The author is a Calgary-based commentator with particular knowledge of family medicine. 'Jack Hobbes' is a pseudonym granted for the protection of the author's situationWhen I was a child, one Doctor Proudfoot served three generations of my family. The care delivered by this doctor — who was effectively a specialist in our family's issues — was superb. Unfortunately, that's not an experience shared by all Albertans these days.As of May 2024, only 190 family doctors were accepting new patients. By conservative estimates, at least 800,000 Albertans are without family doctors and clinics are closing at an alarming rate. Doctor Proudfoot was a member of a now-endangered species.While the government has recently announced a deal with the Alberta Medical Association that might benefit family doctors, it's important to note that this deal does not directly address the systemic issues facing local clinics. Simply put, the business model for local clinics is broken, and that may lead to the complete collapse of primary care infrastructure across the province. What happens then?The financial viability problem is no joke. According to an Alberta Medical Association survey this spring, 20% of family physicians indicated their practices might not remain financially viable beyond six months. Only 21% felt confident about maintaining financial viability for up to a year. Nearly two thirds of family physicians — 61% — were contemplating leaving Alberta's medical system. These statistics are born out anecdotally: I have been made aware of at least a dozen clinic owners looking to close their doors in the new year.Despite the government’s announced deal with the AMA, three significant problems remain.First, there is a dramatic compensation disparity between family physicians and specialists. Canadian family doctors average full-time pay of about $258,000, from which they have to pay $146,000 in business expenses, for a net take-home pay of $112,000. Local numbers may be even worse. The specialists, by contrast, earn much more — usually over $400,000 — with no overhead. It is no surprise that we have more specialists than we do family physicians, as they are receiving four times the compensation. And when the government cut payments to doctors, those cuts affected family physicians — especially rural ones — more than they did specialists.Secondly, the problem is far worse when you consider clinic operations. The burden of establishing and maintaining the local clinic does not fall evenly. The doctor who owns the clinic is responsible for recruiting and retaining other physicians. With family doctors in short supply, those other physicians can drive tough bargains regarding their share of clinic costs. And while family doctors earn less than they used to, costs have not decreased. The clinic owners are between a rock and a hard place, and we have already seen plenty of clinic closures.Finally, the fact is that the centralization of the Alberta Health Services system inevitably prioritizes acute care — hospitals, not clinics. AHS’s Primary Care Network system is a secondary concern, which doesn’t do a good job of consistently and adequately funding family practices. Worse, the system forces family doctors to spend tremendous amounts of time filling out paperwork, which has a cost in both patient care and revenue. Simply put, AHS' centralization is good for hospital-based specialists but doesn't work well for clinics — particularly rural ones.It is true that the recent deal the province made with AMA offers something to compensate doctors for paperwork. However, the deal comes with its own complex reporting requirements to access that funding, and the amount offered is less than what a tradesman would charge for “shop time.” Moreover, there’s nothing here to help the clinic itself: the additional funds appear to be intended to go directly to doctors, bypassing the clinics. It doesn’t help the community medical practices where most of us receive family services.Simply put, today’s system doesn’t value doctors like Proudfoot.The underlying issue is this: clinic operators provide the infrastructure for primary care, as well as the service. We don't want to stop this: we're saving almost a million dollars per clinic in infrastructure costs and at least $150,000 per doctor per year in overhead. With 600 clinics and over 4,000 family doctors, the savings exceed $600 million in operating costs alone. AHS-managed facilities wouldn't just erase these savings; they'd require significant capital investment to replace the infrastructure lost to clinic closures. It's a price that Alberta cannot afford.Our current funding model ensures clinic operators have few reasons to keep their facilities running. To overcome clinic funding woes, we must ensure that funds go to the clinics. The simplest road is to fund clinic operators directly, rather than trying to funnel that money through the AHS bureaucracy. Direct funding, a method used in places like Austria, would allow clinic operators to allocate resources based on specific community needs, enhancing responsiveness and efficiency. It would also minimize administrative burdens, allowing clinic operators to focus on patient care rather than navigating complex funding mechanisms. We could also tailor it to support the needs of the clinics, such as overhead costs, staffing, and infrastructure. Direct funding wouldn't just promote sustainability, but incentivize doctors to open clinics, reversing the current trend of clinic closures.Critics of direct funding might argue that centralized funding would ensure cost control and accountability. However, direct funding tied to patient care metrics will be more transparent and effective. Critics cannot even argue that it breaks a mythical single-payer model: we already pay directly to jails, reserves, soldiers and poor people from different funds. And in the end, clinic owners are accountable in a way that AHS bureaucrats will never be. We trust Proudfoot — not the men in black.However, the Alberta government makes no concessions to those without political power and will to demand it. If clinic owners want the government to take their plight seriously, they will have to organize. To that end, the Alberta Clinic Owners’ Association (ABCOA) was founded in 2024. If the organization can succeed — and one of its leaders tells me that almost half of the clinic owners have already joined — the government will have a reason for reform. If ABCOA isn't successful, the health situation in Alberta will become dire. Albertans will use hospital emergency rooms for things they used to see a clinic for. Wait times and costs will skyrocket; preventative care will become a thing of the past. We will become less healthy.We can all do something about this. Hopefully, policymakers will take action to fund clinics directly. However, more clinic operators need to join ABCOA if they want to have a voice. And people who aren't doctors—like you and me—can write to our MLAs to express support for sustainable primary care.Family doctors like Proudfoot have done good work for us – it’s time for us to support them.The author is a Calgary-based commentator with particular knowledge of family medicine. 'Jack Hobbes' is a pseudonym granted for the protection of the author's situation.
