Doctors also have their “toast case”

A doctor tells me this story to explain to me why, among other things, she left her 2,000 patients last year. Why a bureaucratic trifle can push family doctors into retirement despite the context of a shortage, as I spoke about in a recent column^⁠1.

In May 2019, a postal worker shows up at his Montreal-area clinic with intriguing envelopes for the 12 permanent doctors. They are seized by registered mail: these are 12 lawsuits bearing the header of the Director of Criminal and Penal Prosecutions (DPCP).

So what’s going on? Was there fraud? Did a patient die from a medical error?

No way. The lawsuits rather accuse the clinic of having failed to display the list of costs that are not covered by the Régie de l’assurance maladie du Québec (RAMQ). You know, those fees that are charged for an absence from work report ($25), for employment insurance ($35), for a missed appointment ($30) and so on^⁠2.

The signage violation had been reported by a RAMQ official who had come to inspect the clinic six months earlier. The clinic’s management then explained that the poster had been temporarily removed to redo the paint – it was then fresh – and that a new poster was about to be replaced. Here she is, by the way, Madam Inspector, the headmistress had said.

Everything seemed satisfactory, but the doctors later realized that this was not the case, the official having transferred her report to the DPCP, which filed a lawsuit.

The fine is high: $2,500 plus costs of $1,250, for a total of $3,750… per doctor. Grand total for the clinic: $45,000!

It’s the shock. At the time, seeing the header of the DPCP, young doctors fear ending up with a criminal record and no longer being able to cross the border.

“It was a concussion,” explains the doctor who contacted me in the wake of my column on the retirement of doctors. She sent me all the documents, but wishes to remain anonymous to avoid problems (she works part-time elsewhere in the network).

“I loved my practice from start to finish. I sometimes called my patients on Saturday and Sunday to give them results. But I was no longer able. Knowing that at any moment, an official from the RAMQ or the College of Physicians could send me someone like this, having a Damocles sword above my head, I said to myself: we forget that, she explains.

Like the “toast case”

Once the shock has passed, the clinic contacts the Canadian Medical Protective Association (CMPA), which informs it that they are not the only ones to experience these niggling RAMQ checks.

Quite often, the alleged offense is not linked to the absence of a poster, but to its content: omission of a tariff, error on a tariff, absence of a mention emphasizing that a tariff could, perhaps to be, to be reimbursed by the RAMQ, etc. The display requirement is set out in article 22.0.0.1 of the Health Insurance Act.

“Similar to the case of the nursing assistant suspended for three days for eating toast,” my source tells me, exasperated.

In practice, each physician must contact the CMPA himself and plead not guilty. The files are then entrusted to a recognized criminal lawyer, who defends them as a group.

This criminal lawyer quickly confirms to them, in a letter, that the offense is criminal in nature (such as a traffic violation) and that it will not result in a criminal record.

Finally, after two years of administrative hassle, the 12 doctors learned that the DPCP had withdrawn the charges, in the fall of 2020.

“It seems to me that the RAMQ has other things to do with our money,” the doctor told me.

2,641 doctors targeted by inspections

Verification made, the RAMQ has multiplied this type of process. It has carried out 410 inspections over the past five years targeting 2,641 doctors, especially between 2018 and 2020, the organization tells me.

In the end, the files of 404 doctors were considered sufficiently serious to be sent to the DPCP, in particular those of the 12 doctors whose posters had been removed to redo the painting.

Impossible to know, from the DPCP, how many of the 404 doctors have actually been prosecuted – like the 12 in my story – or how many prosecutions have been dropped.

At the end of 2021, however, it appears that many statements of offense had not been followed up in court because the evidence, obviously, was deemed too weak by the DPCP itself, according to lawyer Pierre Belzile, director of the legal department of the Federation of General Practitioners of Quebec.

“How is it that the violation of where a fee schedule is displayed in a medical clinic can have such disproportionate consequences?” asks M.^e Belzile in a text published in a publication intended for doctors, in February 2022³.

At the RAMQ, I was told that the requirement to display in this way dates back to the end of 2016, when a regulation abolished incidental fees, which had been widely publicized (fees for eye drops, fees for anesthetics during benign interventions, etc.).

The RAMQ says it acted gradually.

“We first took several steps to raise awareness through preventive visits, in addition to the communications sent, in particular newsletter 378 in 2018. It is important that patients are informed of the elements that may or may not be billed to them,” m writes spokesperson Caroline Dupont, according to whom the RAMQ has also issued various reminders.

Surprisingly, the numerous inspections regarding signage have never been listed in the RAMQ’s annual report, although they were 10 times more numerous than all the others appearing there concerning doctors, at least between 2018 and 2020. Caroline Dupont replies that this absence is “an organizational orientation”.

This anecdote is altogether futile. And after 2020, only 49 doctors have been inspected for a posting issue (out of the 2,641 for five years), and none of these files have been transferred to the DPCP. The wave seems to have passed.

However, lessons can be learned from it. First, the media hype about physicians’ remuneration and incidental costs at the time probably contributed to the many finicky inspections by the RAMQ. We overreacted.

Then, one wonders whether the government and its bureaucratic apparatus have shown discernment in this matter, especially in the context of the backlog of front-line care and the significant shortage of family doctors.

Knowing all this, please, let’s try to avoid this kind of hassle for our overwhelmed health system!