Private in health | The hidden face of the Quebec model

The Quebec model is not always what we think. The expression usually refers to the intervention of our State to alleviate inequalities. But in health, it’s more complicated…

Published at 12:45 a.m. Updated at 7:00 a.m.

To convince yourself of this, look at the statistics on doctors leaving the public system to practice privately.

How many are there? In the majority of Canadian provinces, the answer is simple: zero. In 2022, not a single one was found in Manitoba, Saskatchewan, New Brunswick, Nova Scotia, Newfoundland and Prince Edward Island.

What about conservative Alberta? There were only two of them. Same thing for British Columbia.

Ontario is a little different from the average. In 2022, there were 14. These are the last doctors benefiting from an acquired right since the transition to the private sector was prohibited in 2004. After their retirement, the number will return to zero.

Only one nation stands out from this portrait. You understood which one. In Quebec, no less than 642 doctors have left the public network to work in the private sector. And that was in 2022, when the CD Howe Institute published a study on the subject1.

According to the latest count, there are at least 775.

The CD Howe Institute – which is not on the left – sees no advantage in this. Neither does the College of Physicians.

For two years, the management of this professional order traveled across Quebec to meet its members. He then reviewed the studies and interviewed researchers. Its conclusion is unequivocal: society is losing. The private sector must be regulated, and its expansion must be “suspended immediately”. This position was adopted unanimously. And with applause, they tell me.

The Minister of Health, Christian Dubé, in turn promises to tighten the screw. A bill will be tabled by the end of fall.

The intention is modest: to prohibit the transition to the private sector for new doctors, and only in the first years of their practice. Details remain to be clarified.

The Federation of Resident Doctors sees this as “discrimination” by Mr. Dubé. Instead of banning the private sector, we should rather understand why doctors desert the public sector, she says.

The answer is simple: in the private sector, they can treat a lighter and more paying clientele, with a flexible schedule.

The public will never be able to offer this. Vulnerable patients also need to be cared for, even if they are ill on a Saturday.

This flight to the private sector creates two inequities.

The first is for doctors. Those who remain in the public face more complicated cases. They are penalized for their loyalty. This creates a dangerous spiral of demotivation.

The second inequity is for the patient. The richest pay for better access. They can be treated as a priority, even if their illness is less serious.

Of course, there is not a single profile of doctor who migrates to the private sector. Take the case of a specialist doctor. He wants to operate on a Thursday at the end of the day, but no room is available at the hospital. Either he stays at home or operates privately.

From an individual point of view, this approach is understandable.

But from a collective point of view, if we let the private sector grow, it will siphon off the best resources.

One of the studies consulted by the College of Physicians suggests regulating the private sector to avoid this perverse effect. For example, by capping the prices charged to the private sector. The doctors who operate there will do so to supplement their schedule and not to line their pockets. This would make it possible to avoid cases like the one reported by the solidarity deputy Vincent Marissal, who is leading the revolt in this issue: an orthopedist announces to his patient that his hip operation will be carried out in eight months to the public… or in three weeks to the private, for $25,000.

Even though Quebec stands out for its percentage of disaffiliated doctors, this is only a minority – around 4% – of the profession. However, this is not an argument for letting things go. No single measure will cure the healthcare system, and anything that helps is welcome.

This is not the first time that Mr. Dubé has been put under pressure by the College of Physicians.

Last year, the College considered the promise of guaranteeing a family doctor for every Quebecer unrealistic. It is better to ensure that each patient is followed by a health professional, it was argued. Mr. Dubé is now leaning towards this idea.

In March, a draft regulation to restrict the transition to the private sector was ready. Mr. Dubé kept it on a tablet. He is now reactivating it following his release from college – however, how far he will go remains to be seen.

However, he does not intend to give up his plans for private mini-hospitals. A study consulted by the College of Physicians criticizes this model1. The pursuit of profit is not associated with increased innovation. Investors instead make money by screening their clientele, reducing the number of employees and prioritizing profitable medical procedures, whether necessary or not, the researchers conclude in the Lancet Public Health 2.

Mr. Dubé’s strategy is obvious.

It challenges the federations of doctors – especially general practitioners – with whom the renegotiation begins. He tells them: you claim that there is a shortage of doctors, so you cannot be against this measure which limits departures.

Doctors find themselves in a special situation. To access university education, competition is fierce. But at graduation, there’s no competition left. Their clientele is numerous and captive. They can thus behave as autonomous entrepreneurs, enjoying a balance of power to their advantage.

But if we believe that health is not a commodity and that the sick deserve to be treated regardless of their income, then the government can determine the rules of the game.

And even as constraints increase, bright students will still scramble to apply to medical schools in hopes of serving in the health care system run according to standards democratically chosen by those who fund their education.

Another issue: doctors trained in Quebec who move to other provinces or countries. From 2015 to 2017, 15% of our graduates left. There are more than 2,300 in Ontario. This is wasted public funds – this number is not offset by the foreign-trained doctors working in Quebec.

This is not a simple management or expert debate. The question is also political. What value should we place on equity and health? How to organize care?

In other words: what should our “Quebec model” look like?