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On Adaptivity, Listening and Learning

“When are you going to comment on all of this going on, Margie? We are waiting for your thoughts!”

A friend of mine asked me this in relation to the status of “relations” between the physicians and the government a few weeks back. I kept holding off as things were evolving day by day. And then we had a pandemic. Needless to say, the status of relations was not good then, and it is not good now. I’m thinking back to my earlier “predictions” in late 2019 (see my blog on December 10 for the full piece):

Prediction 1: Payment reform is coming to primary care. Previous attempts to make changes were not supported by providers for many reasons. The government is making fee for service unattractive and cutting the very areas that are needed to support strong primary care: chronic condition support. Step one is making the current state unattractive, step two is to paint the future state as more attractive. The government will use the HQCA report as their support. Classic change management theory.

Prediction 2: Cuts to others parts of the system are coming. We all know that is the case, and some have already started. Even if primary care costs more to deliver, the cost savings are still positive. A “bolus” of funding to get it started is needed, which the savings from terminations may come in. Long-term funding can be managed with the cost savings to the system with stronger primary care.

Prediction 3: Alberta Health will be much more involved in physician management. The veto power on negotiations and health service planning is interesting and one that likely can’t be ignored. That may come in the form of tighter controls over Primary Care Networks.

All of the predictions have come to fruition to some degree. Sadly, it is only the cuts that have come through. There has been some movement to make it easier to be approved for ARPs, but the investment end is not there. I do stand by the prediction there will be a change funding models - and the ARP or some form of capitation will mitigate the current cuts of 20-30%.

Where my thinking keeps going back to, and what I wrestle with, is the damage done with the approach taken. This sad fact is driven home by the situation we are faced with today. Overnight, the music changed. We went from a tough negotiation strategy to a public health emergency. We went from cutting front line staff to redeploying as many people as possible back to the front lines. We went from business as usual to emergency planning. The music changed, but the it seems there are some still dancing to the old tune - and it is out of place.

The accusatory nature of the discussions on Twitter and in the media that doctors are taking more than their fair share - illegitimately - essentially erodes a trust that the physicians have with their employer. Many of us have likely been in a position where we had a level of distrust for our boss, employer or organization. Nothing good came from that. We likely left or did the bare minimum. In the case of doctors that means leaving the province or not offering services like after hours care. At a time when we need providers of all stripes to lean in, the conditions were created that made them want to lean out.

These days politics is presented in a way that doesn't allow is to hold polarities. Health providers who are happy, engaged and supported will go the extra mile. The result is better patient care. That is a truth. There is also a truth that we need to sustainably and responsibly spend our tax dollars. There is a truth that doctors are small business owners, and a truth that they are public servants and system stewards. For me, it keeps coming back to trust. Change moves at the speed of trust. Not contracted trust in an agreement, but relational trust that is earned, demonstrated and reinforced on a regular basis.

How do we get to a place of trust? We listen. We seek to understand. Understanding doesn’t mean agreement. It means respecting someone enough to want to know where they are coming from, and being open enough to let it inform our thinking.

But, in our interrupting culture, 140 character snipes and need to “have the answers,” the art of listening, reflecting and seeking to learn seems to be lost. At a time when we need to pull together as a province, we instead hold positions and beliefs without understanding that seemingly opposing beliefs can be at the same time equally true. It is in that “grey” that we can artfully seek ideas together.

Letting go of perceived absolutes could have such a benefit when we are faced with the situation we have today. Recognize that providers run a small business, but are at the same time integral to the public good and are accountable. Recognize that the system we have today is not getting the results we want.

In today’s environment it is more important than ever to listen and learn from each other. This means that the government needs to purposefully ask a question, give latitude to providers to test that question in practice, and then listen and learn for the purposes of policy and payment reform. A current issue we are facing today is the capacity of 811 for screening, and patients getting in to see their provider for other health issues, while keeping people safe and out of clinics. We could do a test of change:

1. Increase the number of visits that can occur by telephone or video. Telemedicine is already here. Let’s acknowledge it is something patients want, and something we need at this time. Open up to an unlimited amount of calls for a few weeks. Ask for data – both quantitative and qualitative. What kind of calls worked well to this approach? What did not? What was the average in a time of crisis? What are some guesses as to what that might look like in a normal week? How did patients react to the call?

2. Healthcare is a team sport – even in community specialty care, and especially at this time. Nurses, social workers and therapists are part of that team. Why do we pay providers to do this on their own? How could nursing staff help with phone triaging and offering health advice? How could counseling by videoconference work? If we need providers to work at their highest scope of practice, what activities should other providers do to open up capacity and access for patients? How many team members are needed based on the panel size?

The only way to change and adapt to our rapidly evolving situation is to listen. Deeply listen and learn together.

Don’t waste a good emergency. The music changed. Let’s get in step - together.

NOTE: As of March 12 the government enacted code 03.01AD in efforts to ensure continuation of care when the patient or physician is in self-isolation due to COVID-19. The code can be claimed:

- One time per patient per day

- When offering advice, new prescription or renewal

- When providing care in relation to COVID-19

The visit must be recorded in documentation and is only for doctor to patient or agent discussion. It cannot be used to provide general information on the virus or claimed for services provided through Health Link.

While this is a good step, an even better step might be trying to foster some curiosity and learning out of this new billing code:

- What might be some benefits to having doctors also do screening for Health Link?

- How might telephone visits be supported by other health care professionals?

- What kind of experiences are patients having with this service?

- What are some of the avoided expenses by using this approach?

- How long do providers spend on the phone?

- What are some of the characteristics of visits that are well suited to this kind of visit?

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