Marie-Claude Prémont, professor of law at l’École nationale d’administration publique in Montreal, has published an important report on health care privatization in Quebec. The paper documents new and complex ways doctors, private clinics and brokers are charging patients for priority access to doctors paid from the public purse. Examples include:
- Charging patients annual membership fees upwards of $1,000 for faster access to family doctors. To get around Medicare rules against two-tier health care, clinics claim the fees are for uninsured services, for example tests and services not deemed “medically necessary” and therefore not covered by public health insurance. The fees do, however, secure faster access to ongoing medical care. In what the author calls a “highly polished ruse”, clinics give “members” priority appointments, using such things as separate waiting rooms and phone response systems to disguise the practice;
- Charging patients to consult specialists, especially paediatricians. Medisys 123, a firm currently under investigation by the provincial government, offers this service at a price of $975 per child;
- Brokerage fees for quick access to a specialist;
- Specialized Medical Centres charging patients between $8,000 to $15,000 for surgical operations (ostensibly to cover facility fees and uninsured staff), with the surgeon billing the government;
- Bribes solicited by some specialists; in one instance, some specialists at two Montreal hospitals received up to $10,000 to give priority to a patient’s surgery;
- Rural health cooperatives charging annual subscriptions of between $30 and $175 for access to doctors; and,
- Telemarketers selling a $228 checkup.
Prémont analyzes the context in which user fees and two-tier health care are growing, including changes in regulation, payment methods, and corporate structures that influence this trend. New business models and corporate medical practices heighten concerns about investor interests trumping clinical judgment. Since 2007, Quebec has allowed doctors to organize their medical practice as a corporation with share capital. This corporate structure is one of several new pressures on medical clinics to increase revenues, all possible factors in the growth of user fees.
“The response of public authorities (especially the RAMQ and the ministry of health and social services, but also the Collège des Médecins),” argues Prémont “towards penalizing certain behaviours that contravene the law or medical ethics, has been weak. This weakness, making it possible to engage in some of these practices with impunity, is undoubtedly another factor encouraging their development.”
The original French publication is in the September 2011 issue of Revue Vie Économique.