Electrophysiologist Dr. Alexios Hadjis, left, performs a ventricular tachycardia ablation at Sacre-Coeur Hospital, July 26, 2023, in Montreal.Ryan Remiorz/The Canadian Press
The rising number of Quebec doctors who are leaving the public system and charging patients for private medical care has led critics to question whether the federal and provincial governments should keep allowing people who consult those physicians to claim tax credits for their medical expenses.
More than 640 doctors, a majority of them family physicians, are currently deregistered from the province’s medicare plan, which is called RAMQ.
Most of these doctors, known as non-participating physicians, practice instead in clinics where patients pay out of pocket. These private pay clinics are growing in popularity in Quebec, which has a lower rate of access to primary care than other provinces.
Quebec and the federal government both allow patients who incur medical expenses outside the public system to claim non-refundable tax credits. For instance, if a patient were to pay out of pocket for something not covered by public health insurance, such as prescription glasses, they would be able to claim the cost to reduce their tax bill.
But these tax credits also apply to private pay clinic expenses, even for care normally covered by the public plan. Public health advocates say this effectively incentivizes people to abandon public health care.
Cyril Devault-Tousignant, a board member of Médecins québécois pour le régime public, a group of Quebec physicians who advocate for public health care, said allowing the tax credits for patients of private pay clinics is a form of indirect subsidy that clashes with the province’s claim that it favours the public system.
“We are indirectly financing medical expenses that are covered by RAMQ. That’s very troubling,” Mr. Devault-Tousignant said.
Karen Palmer, an adjunct professor at Simon Fraser University’s faculty of health sciences, agreed. “It is, in a sense, public subsidization of some private pay services,” she said.
Prof. Palmer said it is time for tax officials to consider whether they want to keep granting tax credits to “people who are either jumping the queue and paying privately, or who feel they have no real choice because they simply can’t seem to access care in any other way.”
Under Quebec law, a provincial tax credit on medical expenses is calculated as 20 per cent of expenses that exceed 3 per cent of a household’s income. At the federal level, the credit is 15 per cent of medical expenses that exceed the lesser of $2,635 or 3 per cent of a taxpayer’s net income.
According to the province’s 2022 report on its tax expenditures, about two million Quebeckers avail themselves of the provincial medical expense credit annually, at a projected cost of $1-billion last year. This amount includes not just credits for care at private clinics, but also for other eligible medical expenses, such as fees for nurse practitioners or eyeglass prescriptions.
The tax rules make no distinction between doctors in the public system and those who left medicare. Questioned about the federal tax credit, Nina Ioussoupova, a spokesperson for the Canada Revenue Agency, said that it’s up to Quebec to determine who qualifies as a medical practitioner.
Others say the tax credits for patients of private pay clinics should not just be maintained, but made even more generous. Pascal-André Vendittoli, a co-owner of Montreal’s Duval clinic, a private pay orthopedic clinic, noted that private clinics are thriving because many patients are not getting timely care in the public system.
Taxpayers who have to visit non-participating doctors are in essence paying twice, he said. “A tax credit is the minimum that could be given to them.”
His views are echoed anecdotally by some Quebeckers. In 2016, a watchdog body, the Quebec health and welfare commissioner, sought public feedback on levels of satisfaction with the health care system. Some people wrote to argue that the tax credits should be expanded, because by paying for their care they were easing the burden on the public system.
In a statement to The Globe and Mail, the Quebec Finance Department noted that the provincial tax credit applies only when expenses are above a certain level.
“The tax credit for medical expenses is not intended to encourage a change in behaviour or to favour individuals with medical expenses to the detriment of others,” the statement said. “This tax credit aims first and foremost to offer tax relief to taxpayers who have to face high medical expenses compared to their income.”
The federal and provincial tax credits were introduced in their present forms in the late 1980s, when there were about 40 non-participating doctors in Quebec.
The increase in Quebec doctors dropping out of RAMQ – driven by a number of factors, including frustration with bureaucratic rules that require them to perform compulsory work in hospitals – is now raising concerns that their departure is siphoning resources from an already short-staffed public system.
A Globe analysis of RAMQ records this summer showed that the rate of departure is rising, with more doctors leaving at earlier points in their careers, some even deregistering as soon as they acquire their licenses to practice.
There is now an array of non-participating options in Quebec, from single-doctor practices to larger chains of clinics that offer services ranging from annual checkups to surgery for knee and hip replacement.
On their websites, many of those private pay clinics remind patients that they can claim the tax credits.