time to teach the next generation of doctors and conduct valuable research without reducing the level of care to patients. These are the types of investments we feel we need to make for the future of our health system and they are attractive contracts to doctors who want to do this range of work.

Because Nova Scotia is among the country's leaders in the development and evolution of alternative funding plans, we are learning and making improvements along the way. There are three milestone pieces of work that are moving us forward in this regard. These include developing guiding principles for negotiating funding plans, developing deliverables for these contracts and establishing an overall framework that we would use to guide future AFPs. All of these pieces of work have been or are being done in partnership with Doctors Nova Scotia, Dalhousie School of Medicine and the district health authorities.

[Page 3]

The AFP guiding principles ensure that all parties at the negotiating table clearly understand the Department of Health's interests. These include patient focus care, transparency, sustainability, equity and accountability. These contracts are signed by several parties, the Department of Health, Doctors Nova Scotia, the district, the individual physician or the groups of physicians and often a department within the Dalhousie School of Medicine.

The principles document - which was just recently signed off actually between the Department of Health and Doctors Nova Scotia - also talks about the roles and responsibilities of each of the parties within the AFP so that all parties are moving in the same direction. As mentioned earlier, AFPs are meant to enable doctors to do things differently yet all of our AFPs presently require shadow billing which is an accounting system structure for the fee-for-service model. Alternative funding plans are more complex and as we continue to ask health providers to work differently, we must also change the way we measure their service.

With no example to follow in Canada, this has been a challenge. We are now working with Doctors Nova Scotia and the district health authorities to develop more appropriate measures of our expectations, or what we call deliverables. These deliverables will be tailored to the individual doctor or group of doctors. They will more adequately and clearly reflect the work doctors do and the role they have in improving the health of their patients and communities. For example, in the case of a family doctor in a rural community, these deliverables will be incorporated into the contract. The parties will work together to determine what service this doctor is expected to provide to the community. In this way, we can ensure doctors have more clarity around their role in the delivery of health services within their communities.

Over this next year, we will be able to finalize what we are calling the menu of deliverables and start incorporating them into physician contracts. Deliverables are also an important part of academic AFPs as well. The Department of Health has committed to ensuring all future contracts will contain deliverables before being finalized.

Our efforts to enhance accountability fall in line with the reviews that have been done over the last number of years. In 2000 and then in 2002, the Auditor General raised concerns about alternative plans. The AG's questions and concerns were in line with our own and certainly they were a reflection of our learning curve. The Department of Health initiated an audit in 2003 which was completed by the North South Group in 2004. We chose to have the largest and most complex contract reviewed as it would give us the most useful information about all the plans.

I think, Mr. Chairman, at this point I will conclude my remarks and turn things over to you again.

[Page 4]

MR. CHAIRMAN: Thank you very much. We will start the questioning now. The first round will be 20 minutes for the NDP caucus.

The honourable member for Halifax Needham.

MS. MAUREEN MACDONALD: Thank you for being here today. I want to start by making reference to a paragraph in the conclusion of the North South audit, which I think sort of sums up the concerns that have been identified in that audit. It's the second last paragraph on Page 131, and I'm just going to read from it quickly. To quote this conclusion, it says, "However, the audit process has also identified many serious administrative weaknesses both in the development, and in the implementation of the AFP. These include: the negotiation process; communication and inter-relationships among the parties; compliance issues; controls; management and accountability; reporting and shadow billing issues; overpayment based on actual FTEs; duplicate benefits; unclear policies relating to payments to part-time physicians; absence of deliverables; reliable information and/or reporting systems; subsidization of the Dalhousie Medical School through the AFP; overhead allocations; absence of required resources at DOH to effectively manage the AFP; and many others."

That paragraph, I think, is quite troublesome in terms of the AFP that was in place. I'm wondering if you agree with the findings of the North South audit, and then I would like to know in terms of the recommendations that the North South report makes, there are 43 recommendations, has the government accepted all of the recommendations from the North South Group?

MS. DOIRON: Thank you for that very important question. I think I want to start out by just quoting one other line in their conclusion, just to kind of set the balance and it's a very short statement I'll make. "Overall, the finding of this audit have brought to light many important benefits provided by the AFP to Nova Scotia's health system." and it goes on to elaborate on that.

The context in which we looked at this report was to say there are many issues, and I guess one of the reasons why we looked for an objective audit by a firm from outside of government was to say, we do want to identify, after having some early years in this kind of an approach to payment, we want to appropriately assess it. There were no real surprises in the report for us so I think we were aware that there were a number of issues that had to be raised, that had to be addressed, and that had to be treated in a way that could be done objectively.

In our view, the findings were appropriate and they were extremely useful to us to help us shape the future direction of alternative funding. Having said that, we have put in place now a steering group and some working groups to actually pick up with all of those recommendations, and to try to tease them through the system and try to understand them

[Page 5]

better, and to make sure that we are jointly with our other partners in this process, coming up with the appropriate approaches.

There are a number of areas that we had recognized ourselves that even by the time the report was published that we were actually advancing on. Maybe one that I should mention is the whole process around the negotiation of the AFPs. During the past year or so, we have actually framed that process more appropriately. We do our homework. There is a negotiating table with a negotiator, that we hired to lead the negotiations. We also go to Cabinet prior to sitting down at the table or partway through any conclusion of offers, we will go back to Cabinet and make sure that the mandate that we have for a conclusion of an AFP is clear and that that direction is provided.

[9:15 a.m.]

As we go back to the table, should that become an issue or a problem, and if there is any substantive change that would be, in our perspective, advisable, or any position that if we don't change ours might lead to some kind of outcome of job action of any type then, of course, we take that back as well. So I think that that is just one example of where we actually have started to make changes that are consistent with what has come up in the report.

Our view was that this is a good thing, we feel we have benefited greatly in many respects from AFPs, that they have been serving us well in many regards, but that we have to go into a future that is much more appropriately and clearly designed around them, that do have deliverables and that are truly open and transparent in terms of the process that's used to arrive at them, and also to evaluate them.

MS. MAUREEN MACDONALD: I'm wondering if you could elaborate a bit on the status of the negotiations for the new agreements. This AFP, in particular, has expired and you are in negotiations now, as I understand it. Can you give us a bit of information on what stage you're at in the negotiations and when you anticipate there will be some conclusion to that, and perhaps, what are the biggest challenges that you're facing in negotiating a new agreement, and whether or not funding, for example, is an issue?

MS. DOIRON: At this point in time we have reached at least a temporary agreement, I think you are probably aware, and that while there were issues that were unsettled - and certainly funding was a major issue that was unsettled and while that is an issue - the agreement was there to continue on with some improvement to the contract for a period of one year. There is, I believe, also an option to go to a second year.

I think there's much that we have to do around that medical AFP, which is our first AFP that we actually initiated in the province, and also the largest one. There is much that is now starting to shift as we talk about things relative to accountabilities, and as we're talking about principles that we have to be in agreement with, and the specific deliverables.

[Page 6]

All of those kind of issues also played a part in how we were going to understand what we were negotiating - and this is a bit of a new process.

My recollection is that it was only on May 17th that I signed the first set of agreements around principles related to the negotiation of AFPs. A few days later than that the president and CEO for Doctors Nova Scotia signed that. That is providing now a basis of framework for us to say, now we have to enter the negotiation around each AFP, and that also applies to this medical AFP. Based on these principles we now have to start framing what some of the specific deliverables are within that. So I think with those things being in progress, and in transition, having that period of a year or up to two years is going to allow us to sort out much of what people need to come to understand differently about how the AFPs are going to work.

I think while there are still issues that are ongoing, that the doctors themselves seem to be very happy to be able to get to the point that they could say, all right, we appreciate that there are a number of issues, including the amount of the increase in funding, but they themselves were valuing so much the framework in which they were working under in AFP, that when they voted they were very heavily in favour of saying all right, we know we have issues to address, let's give us some time to address the issues, and we'll go back to work under the AFP.

I'm just going to defer, if I may for a moment, to Jane, because she actually was much more directly involved at the table, and she may be able to add something more for you.

MR. CHAIRMAN: Ms. Breckenridge.

MS. JANE BRECKENRIDGE: Just in terms of the new agreement, as the deputy mentioned, there is the one-year new alternative funding plan for medicine, which is in some ways a bridging to allow the physicians to look at the issues that were discussed. In that new agreement, we were aware at the time of some of the issues that were raised within the North South audit report. Two, in particular, I think, are important to mention that have been incorporated into that new agreement.

One, in particular, is enhanced accountability, particularly around the billing methods and that we have moved to an invoicing system to ensure that payment is made for all physicians who are in place that are working. The second part is around deliverables, and there is a deliverables document attached to that agreement. We spent a significant amount of our time at the negotiations discussing what those deliverables would be. So the new agreement does include deliverables.

MS. MAUREEN MACDONALD: So, in fact, the existing AFP has been extended with some modifications? Is this what you're saying?

[Page 7]

MS. BRECKENRIDGE: A new agreement has been . . .

MS. MAUREEN MACDONALD: A new agreement has been signed, but it's essentially the existing agreement with those two modifications, an invoicing system and a checklist on deliverables, or some definition around deliverables, is that what you're saying?

MS. BRECKENRIDGE: Actually there was a fairly comprehensive document on deliverables that is attached to the new agreement. It would be difficult to say that it is an extension of the old agreement, it is a new stand-alone agreement, as there are significant other legal changes that were made within the agreement. It is a new agreement.

MS. MAUREEN MACDONALD: Is the agreement available for public review and can it be provided, perhaps, to this committee?

MS. DOIRON: I see no reason why that cannot be provided, certainly.

MR. CHAIRMAN: We will ask you to deliver that to the clerk of the committee for distribution to the committee, thank you.

MS. MAUREEN MACDONALD: I would also make a request that the principles document be tabled, as well, so that we could have an opportunity to review that framework.

MR. CHAIRMAN: The deputy is indicating that that can be done, as well.

MS. MAUREEN MACDONALD: Could you help us understand a bit more about what some of the key issues were for the parties in trying to reach agreement on deliverables? When I read the North South report, one of the things that concerns me - first of all let me say that the report isn't an entirely negative report, I agree with the deputy, that AFPs can provide stability in the system, they can also allow for the retention and recruitment of specialists and physicians that we really need, and our health care system relies on. I think we all recognize that they are a really valuable tool if executed properly.

I think the concern for most Nova Scotians is whether or not we have the health human resources and the system organized in a way that people get timely access to medical services. Certainly, one of the things that jumped out at me in this report was the inability of the audit to say whether or not wait times were, in fact, positively affected, that is reduced, as a result of having AFPs in place. That's something that really concerns me, because on the one hand if we're saying that we're able to retain and recruit physicians, then I would think common sense would dictate that wait times would, as a result of retention and recruitment, be reduced. This audit was unable to establish that.

[Page 8]

My concern is how are we going to ensure that we're not putting in place a regime that costs a lot of money? This is not a cheap proposition, this is a very expensive proposition, that gives us the change in access to high-quality health care when people need it. That is not apparent in this report, so this is a question I have. Perhaps you could speak to that aspect.

MS. DOIRON: This is such a complex issue. First of all I want to say that I believe we have kind of grown up for quite some time now in our public system, with having that fee-for-service approach. Because of that, I guess we measure, in a sense, the productivity of physicians by how many procedures or encounters they bill for. What we also know is that sometimes that approach can actually drive physicians to try to approach their work with increasing or having many encounters or procedures.

Where we want to go regardless of whether physicians are on fee for service or alternative payment funding, is to try to attach the deliverables more to the outcomes of health care. As we know, that's an extremely complex issue to get at, but that's part of what we want to do as we look at the AFPs, and particularly if we look at particular areas of the province, or particular groups of specialties, or whatever, we might find in one area of the province that certain kinds of indicators of the health of the population - let me take a really easy one just to illustrate this - that the rate of pap smears might be very good in one area of the province but not very high in some other area of the province. If we see that as something that is appropriate and desirable, and speaks to a benefit of health and better health outcomes, then it may be that we will look for that to be built into a deliverable. I think that understanding the health of the population throughout the province in various ways is a complex issue, but it's an important one for us to start to get at.

I also in my own mind think about how so many other of our health professionals work. Most of the other health professionals in our system work on a salary basis. We don't spend the same amount of time trying to analyze whether, in fact, we're getting the right level of productivity here. At the same time, we do have approaches and mechanisms within our system, whether people are working in hospitals, or home care, or whatever, to understand some of the outputs and levels of productivity. Some of those same kinds of approaches and measures can be brought against clinical practise of physicians. Those are some of the areas that we tend to work with.

One of the concerns we have is that as this kind of evolvement has occurred with how we pay physicians, we have tried to compare it to fee for service by keeping the shadow billing, as it's called - in other words, they're supposed to send in a claim, if you like, that's similar to what they would have done under fee for service, just so we can keep track of then how many kinds of procedures, encounters, and so on, are happening with the physician.

With the literature that I have read over the past while, when physicians go to a more salary-type approach, or an alternative payment approach, essentially some of that drops off,

[Page 9]

maybe by 25 per cent, sometimes up to a third. Some people will take that as a measure of saying, that means that we don't have as much productivity when, in fact, we're also saying that one of the objectives of this AFP is to encourage doctors to work differently. In fact, we think that in many cases it can be a better quality of care if the physician spends a bit more time with the patient, if there's more teaching for example, or if the physician is engaged better and has the time to engage with the rest of the team.

On one hand we would say, a lot of what we want physicians to do are not things that we've identified as being billable, so we should expect that there's some drop-off in the shadow billing. Plus, we know that nobody is going to be quite as motivated to get every single procedure and encounter recorded when that's not going to form part of their remuneration. So there are many things in that, I think, that we need to understand better. Looking for deliverables is part of doing that.

One final comment I will make on that - there are several I have in mind but I'll just make one more because of time - over time I think we also need to understand how do we actually understand the performance of physicians better? We've been doing it through the Department of Health in the sense of how physicians bill on fee-for-service. It may be more appropriate for us to start to look at how the district health authorities can better work with the physicians, relative to performance and accountability as well, because that's where they are and those are the people who are going to be working with them day in and day out, and would have a much better idea of their daily performance than the Department of Health should have.

[9:30 a.m.]

MR. CHAIRMAN: Thank you. We will move on to the Liberal caucus.

The honourable member for Halifax Citadel.

MR. DANIEL GRAHAM: Thank you for coming, once again. Ms. Doiron you will recall that perhaps near the end of the questions we had in late February, we were actually just touching on this particular issue about alternative funding. At that time I was continuing to express what I have expressed for the last several years, that I am a supporter of alternative funding programs. I think it's important to state that notwithstanding the North South report, which I think is inconclusive with respect to the value for money argument, but does appear to be conclusive with respect to the benefits on recruitment, retention, how this helps with respect to - most importantly - improving the health of Nova Scotians, and also improving the academic environment in which we research important health questions.

Clearly, I would suggest there continue to be benefits but the business case still needs to be made to Nova Scotians. Your department represents about half of all government revenue and the case that North South has put before government, about the mismanagement

[Page 10]

of, or the administrative problems at the very least, with respect to the implementation and execution of the AFP are, frankly, troublesome for a department that spends half of government revenue.

First we had, as you candidly outlined in your opening remarks, the Auditor General's flagging of concerns back in 2001-02. We have recognized that primary health care is the buzz language of the go-forward plan for health reform, health renewal in Canada, and certainly in Nova Scotia. One of the foundation building blocks for moving in that direction is alternative funding programs. If we don't get that right, we're back at square zero, and we're looking at a declining health for Nova Scotians, I would argue. For the two months of this year it seems that we had a decline in moving back to a fee-for-service process, before we captured it and renewed the initiative as we had.

In addition to the remarks that the member for Halifax Needham made, when I was reading through the North South report, I note that there is a reference to a lack of an accountability framework, a lack of specific deliverables, a lack of a clear determination of clinical and academic ratios for AFP physicians, and an intermingling of health and education funding. You said at the outset that there would be a steep learning curve associated with putting a new initiative like this in place, so I'm going to make a statement that we have stumbled coming out of the blocks with respect to the administration of AFP and the only thing that's arguable is whether we've stumbled badly or whether we have simply stumbled. You can comment on whether or not you think it's badly. I still remain a supporter of going forward with this program but I think for Nova Scotians, they need an answer from your department as to how, in a department that is spending half of all of government revenue on one of its most important priorities, you could have stumbled as badly as I'm suggesting you have in the administration of this important program?

MS. DOIRON: There is no doubt that there is a need to build on all of the recommendations of this report. I think that we also believe that a lot more progress was required around accountability and appropriate framework to work within, with these AFPs, a framework that would allow us to understand deliverables and to evaluate outcomes. I don't think that there was never anything there, because from the beginning of AFPs, as I understand it, there was always some definition. For example, like you would find with any employee, I suppose, or any contractor, that there's an expectation relative to the hours of work, that there would be participation with the physician or physician group, with providing 24/7, on call coverage, things of that nature.

I guess, if you go back and look at those early AFPs, in a sense there were some deliverables. One of the things that has had to evolve, I believe, with AFPs, because we are talking about physicians, is that whole transfer or change in the approach relative to the culture of how we work with physicians. Clearly, physicians have in the past - still do but I think somewhat less so - see themselves as independents, as entrepreneurs.

[Page 11]

We know that the health care system of the past has essentially worked with most of the people working in health care having some kind of the typical master-servant relationship with an employer. That has been a very different world with physicians, who see themselves as independent entrepreneurs. So leading up to putting something down on paper that's clearer that says, you are accountable for the following things, has been, I think, a real shift in the headset for physicians, for the organizations which represent them, for the organizations which negotiate on their behalf. What we have done since AFPs have started to develop, is gone through a major shift with the organizations and many of their members, into a time frame now where we can actually take action that's going to frame things in a much more appropriate way. That is not to suggest that we should make excuses for any areas that we should have been able to see earlier on, or address.

Our intent in having the report done was to surface all of that so we could all deal with it, rather than the Department of Health saying, there are X number of areas that we feel need to be improved, that it might be more helpful if all of the parties had input, first of all, to the document and, secondly, that it was an objective document that we could all then react to and work with. Having said that, I think there has been a whole growth that has occurred here that's now at a point of nearing a much more improved state of maturity.

You would know, I'm sure, from your background and from the research you probably had exposure to, that this is a phenomenon that is going on across this country and that, in fact, we're being watched quite closely right now by doctors and by others in other provinces, because we have headed down this road to say, we have to make this framework better, we have to make sure that it's beneficial to the people of this province, that it's accountable for things that we need to be accountable for from the Department of Health, including the funding, and so it is our intent to continue to develop that and during that process, to also engage in conversation and dialogue with other provinces and with other organizations that can be helpful in the process, but that is sometimes a bit of a challenge when you're kind of leading in most of those areas. So certainly acknowledgement of the issues, but I think a good forward-looking vision for this.

MR. GRAHAM: For many years people spoke about the importance of setting out an evaluation framework and basing decisions on the evidence. In the last five or 10 years, and in particular in the area of health, this has been a vitally important thing. You cannot make an application for government funding if you are an outside agency unless you establish an evaluation framework as an automatic, in that you make future decisions based on evidence. That's the standard these days.

We have the number one policy area for the public in health, and the number one issue inside of health, primary health care, squarely before your department - and I appreciate you weren't the Deputy Minister of Health at this time. So we have, one might argue, the most important single evaluation project going on inside government and here's what was agreed to by the parties before they set out, the contracts, the contractual instruments, said

[Page 12]

that deliverables would be developed by the parties and failing that, they would be conducted on the basis of shadow billing.

Furthermore, "that there would be a determination of what portion of the Minister's funding was to be allocated as a Special Increment for Teaching." Now those are basics, it seems and those are already in the document. So those are such general terms. They are not even at the level of detail where the experts work it out. These are general terms and that wasn't even done in these circumstances. I'm wondering, how could we have swung and missed so badly in this era of evidence-based decision making, evaluation frameworks in the most important policy department, and the most important policy decision in government?

MS. DOIRON: I think it has been a period of growth and even if we go back to the accountabilities that were or were not there, just based on the fee-for-service system because I think really there is an issue there as well, basically I think it does go back again to the individual entrepreneurial spirit of the way physicians work. On the other hand, just about all the money that they received is coming through a public purse. I think we have come to the point of saying that that is not acceptable, that we do have to have accountability mechanisms.

As I mentioned when we first started, we now have a position in the department whose job is going to be exclusively to manage the AFPs, have a very small staff. Many areas of the department but certainly in Physician Services over the past, we have added two positions there this year to try to ensure that we can work to improve that kind of position.

There are many other things going on as well that will have an impact on physicians and how they work with their deliverables as well and I will mention one. One of those issues now is the advisory committee to the minister on wait times in the province that is now up and running. I think with engaging in more and more work with physicians themselves in looking at what are appropriate wait times, how wait times impact the outcome of health and care there is a whole variety of vehicles here that we need to use to first of all understand how we should be delivering services to be able to better meet the priorities and to serve people when they need to be served, to improve how quickly people get access and so through the AFPs, through the discussions that we have, regardless of whether physicians are on fee for service or not, through many of the mechanisms we are now using and many of the provincial approaches we are taking to things, for example, we are doing work to look at a plan for orthopaedics that is a provincial plan and wait times will be posted so people can make choices about where they go.

I think that we have basically looked at accountability of physicians differently in the past than we have maybe other professionals and basically this time now has caught up with it and they are very much becoming part of this dynamic.

[Page 13]

MR. GRAHAM: Thank you, deputy. Unfortunately, our time is limited. I'm going to move to one relatively short snapper before I want to move on to the future a little bit. Before I invite you to help us understand the future a little bit better, I just want to take one peek into one window. I'm referring specifically to what is flagged in the executive summary of the North South report on Page v. It refers to those two elements that were missing, that I just spoke about, those two general things that were contracted with respect to establishing deliverables and the special increment for teaching.

Was there even an attempt or a negotiation that was undertaken by the parties to achieve these goals and if there was, was the cause of the breakdown some of what you have referred to with respect to the entrepreneurial spirit or culture of doctors or was it something in the Department of Health? I apologize but we don't have much time with respect to that. I'm just hoping to get some kind of quick window into that.

MS. DOIRON: One of the aspects of that that we are still working on is to understand, for example, the funding to the medical school. Over time, the Department of Education has provided funding to the university but as specific needs and demands have come up, the Department of Health, at various points in time, has secured funding to add dollars to the medical school or the university in order to cause some things to occur. That has happened over a long period of time. We have now gone to the work of saying, well, how does that all come together? How do we understand that funding? What were the accountabilities over these many pots of funding and how can we now take it apart and decipher it in a manner that is going to give us a more appropriate, transparent and accountable way of moving forward? This has become a very complex exercise because of the history that was behind it of . . .

[9:45 a.m.]

MR. GRAHAM: Excuse me. Deputy, I'm just wondering whether or not it was undertaken. Did you undertake the effort?

MS. DOIRON: Yes, we are in that process.

MR. GRAHAM: Did you undertake it in the past? Was it undertaken after the contract was put in place? Did the parties begin down of the road of trying to achieve those two requirements that ultimately weren't achieved? Was there an effort made and if there was, why did it break down?

MS. DOIRON: I'm sorry. Am I misunderstanding the question? I think the initiatives that you are talking about are specifically . . .

[Page 14]

MR. GRAHAM: Establishing deliverables, by the parties. In the alternative, moving to a shadow billing process. Those things weren't done in the end and the special increment for teaching. I'm just wondering, were they not done because there wasn't an effort made or because there was a breakdown in discussions between Health and doctors?

MS. DOIRON: There was an initiative that was happening in advance of the contracts. Some of those activities were things that were done or were underway. I think what I am reacting to at this point, or responding to, is that trying to understand the special increment for funding needs to go back to understanding the basis of that funding in the first place. That has been undertaken as well. It was underway during the period of time of the negotiation of the contract and is continuing. So, yes, those things were underway and yes, the whole issue of shadow billing has been going on since the beginning of AFPs.

MR. GRAHAM: Why did it break down then? Why didn't we get there?

MS. DOIRON: With that particular set of negotiations?

MR. GRAHAM: Yes, with those discussions and let me bridge to the next part of this so that we don't lose all of our time. I think it's important for us to know this is but one contract. It's the largest that you have and there are others out there. I am wondering whether or not we are facing similar problems with the other contracts and whether or not your department is able to provide us with a comment as to whether or not those problems are being addressed and in particular whether or not we still have any outstanding negotiations. The larger ones are more notorious and easily flagged. March 31st we moved to a fee for service, now we are back up and running with AFP and wondering what else is happening with those other contracts and are there other things that should be of concern to us as well?

MS. DOIRON: The breakdown on this particular set of negotiations was primarily around funding and the amount of the increase. Probably some of these other issues played some part. The review of the medical AFP is being approached in a manner in terms of follow-up to look at it as an opportunity to expand beyond the medical AFP and see if the framework that is developed can have application to all AFPs or many AFPs. Having said that, we have 25 AFPs. They don't all get negotiated at the same time so there are always seemingly some that are under negotiation, and for the most part those other negotiations have been proceeding without any real upset or threat of any particular action on the part of the physicians within them. Obviously, there are issues at times when you go to the table for any set of negotiations but for the most part they have played out in a way that has allowed the delivery of health services to continue without too much upset or interruption.

MR. GRAHAM: The negotiations appear to have, when we are to read between the lines of some newspaper reports, led to the resignation of the head of internal medicine. I'm wondering whether or not a permanent replacement has been found for her position.

[Page 15]

MS. DOIRON: At this time, Capital Health is underway with initiating the process for that replacement. That process takes place in partnership with the university, and there's an interim person in place, so we don't have a permanent person in that position at this point.

MR. GRAHAM: Are there any other resignations that have come about as a result of this particular breakdown in negotiations?

MS. DOIRON: Not to our knowledge.

MR. CHAIRMAN: You have 10 seconds left.

MR. GRAHAM: That's fine, I'll pass it to my colleagues, thank you.

MR. CHAIRMAN: We will now move on to the Progressive Conservative caucus.

The honourable member for Pictou East.

MR. JAMES DEWOLFE: Thank you and good morning. Thank you for being with us, Ms. Doiron, again, you are always welcome and provide us with a great deal of knowledge and just shows how vast your responsibilities are with the topics that we bring to this table.

Last week we had with us representatives of the Capital District Health Authority, and a question of adequate government health care funding was raised at that time. A representative from one of the Opposition Parties suggested that our health care system may be over-funded and that we should cut upwards to $140 million from our health care budget. However, I read in the paper an editorial yesterday seeking clarification that no such statement was made. Having reread the media again, I understand there was a request for at least an additional $140 million for education and the media report suggested that the funding could come from the Department of Health. In any case, I'll ask the question again. Ms. Doiron, do you believe that the health care is out of control and over-funded?

MS. DOIRON: No, I don't. Based on the system that we have in Canada and in this province, I believe that the district health authorities, the long-term care facilities, the other agencies in this province, are operating quite efficiently. I say this based on any reviews that we've done to date, and there have been a number of districts that have been audited. I say this based on what we've been able to do compared to other provinces, and the extent to which we are able to get very close to balancing budgets, in comparison to other provinces.

I say this because I've spent my entire life in the health care system, most of it in the delivery system as opposed to in government, and have a reasonable sense, I believe, of where there can be an ability to kind of find incremental funding in the health system. As I'm sure you all know, we went through a period from probably the mid-1980s into the 1990s,

[Page 16]

of looking for any kind of funding that could be reduced or taken out of the health care system. There may be very small pockets of that here and there but it's very minimal.

When we get experts and consultants who do this kind of work nationally and internationally, they do not seem to be able to identify for us any major opportunity to reduce our health care funding. We're constantly seeking, if not to reduce it, at least to contain it.

I think I'm going to make a statement here today that I make to many people, because I often get comments made to me about the fact that we need to do something to contain the growth of the health care dollars. I agree with that because I think there is a question of sustainability relative to health care, and not just health care in Nova Scotia, but health care in this country. When you consider that we live in a province with less than a million people and far less number of taxpayers than that, and yet we are now at a point every year in order to continue delivering only what we're doing, not even adding anything, just to stay where we are, this province needs to now come up with approximately $200 million every year to stay there. Well, I question that and say, how can that continue?

I know that reference has been made this morning to the per cent of the government budget that Health is spending and that is growing. When I look at that I know that most of the dollars in that $200 million go back to collective agreements, their settlements, the negotiations with physicians, that's most of it. The main rest of it has to do with inflation. Medical costs like drugs are way above the normal cost of inflation, similarly for med-surg supplies and other things that the health system deals with.

My view is that unless we, as a province, and particularly unless we, as a country, can deal with those issues and if we're constantly increasing the additional dollars to go to health care that are far in excess of the normal rate of inflation, then that problem continues and sustainability is threatened. So I keep making people aware of that because I think at the end of the day, at some point we are going to have to bite the bullet in this and either something has to happen relative to the labour world and/or something has to happen to determine what is and what is not insured. Somewhere down the road while it's wonderful to have everything we do have, I think we have to understand what dollars are possible and what aren't.

MR. DEWOLFE: It seems to be a national problem from what we hear in the media. I don't know if there's a national solution to the problem but the out-of-control costs are going on in every province. I don't know where it's going to end but . . .

MS. DOIRON: I must say I was rather personally disappointed in some of the work that has been done nationally, if you look at the Romanow Commission, Kirby, or any of the rest. I understood that the fundamental basis of those kinds of reviews or commissions were to look at the sustainability of the Canadian health care system. What happened was that we got a lot of wonderful things being fed back about renewal of primary health care, providing

[Page 17]

more mental health care in communities and at home, all things that I think we can totally agree with . . .

MR. DEWOLFE: But meant more money.

MS. DOIRON: But all of it means more money.

MR. DEWOLFE: I know. Looking at the statistics on doctor billing that we are provided, in the legislative committee binders, I see that the number of doctors has increased throughout the province during the period that we were in power, since the government took office in 1999, there has been a relative, steady increase in the number of doctors. I think this is significant considering the challenges that we have in the province in getting specialists. I know we've had numerous challenges at our own Aberdeen Hospital in New Glasgow, and other communities have as well. But I think this really is a good-news story. To what do you contribute the growth?

MS. DOIRON: First of all I think we have remained financially competitive. We are in the top half of payment for physicians, not the bottom half, that helps. I think we all hear that today people are much more aware than maybe we were for a while, of our living conditions, our living circumstances. Nova Scotia is a wonderful place to live. There are opportunities for doctors to come here to be able to become involved in either academic settings or smaller local areas, to raise families in circumstances that I think many of us would support; much more, I think, awareness of the valuable assets we have, relative to nature and the things that are wholesome and nourishing for all of us. In addition to that, we've had a lot of support and feedback to tell us that the AFPs play a substantial part as well in attracting physicians. If I may, in this case I would like to defer to Jane again, to give you an example of a conversation that took place yesterday.

MR. CHAIRMAN: Ms. Breckenridge.

MS. BRECKENRIDGE: Yesterday I met with two of the neurosurgeons in the province, one in particular, the head of the neurosurgery group and head of the brain repair centre. In talking with him I was extremely moved by his comments about the impact that the alternative funding plan has had in both innovation and in the delivery of care to our province, as well as to Atlantic Canada. There were two particular types of procedures that he was speaking of that would put us leading the country in neurosurgical services that are provided to our province and in terms of the innovation that they are showing and then the impact of that innovation on the direct patient care was extremely moving, as I said. I think that his basic comment is that without the alternative funding plan in place, they would not have the branch and the group that they have right now and they would not be among the leading neurosurgery divisions in Canada.

[Page 18]

[10:00 a.m.]

MR. DEWOLFE: Very interesting. I'm going to pass in a moment to my colleague, the member for Kings North, because he wants to talk particularly about that but what I would just like to finish up with is, there is a decline in our population and Monday night Premier Hamm, during the course of a dinner speech, mentioned that at the time he started as a young doctor in New Glasgow, the Aberdeen Hospital was delivering some 300-plus babies and now it's less than 100. It just shows the decline if this is going on throughout the province, and I expect it is. I know my wife came from a family of 12, my two working daughters each have one child and probably that's going to be all they are going to have. Thank heavens we do have a couple of grandchildren.

This is going on in the province and, as was indicated statistically, there is an increase in doctors so a decline in population, because of this change in ratio, should mean improved patient care. Would that be a fair analogy to this, with the patient growth in decline or is that the case? We do have an aging population so maybe the patient growth isn't in decline at the moment, maybe that's something we will experience later on. Perhaps you can sort that out for me.

MS. DOIRON: Certainly I think your comments are appropriate. While you may have some decline, it's not excessive decline and the growth that is occurring with individuals as they age and the kind of illness and comorbidities that they have as they age make considerable additional demand on the system. In terms of the numbers of physicians we have, I think that we are doing well compared to other jurisdictions but as we know, we have some areas that do have a struggle maintaining an appropriate number of physicians so that there is reasonable and appropriate access for everybody in the province to a family physician.

We're doing quite well with that. Our last figures, as I understand it, indicated that something like 96 per cent of our population had a family physician but there are still those who don't. So we keep making efforts to improve that situation and some of that has to do with locality and some of the challenges that at times occur with that and we will maybe get an area stabilized. If one person moves, it can throw that off considerably or if a couple of people move, as in the case out in your area, I understand, with a husband and wife team. So there are challenges and I think there always will be, particularly when you are working in a province where you have many small, rural communities.

I think the issue here is that we are doing reasonably well and that we are constantly making those efforts to stay on top of it, to provide the incentives such as collaborative practice and other ways to keep physicians in these areas and certainly, as we mentioned in the introductory comments, AFPs are part of that stabilization.

MR. CHAIRMAN: The honourable member for Kings North.

[Page 19]

MR. MARK PARENT: I have quite a few questions on the AFP but you mentioned sustainability just a little while ago, so I will just make a passing comment and then get back to it further. In the issue of sustainability, more and more - and I mentioned this in the late debate one night where I talked about at heart it may be a spiritual problem. I'm relating that to work that the philosopher Ivan Illich made and I don't know if you are aware of Ivan Illich's work, but I think that there is something there that we need to look at but I will get back to that perhaps later in our second half. In terms of AFPs, does it save the system money or does it cost more money?

MS. DOIRON: I don't believe that we are spending any less per physician. In fact, we may be spending slightly more per physician with the AFPs. On the other hand, the AFPs have helped with the stabilization of physicians, as you mention, and because of that there are other things that maybe don't have to occur such as patients being sent out of province for certain kinds of care. We have not done, I don't think, what I would consider to be a total analysis to answer that question well, but I think as a general statement I would say that at best they probably would be neutral.

MR. PARENT: I'm a fan of AFPs because I think it will lead to better medical care, as you mentioned, with the ability of the doctor to spend more time with the patient, plus hopefully it will allow us to plan better from a policy and a department background. As we move from the old model to the new model, there are bumps along the road and we have to be aware of it. What other jurisdictions are using the AFP? Is it across Canada? You mentioned we are the leaders in promoting it.

MS. DOIRON: It is across the country. All provinces are now engaged to some extent in AFPs. Percentage-wise, I think we are the highest or among the highest. The percentages that I gave in the opening comments basically showed that growth, which puts us now at about 30 per cent of doctors paid on this basis and that is referring to doctors who are paid exclusively or fully on the basis of AFPs. We also have a mix so there is a higher percentage, if you add that in, where doctors are paid partially on an AFP and also partially on fee for service.

An example of that might be in smaller communities or districts where maybe a doctor is given a partial AFP to be the physician for that area who is attending to palliative care, may do that full time, may do that part time but in order to provide those kinds of resources, AFPs are a method of allowing that kind of concentrated type of care to be made available because if a doctor working in palliative care had to rely solely on fee for service, it would not likely be that too many physicians would go into that type of practice. So AFPs make it possible for us to advance a concentrated approach to certain areas where we need that kind of quality and attention to patient care that we might not otherwise get.

[Page 20]

MR. PARENT: The benefit to the doctors is fairly obvious. They can perhaps control their time a bit better and have more of a regular lifestyle. And to the patients, it's clear that the doctor would spend some more time with them. What's the benefit to the taxpayers of having the AFP program?

MS. DOIRON: I think that one of the benefits to taxpayers is that through AFPs, we are able to do two or three things that come to my mind quickly. First of all, AFPs have allowed us to very much strengthen our academic programs and when we do that, then generally speaking the amount and the quality of the research that is occurring actually increases, and we've been showing some steady improvement in that arena. I know when Jane was speaking about the AFP providing the opportunity for innovation, much of that innovation is in relation to research that then gets translated to patient care.

Research on its own actually has economic spinoff, as we know. So the more dollars that we bring into this province, the Nova Scotia Health Research Foundation, for example, receives $4.5 million a year at this point but they do a lot of matching funding for other grants that are bringing in substantial dollars, way more than $4.5 million. They leverage dollars to bring dollars in from other Canadian granting processes. So AFPs actually provide a foundation that allow us to continue to build on that potential.

The other thing that I think is a longer-term approach, but we started down the road with, is that whole shift in relation to primary health care. More and more we are seeing physicians wanting to go forward into collaborative practice arrangements, and where that occurs, I think, there is more concentration on the health and wellness of that population in that community. The more that we work on that over time, and certainly with the emphasis we place on it in this province through the Office of Health Promotion, and the attention and awareness that has developed throughout the entire health system, if we can make a positive impact on that then we will make a positive impact on the occurrence of chronic illness into the future.

That should actually translate into improved economic impact as well, and all of that, I think, is to the benefit of individuals, communities, people feeling more energized and healthy, making better contributions to their family and community life, having more satisfaction in their life, living less long with the burden with chronic diseases, and right now we're among the highest in the country in that regard. So we have many targets of that type that we're trying to get at.

In my opinion, collaborative practice arrangements, which call for AFPs on the part of the physicians, is all part of that package.

MR. CHAIRMAN: Thank you. We will turn it back to the NDP caucus. The second round will be 13 minutes each.

[Page 21]

The honourable member for Halifax Needham.

MS. MAUREEN MACDONALD: Thank you. The time is short and I do have three or four questions I would really like to get to, so I would appreciate it if we could keep the answers short. There are 25 AFPs in the province and we've had an audit of one that has raised some fairly significant concerns about how AFPs need some serious improvements. I want to ask, what assurance can you give the public that the flaws that have been identified in this one AFP aren't features of the other 24? Has there been a review or is there a plan to do a review of the other AFPs?

MS. DOIRON: We have not initiated a formal review of any of the other AFPs at this point, but part of the follow-up, as I said, from the medical AFP is to try to understand the implications that were identified there against the other AFPs. So bringing together at the table people who are participating in other AFPs over and above the medical, maybe I'll ask Jane to elaborate on that.

MR. CHAIRMAN: Ms. Breckenridge.

MS. BRECKENRIDGE: There are two pieces of information that would be helpful in this. One is the principles document that the deputy referenced earlier, and in that principles document it talks about the negotiation process as well. As you know, in the North South audit report one of the issues addressed was that negotiation process. That revised, transparent, accountable negotiation process is the one that we will be endeavouring in with all new AFPs that are negotiated, so that's one point and that's while the framework issues are going on.

The other issue that's raised within that principles document that has been signed off by Doctors Nova Scotia as well, and the other parties are in agreement with this issue, is that deliverables would be part of each new agreement that is signed before it is signed. The other is that as part of the work of the department, we will be ensuring that if there are contracts out there at the present time that do not have specific deliverables attached, they would.

MS. MAUREEN MACDONALD: Some physicians certainly have expressed concern about the impact that AFPs have had on wait times and recognizing it's a very complex issue, my understanding is that shadow billing is part of helping us assess the deliverables. The North South report said that there was non-compliance in the shadow billing provisions, so what steps has the department taken to ensure that there would be compliance with that aspect of trying to assess and ensure that there are deliverables?

MS. BRECKENRIDGE: The issues around non-compliance, during the process of the audit there was an audit of shadow billing at the same time. The figures, in terms of both whether you actually did bill and what you billed, was what was seen at the time. The numbers were nearing 90 per cent for accuracy and compliance. Obviously, that isn't 100 per

[Page 22]

cent, but it is a high percentage of when a patient was seen that the appropriate claim was submitted on a shadow basis.

[10:15 a.m.]

MS. MAUREEN MACDONALD: One of the things that the audit found was that we don't necessarily know that we're using AFPs in the best place, because there is no health human resource plan. So I'm wondering what steps are being taken to get in place a health human resource plan and how soon will we see this? Number one. Number two, a concern was raised about the payment of duplicate benefits under the AFP and this does not seem to be one of the things that has been addressed. I'm wondering, what is the Department of Health intending to do with respect to the payment of duplicate benefits? The last question I have pertains to the Auditor General who has identified concerns about cuts to the internal audit function within the Department of Health, and the fact that there aren't enough personnel to ensure the kinds of controls that are required. So those are three questions if you could answer in the time, thank you.

MS. DOIRON: I'm going to try to answer two as quickly as I can, then ask Jane to answer the third. The first one that I'm going to address is the HHR plan. We are in the process of developing a health human resource plan across a number of disciplines right now. That is underway and we anticipate that we should have something developed that would be accessible by the end of this calendar year, that's our objective. We have been working for the last year and a half, maybe two years, specifically with a physician resource plan. That has been going very well.

Certainly, a lot of the physician representatives and administrative people in the province were part of that group that is doing that work, and developed a methodology that is, I think, a much-improved methodology from what previous resource planning used to look at, and understands it from the perspective of the communities and populations in Nova Scotia. In other words, you can't have every specialist in every community, but what does that mean?

There has been a lot of dialogue, specialty by specialty, that's near completion and once that is completed then we'll have a plan that we will start to operationalize within the physician services branch. We were thinking that probably, again, within the next several months that should be something that's nearing completion. We are using portions of it as we go because we keep getting sections of it that are further developed than others, until we complete all those specialty consultations. Anyway, that's well underway.

In terms of the auditing function in the Department of Health, this has shifted around in government over time. At one point in time there used to be a number of auditors in specific departments, they were centralized at another point in time, maybe under the Department of Finance. This isn't an issue that the deputies have been looking at across the

[Page 23]

province to say how this should work. Regardless of the model, we feel that we need some additional staff in the Department of Health. This year I was able to obtain one additional position that will be able to be an auditing function within our Department of Finance.

They are also going to be increasing some Department of Finance central auditing functions and they're setting up a deputy advisory committee around that so that the whole coordination of auditing throughout government departments can be looked at at a reasonably high level. I've been informed that I will be on that committee, and I'm very pleased to hear that because we think there needs to be an appropriate balance of central auditing that deals with compliance with a lot of legislation or government-related issues. We also feel there needs to be some capacity within the Department of Health that would be more content-knowledge specific. So right now, that is very much an issue that is high profile and resources on both of those sides are starting to be added. I'm not sure that we have enough yet but that's going in the right direction.

A third issue, relative to the duplication of benefits, I'm going to ask Jane to respond.

MR. CHAIRMAN: Ms. Breckenridge.

MS. BRECKENRIDGE: There are two pieces of information around the issue of what was referenced as duplicate benefits. On the issue of the practice plan, one of the things that I think needs to be mentioned in that, for some clarity, is that within any of these alternative funding plans, the Department of Health provides funding to the group. The group then develops what they call a practice plan. That practice plan then allocates the monies to the individual physicians based on either seniority or the type of work that they do. So within the Department of Medicine practice plan, benefits was one of the areas that they had decided among themselves was an important area to allocate to the physicians for recruitment, retention and as a group they decide how it is that the money is allocated.

The reference to duplicate benefits spoke to Doctors Nova Scotia and the fact that we have what is called a benefit fund as part of the negotiated master agreement, but those are two separate entities in terms of the fact that this was an allocation decision among the group of medicine physicians of how it is that they had decided would best suit the needs of that group.

MS. MAUREEN MACDONALD: I think I understood that, but I guess the question is the appropriateness of that set of arrangements rather than what the arrangements were.

MR. CHAIRMAN: I'm sorry, you haven't asked a question yet. Do you want to continue or do you want to let Ms. Doiron answer?

[Page 24]

MS. MAUREEN MACDONALD: My question is the appropriateness and how the department is viewing this. Does this mean that in a particular group they are able to supplement benefits that are coming through the benefits plan of Doctors Nova Scotia, establish new benefits that aren't part of the master agreement, whatever, and how appropriate is this in terms of the department's perspective around the health care dollars?

MS. DOIRON: Two quick responses to that. One is that at least from onward now, we will be reviewing the individual practice plans that any AFP group puts in place. We will be able to see what they are doing, their allocation. Generally speaking, the way that works is there is an agreement that there is so much money per physician, whether that is $100,000, $200,000, whatever, but it may be that a junior person coming in would make somewhat less than a senior person who also has a teaching responsibility, for example.

But what they do with the rest of that, relative to where they assign other dollars that may relate to benefits and so on, we will now be in a position to review each one of those plans. Having said that, up until now, how the physicians deal with that pot of dollars has been exclusively the mandate of those physicians. It's our view that we need to start talking about a better approach and method for the dollars that we are putting in to support the other kind of operational support things that need to be there in relation to these AFPs. In other words, things that are there relative to clerical support, billing support, things of that nature. If we start looking at that in a different way and consolidating it as opposed to giving it through each AFP, maybe we can come up with better efficiencies and perhaps there may be a better approach. Maybe it's a mix of physician and administrative input at the district level but what we will be doing is going down the road to explore those potentials as well as the review of the plans.

MR. CHAIRMAN: You have five seconds left so let's donate that to the Liberal caucus. We will move on to the Liberal caucus.

The honourable member for Richmond.

MR. MICHEL SAMSON: Mr. Chairman, I welcome the deputy and her staff here today. Deputy, I think you were provided notice yesterday of some of the questions that I would be asking today. One of the issues with AFPs is the impact it is having on rural communities and especially on some of the chronic shortages that we are having of physicians to cover emergency rooms in rural communities.

As you are aware, the Strait Richmond Hospital has, for the most part, had its emergency room closed Monday to Friday, 8:00 a.m. to 6:00 p.m. since January of this year. We are now going on six months that we have not had daytime emergency room coverage at that facility. It is my understanding that there is an AFP position available at that emergency room that would have a guaranteed minimum. Unfortunately, there doesn't seem

[Page 25]

to be much interest among doctors to take up that particular position. Would the deputy please advise us why it is that doctors are not coming to that specific facility?

MS. DOIRON: If I may, Mr. Chairman, I'll refer this to Ms. Breckenridge.

MR. CHAIRMAN: Ms. Breckenridge.

MS. BRECKENRIDGE: As you mentioned, there is a contract available for that location. Within our physician services branch we do have a significant amount of recruitment tools that are utilized and all of those tools are potentially available for that area. With all of the recruitment issues, it's a matter of physician choice and trying to match physicians with the appropriate community. We have had several visits to that community and we have, over time, had some physicians stay, but obviously it's a matter of choice in terms of where they locate. But all of our recruitment tools and efforts have been available to that location.

MR. MICHEL SAMSON: I appreciate that. I guess the frustration comes that it is almost six months and I don't need to sit here and criticize your recruitment tools, I think the closure speaks for itself, so something is not working. The question becomes, what can we do differently?

When we did the Health estimates the deputy was here and heard me talk about the fact - and we have heard it year after year - that doctors at the Strait Richmond Hospital doing daytime emergency room coverage are not paid at a level that is comparable to physicians in the surrounding areas. It becomes a very big bone of contention with physicians there and before long, they are gone. I guess my question becomes again, is the department prepared to review the salary arrangement at that facility so that it can be amended to better reflect the salaries being earned by doctors in the surrounding communities?

MS. DOIRON: I think this is also a long-standing issue that probably doesn't have one answer. The salary level, I think, we have addressed and have seen that this has been a unique setting in which to try to maintain physicians and because of that we have provided incentives that we can. I don't believe that this is totally a salary issue.

We do know it is very difficult to get physicians to agree on a long-term basis to settle in that particular facility. It may have to do somewhat with location, with what else surrounds the hospital in terms of what they need or feel they need to get involved in, participate in, some of the challenge that is there relative to that location. We are encouraging the district health authority, GASHA, to approach this as well with any kind of innovation or creativity that they can bring to it. In other words, is there some other approach that can be taken, whether it is at that site or not, around accessibility for emergency and urgent care for the people who need to be served in those communities?

[Page 26]

I would say that in addition to providing additional incentives that are financial, which we're doing, that's not providing the resolution that we are also open to saying, is there some other design of how this could take place? If, in fact, the community and the district health authority can come up with another more innovative approach to making sure there is access, we are very open to working with them and to assessing something that might be more constructive, I guess, or serve people better in the long term.

[10:30 a.m.]

MR. MICHEL SAMSON: In no way am I suggesting that simply the salary is the only issue. My point and the frustration of the community is that of leaving no stone unturned in trying to make that facility as attractive as possible, and that is one of the elements that has been brought to our attention, so we at least know there is one aspect that can be addressed by the department that unfortunately, to date, has not. I know there have been incentives, we put in incentives when we were in government, but they still don't match the surrounding salaries.

A doctor in Arichat is making significantly more money than a doctor at the Strait Richmond Hospital. It is no different than St. Peter's, in L'Ardoise, or in Port Hawkesbury, the problem with this facility is that the volume is just not there. Because of that, there is a guaranteed minimum, but unfortunately, the minimum seems to be more the norm at that facility, whereas doctors in surrounding areas are making significantly more money.

I do appreciate what you're saying that you are interested in more options and I'm sure the community and GASHA probably have more. As you know, those options come with a price tag, so I guess my question is, is it your statement today that the Department of Health is prepared to put more money forward to assist GASHA and the Strait Richmond Hospital, to put in some additional outside incentives, whether they be in the construction of a home for the physician, which is something other communities have looked at doing. For example, is the Department of Health prepared to put the necessary funding available if GASHA and the community come forward with some proposals?

MS. DOIRON: If the approach that is suggested to the Department of Health for funding is consistent with what we negotiate with Doctors Nova Scotia, then I think we would consider that. What we would probably not consider is something that is going to cause a ripple issue throughout the understandings we have in the contracts with Doctors Nova Scotia, so as to lead to maybe ramifications that we would find difficult to address.

We cannot, independently as the Department of Health, take an approach to the funding of an emergency department or a physician that is inconsistent with the negotiated contracts that we have. So we have to find a way that is appropriate, that can give the appropriate response to a specific site or community, that can also be consistent with those kinds of agreements. We are very open to doing that and we are very open to exploring any

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potential with Doctors Nova Scotia. But if you are saying will we make that emergency department a different level emergency department than what it is defined as, without some criteria on which to do that, we can't just automatically do it, and we do have other parties to consider in that regard.

MR. MICHEL SAMSON: I appreciate that and that's the answer that was given to me by the then Minister of Health back in 1999. It has been six years, this facility has proven itself to be a unique facility in the challenges it faces. I appreciate what you are saying because what we hear is, well, there are contracts with Doctors Nova Scotia and we need to get approval from the College of Physicians and Surgeons on whether they have the criteria to be qualified to be a doctor. We saw what happened recently, as I mentioned in the budget estimates, we waited three months to find out if a doctor who wanted to locate to the facility was qualified, to be told at the end he was not; it is completely unacceptable.

I hear what you are saying about we can't change one facility for all of the others, and that almost reminds me of the commercial where you have two gentlemen sitting on an ice floe in the middle of the Arctic. One opens up a bag a chips the other asks if he can have a chip and he says, if I give one to you, I'll have to give one to everybody around - there's nobody around. This is a unique facility, it needs to be dealt with in a unique way. If Doctors Nova Scotia doesn't understand that, then let them say it so that we can deal with them, rather than the Department of Health, if they are the ones holding up changes at this facility.

I just want to close by saying the community is frustrated, we are looking for leadership, we're looking for innovation. We cannot treat this facility like all other facilities because it is just not working. I appreciate your recruitment efforts, six months, something is not working, and we've seen this time and time again over the past six years and before that. We need to take a unique approach and it needs to be done soon.

If someone is holding it up, if it's Doctors Nova Scotia, if it's the College of Physicians and Surgeons, then say so. As I told the minister, there's no need to blame the Department of Health if it is someone else who is holding this up, let us deal with those individuals and those organizations if need be. But something needs to be done differently, because the approach right now has failed and it's just a matter of time until someone's life is put at risk because of the closure of that emergency room. Thank you.

MS. DOIRON: I want to say that I really appreciate the frustration and the time frames that this locality has been trying to deal with, relative to the service provision. I think everybody has tried hard and I don't want to suggest that Doctors Nova Scotia are holding up anything. I think that's just a reference to the process we go through.

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It does happen that Strait Richmond and Arichat both are the same level of emergency departments. They're both Level 4 and, consequently, the remuneration for working at either of those sites is the same, except that we have tried to provide incentives for Strait Richmond in the past that are over and above what we're providing to the physicians in Arichat.

We've tried to work within the parameters that we have and tried to stretch them, to attempt to get recruitment that's successful for Strait Richmond. That's why I'm saying that while we continue down that road and we'll continue to work hard at it, with everybody's best efforts we're not succeeding. We're not succeeding, at least, on a sustained basis. Maybe there are some other kinds of arrangements here that need to be thought through to serve people. We are certainly open to looking at those other options.

MR. MICHEL SAMSON: One final thing. Keep in mind that in Arichat there is a private clinic just down the road that the doctors have access to, where they see in excess of 100 people a day. That doesn't exist at the Strait Richmond. The problem is that the doctors in Arichat have a clinic next to an emergency room which is very important that they have. We don't have that at the Strait. It's not comparable, not at all, in the amount of people they see during the day and that's why the salaries are so out of whack between the two of them. Again, that goes to the uniqueness of where the Strait Richmond is located. There is no clinic for the doctor during the day to be able to work as well.

MS. DOIRON: My point exactly, Mr. Chairman, that maybe that means that a different location and model needs to be looked at for the people who need to be served from this area.

MR. CHAIRMAN: Thank you. I know the member for Halifax Citadel wants to get something in. He's got 50 seconds.

MR. GRAHAM: I'll do what sometimes happens, I'm going to pile two questions into one and they are completely unrelated. The first is, whether or not you know of the concerns with respect to anaesthesiologists. Was there any consideration given to a blended approach - not just an AFP but a blended approach - with respect to anaesthesiologists?

My second question, in your answer to the member for Pictou East, you indicated that you are concerned about whether or not we are going to get swallowed by the funding crunch. My question is whether or not you believe that, in fact, we are on that path or whether we are on the path of recovery where we are not going to get swallowed by that funding crunch in the end?

MS. DOIRON: In relation to anaesthesiology, I don't believe we have explored a blended approach. We have just kind of initiated a very short time ago, the anaesthetists have not been on the alternative payment approach for very long yet. We are seeing some results

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that would suggest that the AFP is going to have a positive impact there, but at the same time, as you say, we are short. The Capital District is short six anaesthetists. They do have six that they are considering but that's not finalized yet. As we know, I think it's about 400 anaesthetists that are required across the country. Would we consider a blended approach? It hasn't been discussed yet so I'm not saying we would not but the AFP is very new there.

In relation to the funding that I think at some point is going to overcome us, I think we are on that path in this country. I don't think it's a Nova Scotia-exclusive issue. I think it's a national issue and I think that it's something we need to start paying serious attention to so that we can understand from a dollar perspective how we can sustain a future public health system.

MR. CHAIRMAN: Thank you very much. we will move on to the Progressive Conservative caucus.

The honourable member for Kings North.

MR. PARENT: Thank you very much, Mr. Chairman. In your comments, you were talking about how AFP allowed doctors to focus more on primary care. I think that's a segue back into my comments about Ivan Illich, because with the fee-for-service, there is almost a vested interest for the doctors to see more illness, in a sense, and to do less health prevention and promotion. So the alternative funding program allows for that emphasis and I'm glad that you brought that out because I think that's a very important benefit of the AFP. As I said, I think the AFP program is the way to go. I'm going to ask some very quick questions, though, about potential problems with it and then, through the Chair, turn it over to my colleague.

The question is, in terms of work output, most doctors are professionals, they are going to work hard. But I have had concerns raised by former health authority members where there was a doctor in a community on an AFP program. He was the only doctor there. He was building his new house and he just would close the office for two or three hours because it made no difference to his salary whether he was seeing patients during that time, to go and make sure that the new house was doing well. How does one have one's cake and eat it too, in terms of ensuring, and I admit they're in the minority, but ensuring that the output is there?

MS. DOIRON: Again, I want to emphasize the point you've just made and that is that most doctors are very professional, they are there to do a job like other professionals are and they do, in fact, go well beyond what seems to be reasonable in terms of the demand on them, their time and energy.

Like in any area, I guess, you have exceptional cases where, maybe, the productivity and the dedication is not what you would like it to be. In those kind of situations, those cases

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have to be dealt with on an individual basis. Anybody who is performing on the kind of basis you describe, I think that would become fairly apparent.

There is room through the district health authority and their advice to the department for it to be able to follow up, even on the deliverables that are already in these contracts which require a certain number of hours of work or certain other kinds of coverage. We have that to fall back on but I do think that we have to build in mechanisms that are actually more active, more successful and better mechanisms to look for those accountabilities.

MR. PARENT: The other question is, does the AFP- and, again, I am in favour of the AFP, don't get me wrong - but is it a potential problem that in order - and I'll draw the parallel with bonuses that you have with civil servants, so that when they're at the top of their salary bracket or something, in order to get extra work out of them or whatever, you provide bonuses, the AFP, with physicians, will that open the door to providing big - because some of these things are very irritating to taxpayers. In the old fee-for-service system, for example, physicians' children would receive funding for university education. People find that very upsetting when these are such well-paid individuals. Will the AFP lead to more of those little extras added on?

MS. DOIRON: I believe it will in a sense. If you kind of make that analogy between civil servants and bonuses, whatever, then within what we do - for example, if I just use myself as an example, on an annual basis I need to state some objectives and goals that I am trying to achieve for the Department of Health. I am measured on whether those things are achieved or not, or reasons why they are or are not achieved.

Similarly, now that we are going down the road to start building in specific deliverables to AFPs, we won't moreover have, in the future, the potential to kind of measure output in the sense of the benefit to the system, to the population, to the output of health.

As we continue down that road and if we look at ways in which, not only we define deliverables, but how and who actually assesses and manages it, I think it builds a whole different perspective around performance accountability. I think the AFPs do permit us to do that more effectively than fee-for-service has.

MR. PARENT: Thank you very much. I would love to have a chat about Ivan Illich's trenchant criticism of the medical system but we don't have that time and my colleague would like to have some questions.

MR. CHAIRMAN: The member for Waverley-Fall River-Beaver Bank.

MR. GARY HINES: Thank you, Mr. Chairman and thank you, guests, for coming in today. I am bringing you good news this morning. As I was having my breakfast at the

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local coffee shop, a trucker pulled in who was moving two doctors back from Alberta. (Laughter) We've got a plus two starting out this morning.

I would like to pursue the Clinician Assessment for Practice Program. There's discussion there. The question will be broad and allow you a very broad answer. Two of the things I would like you to address are, how the application process takes place and do you actively recruit people to come to the program? The other one is, are there sponsorship or mentor programs included in this, in terms of doing this? Then I would like you to end with, if there is a program similar that would bring physicians from other countries?

MS. DOIRON: I'll defer that to Ms. Breckenridge.

MS. BRECKENRIDGE: On the CAPP program there will be a job fair on June 6th,

next Monday, where all the potential candidates will be able to meet the various district health authorities and others within government so that, in some ways, is a matching system per se.

On the issue of mentors and sponsors, one of the requirements of the program is that the successful candidates, after they have gone through the program, will be matched with a mentor and the mentor would be taking them through the next period of time as designed by the program. So yes there is a mentorship and a sponsorship aspect to that program. It's a very important part of it.

MR. HINES: Now when individuals come into the program, is there a follow-up to see if successful applicants are integrating into the communities and setting up their practice and so on? Is there a follow-up with the CAPP?

MS. DOIRON: Yes, there will be and the mechanisms that have been built into the CAPP program provide the opportunity to retain the physicians who are mentored through that process for a period of time. There are a couple of other programs in the country where there are shorter periods of time, they do not have the length or the formality of the mentorship program developed to the extent it has recently been developed here and endorsed by not just the College of Physicians and Surgeons but also by Doctors Nova Scotia and the department and the university. So I think that the design that we have here encourages continued sustaining of these individuals with incentives and so on that would allow them to hopefully be interested in staying here for two, three or more years and it will have a follow-up and evaluation because it's a reasonably new program.

We are looking at these initiatives as well. When we look at these things in the Department of Health, we are also working across government departments so differently now that we automatically look at where we should have partnerships. One of the most obvious and immediate ones that comes up when you are looking at these kinds of issues is the new Office of Immigration. Even in the development of the CAPP program, one of the

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groups that sat at the table for briefings and some input was the new Office of Immigration so that we can jointly make efforts that will assist with recruitment and opportunities.

MR. HINES: I guess what you may be suggesting is that you will see the CAPP program expand so that it also includes international applicants who may want to come as well.

MS. DOIRON: Absolutely, yes.

MR. HINES: Let's move now to the retainment of student doctors coming out of our universities. What programs are in place to retain students coming out of our universities, how successful has it been? In comparison to other provinces, where will we fit in terms of retaining?

MS. DOIRON: First of all, I want to just add to your last question that despite our efforts to attract more people from other countries and so on, 25 per cent of our current physicians are trained out of country, if we go and look at their backgrounds. So we have been attracting people but we want to do even a better job of that.

In terms of the students, there are several mechanisms when they graduate that we have in place to try to interest them in staying here. First of all, even before they graduate, the university, with our support as well and the district health authority's support, is a very effective mechanism for placement of students into clinical practice. When they are going out to do their residencies and so on, we have probably the highest - I think it's the highest still - rate in Canada of attracting students to actually go into family practice residencies. This has become an increasing problem across other provinces in Canada and something that has actually come to the attention of federal-provincial committees to try to deal with some of the aspects related to it. We're still enjoying a pretty high level of those kinds of placements which, in our opinion, bodes well for the future placement of family practice physicians in our province or in the Maritime area.

Having said that, we also have programs when students graduate. For example, we have a debt repayment program that allows students who are willing to go to areas that we see as areas that are harder to attract to, to have the benefit of having X number thousands of dollars - I think it's about $15,000 right now - paid on their debt for a period of three years. There may be others but those are the prime things, I guess, that we're doing.

MR. HINES: Just one short question. The fact that this government has established stable funding or long-term funding for Medicare, is that helping you with your AFP program so that you have an idea financially where your programs are, and to allow you some flexibility with the guaranteed funding?

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MS. DOIRON: The guaranteed funding I think you're referring to is the three-year rolling funding for the district health authorities. That keeps getting some very positive feedback from the districts, and from their boards and so on. The AFPs provide stabilization in some ways, but like any form of work or practice, they are open to renegotiation and each time then you're into a set of negotiations and they're not done in advance, they're open before the conclusion of the contract normally. But regardless of whether a physician is in fee for service and they're under the master agreement, or whether they're on an AFP agreement, there is no guaranteed funding in a sense attached to that.

MR. CHAIRMAN: Thank you very much. That concludes the question and answer portion of our proceedings. Ms. Doiron, you may now take up to five minutes, if you wish, for a closing statement.

MS. DOIRON: Mr. Chairman, I don't have a lot of statements to make in closure. I would like to say that we very much appreciate the questions that we've received here today, the opportunity to put on the table with you - and hopefully with the public - the intention that we have in the Department of Health to be open and transparent, to improve and to continue to improve in all the areas that are connected with quality, patient safety, medical error, work going on in that regard. The intentions that we have across many areas, but certainly physician performance and payment being one of those areas where we're increasingly building what we think are the more appropriate kinds of accountabilities, and transparencies for us and for the public. Certainly, when we come to committees like this it causes us to stop and reflect on that to see are we really doing everything we believe we should be?

While there are lots of issues and there have been many past problems, I think that we are on the right path and that we will continue down the road to try to understand how the department and the physicians in this province can perform more effectively and in the best interests of the public. I will close with that, thank you very much.

MR. CHAIRMAN: Thank you. Members of the committee will note that this is the last meeting of the committee before our usual Summer break but for the meeting that's tentatively scheduled for June 29th to receive the semi-annual Report of the Auditor General. That is tentative, depending on printing dates and the availability of the Auditor General himself. That will be confirmed by the clerk of committees at some later time. Whenever that report is available, we will be having one more meeting.

Other than that, the members of the Subcommittee on Agenda and Procedures can expect to be convened in early to mid-September so that we can start the work of planning our next hearing year. Are there any other items that require the attention of the full committee? Motion to adjourn.

Would all those in favour of the motion please say Aye. Contrary minded, Nay.

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The motion is carried.

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This meeting of the Public Accounts Committee is adjourned.

[The committee adjourned at 10:54 a.m.]