A new piece of legislation in Quebec
could mean the beginning of the end for the province's
medicare system — or the start of a promising future
for doctors to work in private practice. It all depends
on who you ask.
Bill 33, slated to be passed this
fall, is the province's response to last year's Chaoulli
decision — the Supreme Court ruling that found
long wait times in the health system violated Quebecers'
right to life. The bill was designed to speed up access
to specialized medical services.
Bill 33 establishes a role for
private healthcare delivery in the public system, in
hopes of alleviating unacceptably long wait lists that
have become the bane of the Canadian healthcare system.
EXTENSIVE
REFORMS
But Bill 33 is more complex than just cutting wait times.
It proposes sweeping reforms that seem destined to re-draw
the province's medical landscape. Many doctors have
criticized Bill 33 for going beyond what they had seen
as necessary in its introduction of limited private
delivery of public healthcare.
The Bill will give doctors permission
to run publicly funded, privately owned, for-profit
surgical centres. It will also create a wait list management
system in public hospitals to determine when overflow
patients must be sent to private clinics. And it will
end the province's absolute ban on private medical insurance,
which will now be available — albeit only for hip,
knee and cataract procedures (the operations with the
longest wait times) in private clinics.
NEW
VENUES
The Bill will change the structure of Quebec's surgery
queue with the licensing of non-hospital surgical centres
for hip, knee and cataract procedures, which will have
the possibility of expanding into other specialized
surgeries and imaging in the future. Some of those surgical
centres, called affiliated medical centres, will essentially
function as 'safety valves' to accommodate patients
whose wait times at public hospitals exceed predefined
limits. Affiliated medical centres will be privately
owned, for-profit institutions run by doctors who will
be subcontracted by the province's public hospitals
and who will remain part of the Régie de l'assurance
maladie du Québec (RAMQ), the public insurance
system. This is the change that specifically responds
to the Chaoulli decision's requirement to improve accessibility
to public healthcare by implementing wait time guarantees.
Other surgical centres, called
specialized medical centres, will be privately owned,
for-profit clinics as well — but these can be staffed
only by doctors who have opted out of RAMQ and decided
to provide services to patients who want to pay out
of their own pockets or with private insurance.
Such privately owned, privately
funded clinics are not new: Dr Nicolas Duval of Montreal
was the first orthopedic surgeon to opt out of medicare
in Canada in 2002, when he opened his own private surgical
centre. Not surprisingly, Dr Duval favours a two-tiered
healthcare system. "We need that safety net that we
get with the public system, but we can make it better
with private clinics as safety valves," he says. According
to Dr Duval, the public system will benefit from private
clinics that can alleviate some of the demand on public
resources, especially when it comes to non-emergency,
elective surgeries.
DOCTOR
SCHISM
But not everybody shares Dr Duval's enthusiasm. Most
doctors in Quebec oppose Bill 33, according to Dr Simon
Turcotte, the spokesperson for the recently established
Médecins pour l'accès à la santé
(Doctors for healthcare access), an alliance of Quebec
doctors who oppose the expansion of the role of private
enterprise in healthcare.
Every Quebec medical association
is against Bill 33, says Dr Turcotte. "The Bill doesn't
fit the reality of how we deliver care, what we offer
and in what ways. We're stunned by it."
The Bill, he adds, is devoid of
creative thinking and doesn't address the underlying
problem that prompted Dr Chaoulli's landmark case: an
inefficient and outmoded public hospital system that
has not adapted to keep up with demand and to incorporate
contemporary practice methods. Instead of seeking to
fix the public hospital system, Bill 33 will simply
identify at which point that system falters and send
the overflow to a private clinic. Rather than subcontracting
that work out to the private sector, hospitals should
adjust their own resources to fund publicly owned ambulatory
clinics, suggests Dr Turcotte.
One concern among doctors is that
expanding the private sector's role in the delivery
of healthcare could lead to increased administrative
costs and further staffing shortages by potentially
splitting specialists between the separate public and
private systems. That, in turn, it is feared, could
put poorer patients at risk.
"In other countries with parallel
systems, they drained the public system to provide more
care in the private system," Dr Turcotte notes. "It
will result in deteriorating access for the majority
who cannot afford private insurance."
WARNING
TO OTHERS
The government has left the door open for expanding
the role of the proposed private surgical centres. This
could make going solo more attractive for doctors in
the future, surmises Antonia Maioni, Director of the
McGill Institute for the Study of Canada.
Other provinces, says Dr Turcotte,
should see Bill 33's drastic reforms as a warning to
improve their public hospital systems.
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