The last few months have revealed how difficult it is to implement the government’s plan resulting from the adoption in 2023 of Bill 10, aimed at reducing the use of private placement agencies for nurses and other health workers, particularly in certain regions.
As the Auditor General pointed out in 2023, reliance on such private suppliers should be avoided if we want to guard against such a difficult withdrawal.
In some respects, there may be an analogy to be made here with the case of doctors who decide to practice outside the public health insurance plan, by taking the status of “non-participants”, allowing them to offer services that patients must pay for, without a price limit and without the possibility of being reimbursed by the Régie de l’assurance maladie du Québec (RAMQ).
While this phenomenon was marginal for a long time, there are now more than 500 Quebec family doctors practicing outside the public system, or 4.8% of the workforce (compared to 0.48% in 2005), and approximately 270 specialist doctors, or 2.3% of the total (compared to 0.53% in 2005).
Double standard
As in the case of private placement agencies, the same dynamic seems to exist, that of professionals who, faced with certain very real constraints of the public system, decide to escape it in order to obtain working conditions that suit them better, on one level or another (working hours, caseload, remuneration, etc.).
In doing so, they contribute, perhaps unintentionally, to maintaining this negative spiral which could be summed up as follows: their colleagues who remain in the public sector are fewer in number to share the tasks or difficult schedules; exhaustion and frustration gain ground, pushing others to leave for the private sector, etc.
Ultimately, it is the very foundations of the public system that are crumbling, with significant effects on access to services and their financing.
How then can we explain the government’s inaction in this matter, compared to the rigour, albeit belated, which seems to be being deployed to limit the use of private placement agencies?
Unless budgetary reasons or challenges in negotiating with the unions concerned are at issue, this double standard is difficult to explain since, unlike the staff of private agencies who continue to provide services within the public system, non-participating doctors are completely exempt from it, not being required to make any contribution to the operation of this same system. This is far from the idea of the current government’s “Health Plan” of “making more room for the private sector, while respecting universality and free care”.
Powers
The government and the Minister of Health could consider different means to limit or, better, regulate this phenomenon, but, already, they have all the powers, in the Health Insurance Act, to put an end to what some call the “exodus” of doctors to the private sector.
They can thus impose on those who have already left it to respect the pricing of the public system, by allowing their patients to be reimbursed by the RAMQ. These powers were also consolidated by legislative amendments made in 2006, which aimed to follow up on the Chaoulli decision, in the context of which they had been identified as a means of ensuring the viability of the public system.
This was the case from the very beginning of the establishment of this same system, in the parliamentary debates which led to the adoption of the Health Insurance Act in 1970.
Let us recall that in Ontario, this status of non-participating physician does not exist, physicians who want to leave the public system are forced to respect its fees, and their patients can, for their part, be reimbursed by the State. Elsewhere in Canada, the rules may vary, but for the most part, the number of non-participating physicians is negligible, in no way comparable to the situation in Quebec.
Of course, the ideal solution would be to get the public system to become a real “employer of choice”, so that the temptation of the private sector fades. We must certainly focus on this approach, but we must understand that inaction in the face of the departure of several doctors to the private sector contributes precisely to making the public system less attractive to those who remain in it.
Not acting now on this situation, on the grounds that it currently only concerns a small proportion of doctors, is to run the risk of arriving at problems of such magnitude that they will be even more difficult to resolve, a bit like what we are currently seeing with private placement agencies.