Healthcare in Quebec took an
exciting leap forward late last June, when Quebec Health
Minister Phillipe Coulliard reached an agreement with
the GP association, the Fédération des médecins
omnipraticiens du Québec (FMOQ), to introduce the
new "cliniques-réseau," or network clinics as they're
called in English. It's hoped these clinics will prove
to be more popular with doctors than the family medicine
groups (FMGs) that were introduced back in 2001 —
and which were met with widespread physician disdain.
After five years of delays, a unique
brand of network clinic has been created and implemented
in Montreal thanks to pressure on the part of Quebec's
physicians, and some shrewd negotiating on the part
of Mr David Levine, CEO of the Montreal Development
Agency.
"We are looking to set up 36 network
clinics in Montreal," says Mr Levine. "We're designing
the protocols. This is a chronic care approach that
will cut ER visits, increase homecare use, offer better
medication control and cut down the time people spend
in hospitals."
Mr Levine, in conjuction with the
local Regional Department of General Medicine (DRMG),
convinced the decision makers at the health ministry
to pony up $300 million a year to implement and maintain
the networks. So far, doctors are quite happy with this
sum, after waiting for several years for government
funding to be finalized.
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The nuts and bolts of network
clinics
Money
In addition to their regular fees, doctors will
also be paid $80 for each four-hour evening and
weekend shift in the walk-in part of the clinic.
The nearly 100 GPs so far working in network clinics
stand to earn an extra $25,000 a year administering
preventative care and looking after rostered,
previously-orphaned, vulnerable and chronic patients.
This is up from the $10,000 boost offered by the
FMGs. Further details of the remuneration modes
were being negotiated between the health ministry
and FMOQ president Dr Renald Dutil at press time.
Hours
These will be standardized and uniform, allowing
for greater and easier access. Clinics will be
open 365 days a year from 8am-10pm on weekdays,
and from 8am-5pm on weekends and holidays. Additionally,
an on-call schedule is still being hammered out
for vulnerable patients.
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FUNDING
PREREQUISITES
In order to get their hands on the money (between $250,000-300,000
per network clinic), the clinics must meet certain criteria,
such as agreeing to set up site radiology and blood
testing facilities, meaning doctors will finally be
able to provide sorely needed diagnostic testing.
"It's significant that radiology
testing will be involved as well as blood tests, coupled
with the ability to send the results seamlessly to the
hospitals, allowing us to open the corridors of communication,"
says Quebec Medical Association (QMA) president Dr Robert
Ouellette.
Additionally, the clinics must
hire two nurses who will act as liaisons to give doctors
smooth access to the second and third line of healthcare,
such as ensuring a patient sees a specialist. And although
up to 50% of the clinic's clientele can be walk-in patients,
the rest must be rostered, and followed up by the doctor.
"I feel positive about it," says
Jacques Fortin, director of home services at the hectic
Metro CLSC (the traditional government-run clinic) in
downtown Montreal which is about to form a network clinic
with another CLSC in nearby Westmount. "We have a dynamic
relationship with the Westmount clinic — two partners
willing to connect and share ideas, patients, radiology,
laboratory, and psychosocial services. Now we're forced
to communicate because we share the same clientele."
URBAN
PLANNERS
Montreal has a far different medical landscape, and
populace, than other regions of the province, and the
city actually has a relatively good doctor-patient ratio.
The problem, however, is that Montreal's front line
healthcare is fragmented, highly disorganized and, in
many instances, unresponsive. Its healthcare infrastructure
is essentially a vast sprawl of largely uncoordinated
institutions.
In January 2004, Bill 25 was passed
and called for a sweeping reorganization of Montreal's
healthcare resources and the establishing of local health
networks. Under this scheme Montreal's medical imbroglio
(and acronym alphabet soup) is being pared down to 12
districts with each containing a CS3 (centre de santé
des services sociaux) headquarter office at its core.
These CS3s will merge previously autonomous hospitals,
CLSCs, CHSLDs (extended and long-term care homes), and
CHSGs (specialized hospital centres) into a single coordinated
network. The linking will be done via a computer information
system, and this system has some doctors champing at
the bit.
"I'm excited about the information
system, but we need to integrate all the family doctors,"
says QMA president Dr Ouellette, who's also a specialist
in radiology with a passion for information technology.
"The government is paying for the clinics to be connected,
but essentially saying to the private practice physician,
'If you want to be linked, join us. If not, that's your
problem' — they shouldn't do that. These men and
women are the first line of primary healthcare."
MOVING
AHEAD
Most of the glitches of the network clinic's predecessor
— the FMGs — have been addressed in the new
model. Doctors feel that the network clinics have a
much more flexible interface than the FMGs, which were
often seen as too legalistic and rigid. Another big
bonus with the network clinics is the axing of the loathed
$55,000 quarterly salary cap that beset docs working
in FMGs.
"With the FMGs, it was financial
— there were no incentives," says Mr Fortin. "If
doctors reached their cap, why would they work more?"
Although there is some resistance
from CLSCs, Quebec's doctors are on the whole ready
for change. The former feelings of desperation, rage,
and despair have turned to optimism tempered with a
cautious "wait and see" outlook. "It's a move in the
right direction," says Dr Ouellette, "but more has to
be done to integrate the doctors."
One particular area of concern
is physicians who choose to stick with private practice,
and thus cut out of the new deal. In a show of support
and empathy for those colleagues, Dr Marc-André
Asselin, president of Montreal's GP association, recently
wrote in the association's newsletter: "We are now reviewing
different models that would enable [private practice
doctors] to have access to a modified model of [network
clinics] ... and with a good bit of good will on the
part of the [health ministry], this could be possible
and easy to establish."
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