It is little known that in Quebec, first-line medical services (family medicine) are largely in the hands of the private sector. In fact, although general practitioners are paid out of public funds, they are not government employees like other workers in the socio-health network.
A majority of family physicians tend to be small health entrepreneurs who practice in private clinics or in family medicine groups (GMF), which are also, for the most part, private companies. In addition, knowing that 53% of general practitioners have chosen in 2021 to take advantage of the considerable tax advantages allowed by the incorporation of their medical practice into joint-stock companies or general partnerships, we can truly speak of the existence in Quebec of a ‘medicine inc. front line.
Failure of “medicine inc.” »
What is known as the “front line” is of crucial importance in the organization of health and social services. It represents the “gateway” to the entire socio-health network. It should make it possible to avoid the deterioration of health problems and social problems and to prevent hospitalizations, emergency room overcrowding and recourse to often more costly specialized services.
However, in Quebec, private medical clinics have never been able to adequately fulfill this function. It is in large part because of this failure that the government created, in 1971, the local community service centers (CLSC). This network of public clinics aimed to offer the full range of current medical, health, social and community services.
This was a first attempt to nationalize front-line services in Quebec, an attempt that the medical profession fiercely opposed. Refusing to join the CLSCs and to lose their status as entrepreneurs to become state employees, most general practitioners reacted by developing a network of private polyclinics parallel to that of the public system.
It is from these polyclinics that the FMGs were created in 2002. Since then, they have largely replaced the CLSCs […]. However, 20 years after its creation, this private model of organization of medical services has, like small traditional medical practices, demonstrated its inability to fulfill the functions expected of an effective first line. While the FMGs aimed to improve access to family doctors, relieve emergency room congestion and promote access to psychosocial services, the data clearly show that they have failed to achieve these three objectives.
Two paths to nationalization
Faced with these repeated failures of “medicine inc. », it is imperative to complete the work begun when the CLSCs were created in 1971, and to make the first medical line entirely public in Quebec. Two avenues must be taken to achieve this.
The first consists in using the infrastructure of FMGs, the development of which was largely financed by public funds, to rebuild a model of institutions inspired by that of CLSCs. This would include converting FMGs into non-profit organizations fully integrated into the public network and managed in a transparent and democratic manner by elected boards of directors, made up of people representing the entire multidisciplinary team as well as citizens and citizens. Physicians who own FMGs who refuse to make this conversion would be deprived of any form of public funding, including remuneration.
This brings us to the second avenue, complementary to the first: doctors must be fully integrated into the public system and become state employees like other network employees. The development of “medicine inc. is closely linked to the fee-for-service method, which continues to predominate widely within the profession. […] However, if it promotes the “productivity” of doctors, this fee-for-service method poses major problems.
Indeed, it is one of the causes of the problems of overdiagnosis and overtreatment, since it financially encourages physicians to multiply procedures, including unnecessary or even harmful procedures. In addition, fee-for-service discourages interprofessional collaboration: with this model, team meetings are not profitable, and the management of health problems by other professional categories represents potential loss of income for the doctors. Finally, fee-for-service is also one of the major causes of the hypertrophy of medical remuneration, which has reached stratospheric levels in recent years.
As in 1971, these reforms will arouse the opposition of doctors. However, recent decades have shown that it is high time to abolish the backward-looking model of private, for-profit medicine.
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