AT PATIENTS’ EXPENSE
It’s important for the public to understand what’s at stake in Bill 20, says.
The bill is deeply flawed in that it does not consider normal human behaviour in its design, and may actually serve not only to punish physicians, but the general public, as well. David Luckow Regardless of how a physician responds to Bill 20, the province benefits; meanwhile, the physician, the public — or both — suffer.
Bill 20 will have an impact on the medical practices of most, if not all, physicians in Quebec. As such, this law also touches every citizen of Quebec who has contact with the health- care system.
I find it surprising that so little unbiased information has been provided to the public, other than statements from the government and advertisements from the doctors’ federations. It is imperative that in considering the impact of Bill 20, everyone understand both the intent and the consequences of this proposed law.
In the late fall of 2014, Bill 20 was proposed with the intent of increasing the number of patients who would have a primarycare physician. It proposes to accomplish this by imposing two requirements: 1) physicians must offer medical care in underserved populations or priority services and 2) physicians must assume medical responsibility or “prise-- en- charge” to a given number of patients. Should a physician choose not to comply with Bill 20, his or her salary would be reduced by up to 30 per cent.
On the surface, any change in health- care structure that promotes access to primary care services seems welcome, plus, Bill 20 attempts to achieve this with the added potential benefit of lowering government costs. However the bill is deeply flawed in that it does not consider normal human behaviour in its design, and may actually serve not only to punish physicians, but the general public, as well. Allow me to explain.
At the present time, there are two major coercive pressures applied to family physicians: PREMs and AMPs.
PREMs restrict the hiring of physicians by region. Only a certain number of physicians are allowed to work in any given area. A physician not authorized to work in a given region would have his or her salary penalized by 30 per cent. While the PREM system was originally intended to distribute physicians evenly across the province, it actually evenly distributes shortages across the province. The consequence is that physicians who are not granted a PREM permit for their chosen region must decide either to work in another region, face financial penalties or leave the province altogether, thereby adding to the shortage of physicians in the Quebec healthcare network. This measure has been in place for about 10 years.
The AMPs require physicians to work an average of 12 hours per week in a “priority” service, such as an emergency room, a hospital ward, a rehabilitation centre or home care. Every hour that physicians spend fulfilling AMP requirements is an hour that they are not available at their primarycare clinic seeing their own family medicine patients. In addition to AMP hours and family medicine patient care, family physicians are also called to assume administrative duties and engage in medical teaching, both of which take time away from patient care.
Bill 20 requires family physicians to register patients to their clinic with the intent of offering continuity of care, known as “prise- en- charge.” This offers the patient a home base from which to seek health care, always first contacting that particular physician or group, as opposed to going to a walk- in clinic or emergency room, but physicians are to be penalized if too many of their patients choose to seek health care elsewhere, such as a colleague’s clinic, a walk- in clinic or an emergency room. The law provides no exceptions if patients who live and work in two different areas seek health care from two different clinics, one near their place of work and one near their place of residence.
Part- time physicians will be specifically punished, as they will not be able to provide continuity of care to the required number of patients. This includes physicians who are in the process of retiring and downsizing, working parttime due to personal or family reasons, on maternity leave, or on sick leave or disability.
As a result of these potential penalties, physicians are faced with three choices should the proposed Bill 20 become law.
1) To comply with Bill 20. In a system of finite resources, prioritizing one service takes away resources from other services. A physician complying with Bill 20 will abandon non- AMP and non-prise-en- charge services in order to have the time to offer continuity of care. Some services that risk being terminated include offering care at walk- in clinics, medical teaching, curricular development and working in specialty clinics such as mental health clinics or pain clinics. For the province, a physician’s compliance with Bill 20 is cost- neutral: a physician who complies retains his or her base income, before potential fines. For the public, however, this law is dangerous. Not only is there harm to the public from an end to physicians’ participation in other clinics and teaching, a perverse financial incentive risks muddling the doctor- patient encounter: The present wording of Bill 20 states that a physician could face a penalty if their patient seeks health care at an emergency room. As a result, physician who might normally suggest a further diagnostic work- up in an emergency room to rule out a life- threatening pathology would instead be more likely to downplay the risks to the patient and suggest avoiding the emergency room, to avoid such a financial penalty, thus exposing the patient to potential harm.
2) To ignore Bill 20. For the physician, this would result in a loss of up to 30 per cent of income, for doing the job as presently performed. For the provincial government, there would be savings. But for patients, even if existing services may not appear to have changed, the consequences could be poor satisfaction with service provided by a disgruntled physician.
3) To decide the RAMQ is too onerous and opt out of medicare altogether. The only way to avoid the prospect of a future punishment being levied through no fault of their own is to avoid the RAMQ altogether. A physician could offer whatever services the market would allow, not what the government would allow. The government would save money, as RAMQ would no longer pay that physician. However for the public needing access to primary care, this would be a catastrophe. Many patients do not have the means to pay. Those who do will effectively be paying twice for each and every service: once with their taxes, and a second time to the physician.
It is imperative to note that regardless of how a physician responds to Bill 20, the province benefits; meanwhile, the physician, the public — or both — suffer.
That Bill 20 was tabled amid suggestions that primary- care physicians are lazy was simply an inaccurate and unnecessary insult, and serves only to poison any future negotiations. Physicians are already beginning to adapt to the possibility of Bill 20 in the form of early retirement or leaving RAMQ altogether.
I urge the public to fully appreciate the details and consequences of Bill 20 and how it will affect their access to care. I urge members of the National Assembly to also fully appreciate the consequences of Bill 20 and to have it modified accordingly.