600+ Québec doctors opt out of public health care

Doctors in Québec are taking patients with them into private for profit medicine at a rate more than double it was ten years ago.

An investigation by the Globe and Mail shows growing numbers of Québec general practitioners (GPs) completely opting out of the health care system.

In this area, as in so many others, Québec has a different model.

Nebosjsa Kovacina, a researcher for OurCare, a Canada-wide research project looking at the future of primary care, says the situation has reached crisis proportions.

In the spring of 2023, according to the Globe, there were 642 non-participating Québec doctors: 432 family physicians, representing 4 per cent of GPs. In 2012, there were 280 completely opted out doctors, of whom 195 were family doctors, representing about 2 per cent.

According to the investigation, today, there are new physicians in Québec who leave the public system almost immediately after graduating.

There are three categories of GPs in Québec: those who practice inside the system (les engagés), those who practice outside the system but bill the system (les disengagés), and those who are completely outside the system (les non-participants).

Québec was the last province to adopt Medicare in 1968 during vehement objections from doctors, especially specialists.

Québec’s specialists went out on strike over it in 1970, and were legislated back to work. To calm the waters, the Québec government came up with a new and unique approach. There would be three categories of doctors. Doctors could work with the Régie de l’Assurance Maladie du Québec (RAMQ), (originally called the Quebec Health Insurance Board (QHIB)) or they could opt out of Medicare billing – except that they had to charge public rates so patients could be eligible for a reimbursement.

Physicians who didn’t want any restrictions on billing fell into a third category, staying fully outside the public system – but their patients couldn’t make a claim with RAMQ.

According to Tu Thanh Ha and Yang Sun of the Globe, that last category has expanded dramatically in the last few years with about 600 Québec GPs working in private completely for-profit clinics, where patients pay for all services from their own pockets.

This group is called “non participating,” colloquially known as those who have “aller au privé”– gone over to the private side. The term refers to both physicians and patients.

There are roughly 12 doctors who have chosen to become non-participants, or opt out completely from the health care system in the rest of Canada combined.

Isabelle LeBlanc, a GP who teaches at McGill, told the Globe that these completely private clinics skim off the healthiest and wealthiest patients, while sicker and poorer patients are left in an increasingly understaffed public system waiting for care.

Dr. Leblanc is the former president of a group of Québec physicians advocating for public health care.

Médecins Québécois pour le regime public (MQRP) has asked the Québec government to apply sections 30 and 30.1 of Quebec’s Health Insurance Act to correct this situation.

In other words, the Québec Health Insurance Act gives Québec Health Minister Christian Dubé the right to intervene if he deems there are too many non-participating doctors, to suspend the right to withdraw from RAMQ, or to require private physicians to charge medicare rates so patients can be reimbursed by the public plan.

When asked by the Globe, Dubé’s office declined to specify how many non-participating doctors it would take before he would make such a move.

One in five Quebecers does not have access to primary care. Statistics Canada reported that one in five Quebecers do not have a regular health care provider or nurse practitioner that they could see regularly, compared with about one in ten in the rest of Canada.

Since Medicare was introduced in Canada, many physicians have objected to public insurance schemes, saying that it would limit their freedom of practice and charge the fees they deem appropriate. This tension has resulted in multiple doctors’ strikes.

Provinces placated them by allowing doctors either to charge more than what medicare covered, or to let them work outside the public system and have patients get reimbursed from public insurance.