Why more Quebec family doctors are leaving the public health system

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Serge Roy wasn’t happy last February when the letter arrived at his home, informing him that he would lose his family physician. But the phone call afterward perturbed him even more.

The doctor was leaving the clinic where Mr. Roy had consulted her for nine years, to start a private practice where she charges her patients directly.

A 68-year-old appliance salesman from Granby, Que., Mr. Roy suffers from chronic obstructive pulmonary disease and needs regular checkups.

However, when he dialled the local government number to get on a waiting list for another doctor, no one answered, the voicemail box was full and the system kept hanging up.

After a few more attempts, he filed a complaint online. A health official later called and explained that the line had been overwhelmed after several doctors left the public health care system at the same time, leaving behind thousands of patients.

“The future really didn’t look promising,” Mr. Roy recalled in an interview.

What happened to him isn’t rare in his province – but it is particular to Quebec.

Because of a series of decades-old government decisions, Quebec has quietly developed a parallel, privately paid health care sector that defies the conventional wisdom about Canada’s embrace of universal medicine. Data analyzed by The Globe and Mail show that this unique feature of Quebec health care, although still a small part of the system, keeps growing – particularly among family doctors, who are leaving the public system at a quicker rate than before, and earlier in their careers.

The privatization of health care has been a divisive issue in several provinces, with debates centring on whether to subcontract for-profit clinics to alleviate waiting lists. However, these controversies involve private facilities whose services are ultimately paid by the provincial and territorial health care insurance plans known collectively as medicare.

Quebec, though, has a number of fully private clinics that operate completely outside the province’s health insurance plan. There, patients, rather than the public insurance provider, foot the bill for services already covered by medicare, such as family medicine.

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This has grown to a scale unseen elsewhere in Canada, raising concerns about its ability to draw away health care providers from the public system, and spotlighting Quebec’s mediocre record on access to family doctors.

Doctors who work in those clinics aren’t enrolled in the provincial public health insurance plan, known as RAMQ. They are called non-participating physicians. In Quebec, “aller au privé” (“going private”) refers both to doctors leaving RAMQ and patients consulting them.

Quebec has more than 600 non-participating doctors, against a dozen in all other provinces – nine in British Columbia and three in Alberta, according to interviews with health officials as well as The Globe’s analysis of Quebec’s data.

Non-participation is not to be confused with opting out. Doctors who opt out charge directly but still follow the medicare fee schedule so patients get reimbursed by public insurance. In contrast, non-participating doctors work completely outside medicare.

The Quebec model is significantly different from those in other large provinces.

B.C., for example, doesn’t allow non-participating doctors who work in hospitals and community care facilities to charge more than the public insurance rate. And Ontario doesn’t have non-participating family doctors because the province made it illegal to ask patients to pay for services already covered by OHIP.

In Quebec, there is no such prohibition, and the ranks of non-participating physicians keep expanding. While they remain a minority of all licensed family doctors, their proportion has doubled in the past decade.

This spring, there were 642 non-participating Quebec physicians, including 432 family doctors, or 4.13 per cent of licensed GPs.

That’s up from 2012, when there were 280 non-participating physicians, including 195 family doctors, representing 2.1 per cent of licensed GPs.

The Globe analysis also documented a trend starting in the late 2000s: family doctors leaving medicare just after getting their medical licence, having barely worked in the public system.

Quebec facilities operating outside medicare now range from one-doctor offices to networks of larger clinics staffed with dozens of GPs, specialists and nurses.

Some charge by the visit. For example, in Saint-Jérôme, family doctor Pierre Tardif bills $300 for the initial checkup and $240 for each subsequent consultation. Others have more elaborate pricing. The Lacroix clinics offer annual health plans from $799 to $4,999, or you pay “à la carte,” from $249 for a family medicine consultation, to hip replacements that start at $24,699.

For years, large numbers of Quebeckers didn’t have timely access to doctors, creating a pool of potential clients, matched by a pool of unhappy doctors itching to leave the public system. Meanwhile, a significant court case led to the normalization of a competing system outside of medicare.

Quebec has some of the worst indicators for access to primary care. According to Statistics Canada, in 2021, one in five Quebeckers (21.6 per cent) didn’t have a regular health care provider, compared with 10.3 per cent in Ontario and 14.5 per cent nationally.

Those numbers mirror a poll of 9,000 Canadians conducted last fall for OurCare, a countrywide initiative looking at the future of primary care. The survey found that 31 per cent of Quebec respondents didn’t have a family doctor or nurse practitioner they could see regularly, compared with 22 per cent nationally.

Of those without a regular primary-care provider, 37 per cent in Quebec said they have had to pay a fee for non-urgent care, compared with 21 per cent across Canada.

OurCare’s lead investigator, Tara Kiran, said the poll doesn’t differentiate whether respondents paid a doctor or other professionals, such as nurses or pharmacists.

“People who didn’t have access ... are turning to all sorts of places to try and get care that’s not urgent but worrisome. And in many cases, they have to pay out of pocket,” said Dr. Kiran, a family physician and scientist at St. Michael’s Hospital and the University of Toronto.

The migration of GPs out of RAMQ is “a crisis for us right now,” said Nebojsa Kovacina, a researcher for OurCare in Quebec.

He said any departure from the public network will strand thousands of patients. “Even three, four doctors leaving and going directly from the public to the private system, it’s a huge loss,” said Dr. Kovacina, who teaches at McGill University’s Faculty of Medicine.

Isabelle Leblanc, a family physician who teaches at McGill, said private clinics skim off the wealthier, healthier patients. “Very sick people, with cancer, with big mental health issues, with schizophrenia, bipolar disorder, with dementia, they’re not people who go private. They can’t afford it.”

However, advocates for private clinics argue that patients come see them because the public system is unable to provide timely care to ailing people.

“Our clientele are everyday people, wage earners, not just people with above average income,” said Marc Lacroix, the founder of the private clinics bearing his name.

“People are seeking services. We give them services,” Dr. Lacroix said in an interview. He started a fully private clinic 14 years ago and now runs 15 facilities.

Dr. Lacroix feels that private health care providers have good prospects under Premier François Legault.

The Legault government has proposed building two “mini-hospitals” that would be privately owned but paid by RAMQ.

Dr. Lacroix also took note of Health Minister Christian Dubé's call for private-sector “top guns” to help manage the health system.

The Minister’s office said he wasn’t available for an interview but gave a statement reiterating his position that private clinics complement the public system, and that privately owned, RAMQ-paid facilities can help clear backlogs.

“We are aware of the current issues and are now working to reverse the trend so that there are more doctors in our network,” the statement said, adding that “our priority is access to better free and universal care.”

Dr. Leblanc, of McGill, used to be the president of a group of physicians advocating for public health care. They have asked the government to apply sections 30 and 30.1 of Quebec’s Health Insurance Act.

Those sections allow the minister, in the event 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.

Mr. Dubé's office declined to specify how many non-participating doctors it would take before he would make such a move.

The Minister’s office instead referred the query to the health department, which said forecasts suggest the number of family doctors will increase at an 8-per-cent pace while the general population’s growth is only 4 per cent.

The department declined to release those forecasts to The Globe. It said they are based on future medical school enrolment and demographic projections for 2022-2027. Mr. Dubé announced in July that Quebec will add 660 additional spots in medical school admissions over four years, up from the current annual enrolment of 969.

However, the department’s analysis covers only five years so it’s not possible to say when the increase in family doctors would meet the population’s needs, spokeswoman Noémie Vanheuverzwijn said.

And the current paucity of family physicians has already had an impact on people like Jacinthe Evers.

A nursing home worker in Saint-Flavien, 55 kilometres from Quebec City, she has to drive an hour to consult her GP.

Her 81-year-old father, Jean-Louis, hadn’t seen a physician since his doctor retired, years ago. He used to be fit but has declined recently. “Often he didn’t feel well. But then he’d feel better … before he could get an appointment,” his daughter recalled.

She got him to see a private nurse practitioner, but he didn’t get better. He had dizzy spells, lost his appetite, and had coughing fits.

In a team effort, Ms. Evers, her daughter, and her father’s girlfriend worked the phones and went online, in a vain attempt to find him a physician. They debated whether to see a non-participating doctor.

But his condition worsened and he had to be hospitalized. He had lung cancer and, last April, received medical assistance in dying.

“It could have been detected earlier if he had a doctor,” Ms. Evers said.

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Paradoxically, Quebec once had fewer issues with people having to pay for medical care. However, decisions made years ago unintentionally set the stage for the growth of privately paid clinics.

Since medicare began in Canada, many physicians objected to public-insurance schemes, saying that it would limit their freedom of practice. 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.

Quebec, the last province to adopt medicare, took a different path. Faced with a strike by specialists, the government came up with a new approach unseen elsewhere in Canada. There would be three categories of doctors. Doctors could work with RAMQ, or they could opt out of medicare billing – except that they had to charge public rates so patients could be eligible for a reimbursement.

If doctors wanted no fee restrictions, they had to be in a third category, staying fully outside the public system – but their patients couldn’t make a claim with RAMQ.

Meanwhile, other provinces (except B.C.) still allowed doctors to charge above the public insurance rates, a practice called extra-billing or balance billing. That ended in 1984, when Ottawa introduced a new law. Under the Canada Health Act, provinces and territories are penalized if doctors who worked under medicare engage in extra-billing.

Ontario went further by tabling in 2003 legislation banning doctors from charging for services already publicly insured. “It will make two-tier, pay-your-way-to-the-front-of-the-line health care illegal,” the health minister at the time, George Smitherman, said.

Since the 1990s, Quebec has imposed several requirements on family doctors that aren’t widely practised elsewhere in Canada.

One of those terms is PREM, which determines how many family doctors work in a region. Those who practice outside PREM have their medicare billings cut by 30 per cent.

The other is AMP, compulsory shifts in short-staffed hospitals and other public facilities. For the first 15 years of their practice, family doctors have to contribute 12 hours weekly.

AMP helped prop up the staffing in emergency wards, nursing homes and community clinics, but it also chipped away at the availability of physicians and made working in the public system less appealing.

Dr. Leblanc said her students are lured to private clinics because of the prospect of lighter caseloads and not having to deal with PREM or AMP.

At first, the departure of Quebec doctors from medicare didn’t register in significant numbers. But among the six family physicians who pulled out in 1996 was Jacques Chaoulli.

In 1998, Dr. Chaoulli began a legal battle that would land before the Supreme Court of Canada.

Along with a patient, he challenged Quebec’s ban on private insurance for health care services already covered by RAMQ. They argued that it was a Charter infringement to make it hard for people to afford private care, while at the same time letting patients languish on waiting lists.

While the case made its way through the courts, in 2004, three Montreal doctors opened to great fanfare one of the first fully private clinics, MD-Plus.

The following year, the Supreme Court issued its judgment in Chaoulli v. Quebec (Attorney General).

The court was deadlocked over whether the private insurance ban violated the federal Charter of Rights but a majority agreed that it contravened the Quebec Charter of Rights.

The ruling applied only to Quebec and its government responded in a narrow fashion, allowing surgeries for cataracts and knee and hip replacements to be covered by private insurance and performed in a number of accredited private clinics.

In the end, Dr. Chaoulli gave up on his quest and now practises in southern France. But his case still looms large in Quebec, and mere discussion of the ruling had a ripple effect beyond elective surgery.

A Canadian Medical Association Journal paper shows that the number of family doctors leaving RAMQ increased after the Supreme Court decision, even though GPs weren’t directly affected by the judgment.

“Because the ruling itself had very little, if any, impact on the practice of family medicine, our findings are consistent with the hypothesis that shifts in social views prompted by judicial and policy debates can affect physicians’ decisions to opt out,” said the 2021 paper by Damien Contandriopoulos at the University of Victoria and Michael Law at the University of British Columbia.

Dr. Lacroix, for example, said the Chaoulli case and MD-Plus opening inspired him to start his first clinic.

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As part of its data analysis, The Globe also charted the number of family doctors who deregister from RAMQ each year.

Aside from the rise after the Chaoulli ruling, another surge occurred around 2015. At the time, the Quebec government was debating Bill 20, legislation requiring GPs to have a minimum number of patients.

Similarly, there was an upswing in departures last year, after a rancorous period when Mr. Legault complained that GPs weren’t signing up enough patients.

In theory, family doctors could depart RAMQ for a number of reasons – but the vast majority remain in Quebec to practise privately paid medicine.

The Globe identified the professional whereabouts of 438 current non-participating Quebec family doctors. Only 28 had moved out of Quebec or no longer dealt with the general population. More than 93 per cent (410 physicians) still dispensed medical care, in fully private Quebec clinics.

Of those 410 non-participating family doctors, 60 offer cosmetic services and six do sports medicine, meaning that 78 per cent of GPs who left medicare still practise primary care, but now with patients paying them out of pocket.

Dr. Kovacina and Dr. Leblanc both teach and said that it has now become a new norm among residents to consider withdrawing from RAMQ soon after acquiring their medical licences.

“Now, in almost every cohort we have someone who is going to the private sector from the get-go,” Dr. Kovacina said.

And Quebec struggles to draw students toward family medicine.

From 2013 to this spring, a total of nearly 550 family medicine residency positions went unfilled in the province.

In fact, there have been recent years – 2014, 2016, 2017 and 2018 – where Quebec accounted for 100 per cent of all of Canada’s unfilled family medicine residencies.

Dr. Lacroix, meanwhile, expects to recruit more physicians to his clinics. He hired 37 new physicians last year and has already signed up 30 by June. He’s retained a team of lobbyists to advocate for private clinics with the provincial government.

Back in Granby, Mr. Roy, the salesman who lost his family doctor, is adjusting to a new reality.

He has to call a walk-in clinic as early as 7 a.m. to see a physician.

And he isn’t eager to pay out of his own pocket if he wants to consult a doctor. “If I go to a private facility,” he said, “the question remains: Can I afford it?”

Editor’s note: An earlier version of this article incorrectly stated B.C. bars all of its non-participating doctors from charging more than the public insurance rate. This version has been corrected.