Dr Chaoulli
Photo: Liam Maloney
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Dr Jacques Chaoulli, the Montreal
GP who singlehandedly brought Quebec's medicare system
to its knees, is at it again.
On May 7, he announced plans to
take his healthcare privatization argument a step further
with the upcoming launch of a private physician-services
brokering firm, the eponymous Chaoulli Group (CG). The
new membership-based venture will allow patients to
pay doctors a fee to see them faster.
Dr Chaoulli won his landmark constitutional
case against Quebec in the Supreme Court of Canada in
2005. The decision prompted the province last year to
overturn its ban on private health insurance for services
covered by medicare and beef up attempts to tackle notoriously
long wait times. At the time of his win, Dr Chaoulli
insisted he wasn't out to kill medicare. That's still
the case, he says.
MEMBERSHIP
MEDICINE
When it launches this summer, the CG will charge patients
a $40 membership fee to have access to member doctors.
The suggested per-visit fee will be $100 for a GP visit
and $200 or more for a specialist visit, depending on
the type of work (doctors can set the fees themselves).
While he'll keep the $40, he won't skim anything off
the doctors' fees, says Dr Chaoulli.
Dr Chaoulli says several Quebec
doctors have already been in touch through his website
(www.chaoulli.com)
to express their interest in joining CG. But so far
the only official members are pretty uncontroversial:
the entire Association of Pediatric Dentists of Quebec,
which says it signed on because of long wait times for
publicly-covered dental care.
Dr Chaoulli is confident patients
will be willing to pay for visits rather than wait.
For certain procedures, like cancer treatment, the longest
wait times are often the initial ones — getting
that initial FP visit, and then waiting to see a specialist.
Dr Chaoulli predicts this will lead to shorter wait
times in the public system by removing some patients
from the queue.
FRIEND
OR FOE?
Critics say this diversion of physician resources will
weaken the public healthcare system. Dr Chaoulli dismisses
such allegations brusquely. "They have to think again,"
he says. "I want to protect the public regime." He says
his proof is that he's making doctors who join CG promise
not to reduce their patient load in the public system.
The idea is they'll see CG patients in their spare time.
But Michael McBane, the national
coordinator of the pro-medicare Canadian Health Coalition,
says requiring CG-affiliated doctors to maintain their
public-system workloads is "nonsense." "Doctors are
run off their feet," he fumes. "They're working 80 hours
a week — and he'll tap them for an extra 20? That's
not credible."
Six of Quebec's top legal minds,
including longtime Chaoulli critic Marie-Claude Pr�mont
of McGill, wrote an opinion piece for the May 15 edition
of the Montreal daily Le Devoir criticizing the
plan. Healthcare access problems in Quebec are caused
not by doctors with their hands tied by bureaucracy,
they write, but rather by "budgetary constraints" and
a shortage of doctors and nurses.
For his part, Mr McBane doesn't
pull any punches: "The whole proposal is based on a
misrepresentation of the facts," he says. "The fundamental
motivation is commerce."
PUBLICLY
PRIVATE
Two referral models will be available for patients using
the CG. In one, the patient will be referred to a doctor
who will see them outside regular public-system office
hours and therefore outside regular wait lists. In that
situation, the physician will bill the government for
the visit and collect an "accessory fee" from the patient,
says Dr Chaoulli.
And it's all perfectly legal, says
Dr Chaoulli. According to his interpretation of a clause
in the province's Health Insurance Act, the membership-based
model allows doctors working with the CG to bill patients
directly for medically necessary services. That's because
if a patient and a doctor are part of the same organization,
he claims, then the doctor can bill the patient for
medically necessary services. "It can be any service
at all," asserts Dr Chaoulli.
The lawyers writing in Le Devoir
are dubious about this interpretation of Quebec law.
They say the clause in question pertains only to services
not covered by the public insurance plan in the first
place — not to any old procedure.
This legal grey zone doesn't surprise
Mr McBane. "We would have to be naòve to assume
that Dr Chaoulli, who is a very strong ideologue, would
have his facts right," he says. "We need to be vigilant
against him. He seems to be on a singlehanded mission
to destroy Quebec's public healthcare system."
But Quebec doctors may risk violating
professional ethical guidelines if they join the CG,
warns Dr Marc-Andr� Asselin, president of the Montreal
Association of General Practitioners. "The doctors are
going to be walking on thin ice," he says. "The College
of Physicians and Surgeons code of ethics says a physician
must safeguard professional independence and avoid any
situation of conflict of interests especially when a
conflict may favour a certain group" — like a group
of higher-paying customers, for instance.
POLITICAL
HEAT
The organization will also serve as a platform for Dr
Chaoulli's politics. The CG will provide funding for
research in public health policy that is intended to
help patients, and Dr Chaoulli says he's thinking about
starting his own private health insurance company.
Dr Chaoulli has already used the
CG as a platform to speak out against the Quebec government,
announcing that the CG would not refer patients to public
hospitals until the province makes its nosocomial infection
management and reporting systems more transparent and
institutes an admissions screening program to identify
patients at risk of carrying potentially dangerous infections.
The government's reaction to the
CG thus far has been limited. The Ministry of Health
and Social Services referred the matter to its lawyers,
reported the Montreal Gazette. Meanwhile, a number
of lobby groups are calling on Health Minister Philippe
Couillard to stop Dr Chaoulli from going ahead with
his plan.
Asked whether a similar privatization
push could happen in Ontario as a result of the recently-filed
lawsuit by cancer patient Lindsay McCreith — which
cites the 2005 Chaoulli decision as precedent
(see "Chaoulli
copycat cases crop up across country," Jan 15, 2007,
Vol 4, No 1) — Mr McBane says, "The Ontario government
is not the Quebec government — the Ontario government
believes in medicare. The Quebec government does not
seem to."
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