HEALTH LAW & POLICY SEMINAR SERIES
presents
Marie-Claude Prémont
Professor of Law
École nationale d'administration publique (ENAP)
Post-Chaoulli direction for healthcare: worrisome signs from Quebec
Thursday, November 29, 2007
12:30 - 2:00 p.m.
Solarium (room FA2) - 84 Queen's Park
Bio:
Member of the Quebec Barand Quebec Professional Engineers Corporation (Ordre des ingénieurs du Québec). Researchi n Health law, Municipal Governance and Legal history. Founding Member of the Working Group on Quebec health care system, following the Supreme Court of Canada decision in Chaoulli. Presentations before public commissions of the Legislature of Quebec and government ofCanada on health policies.
Summary:
Bill 33, enacted in December 2006 is the Quebec Government's response to the Chaoulli decision of the Supreme Court of Canada ofJune 5th 2005, concerning unreasonable wait times for some services in theQuebechealthcare system. First, we must bear in mind that the argument thatQuebechas no other option following the Chaoulli decision is highly arguable. This argument profoundly confuses the roles of the judiciary and of Parliaments and only serves to promote the direction set by the Bill.
Beneath a benign façade, the Bill sets up fundamental changes to core principles of the Quebec's approach to healthcare, which up till now, have assured that maximum financial and human resources be channeled towards the healthcare system devoted to the whole of the population, and, a contrario, minimized public support of the private system that caters to only a small portion of the population. Bill 33 does indeed include some positive change with the introduction of centralized public waiting lists for specialized and superspecialized services and with management of service corridors inside the healthcare network. However, other main features of the Bill are far less reassuring for the future of public healthcare. Below are four core issues raised by Bill 33.
First, Bill 33 will legalize "private hospitals", called "Specialized Medical Centres" in the jargon of the Bill. These Centres will be able to offer services (or focus on some of them) which are today delivered by Ambulatory Care Centres (for authorized one-day surgery), hospitals (for authorized services with overnight stay) and private clinics as we know them across the system. These new private hospitals could be of two types. The first type, where services are paid for with public money, will become some sort of a "private extension" of the current hospital with which renewable exclusive five year contracts will be signed. The Centre then becomes what the Bill calls an "Associated Medical Clinic". Private laboratories and doctors' private offices can also sign such exclusive contracts with hospitals. This delegates by contract the provision of public services to for-profit private capital corporations. This is not benign. The second type of "private hospital" envisioned by the Bill is also a private corporation but here services will have to be paid for by private money. The second type of private hospital will be staffed by opted-out physicians who, from then on, will be able to offer (legally) authorized surgical services including overnight bed stay.
Other aspects of Bill 33 establish the conditions which will facilitate market growth for these private hospitals. First is the provision that the list of authorized surgical services that may be carried in Specialized Medical Centres (restricted in the Bill to knee and hip replacement and cataract surgery), can be extended in the future by simple regulatory changes by the Minister of Health and Social Services. Next, Bill 33 will allow private insurance for services carried out in the second type of Specialized Medical Centres (with opted-out physicians) and the list of such services could be extended beyond the three acts to cover some or all of the authorized surgeries in the private hospitals by simple regulation of the Government, after discussion at the appropriate committee of the National Assembly. It is important to understand that the private insurance contract will cover both physicians' costs and "hospital" services associated with overnight bed stay. This is a major departure from current public policy. Finally, Bill 33 is connected with the administrative compliance with a waitlist guarantee to be implemented, which may result in publicly insured patients being sent to private hospitals staffed with opted-out physicians.
The Government of Quebec has stressed those aspects of the Bill that limit for the time being the extent of the introduction of private health insurance and the extent of cross-subsidization of public and private healthcare systems. No one will be fooled by this. We are expecting any day a new regulation which will lengthen the list of medicals surgical acts which could be performed in those private hospitals. Moreover, such drastic changes in the course of healthcare delivery and financing could only be done in incremental steps anyhow. There is no doubt that the structure set in place by Bill 33 lays the corner stone on which two-tier healthcare can and will gradually develop. The Bill itself is being set in force incrementally, thereby allowing contracting out of public services in a mode which other «not in force sections» of the Bill would limit or prohibit. Directions set by Bill 33 for the future of public healthcare should indeed be a matter of serious concern to every citizen of this country.
A light lunch will be served.
Jointly sponsored by the Faculty of Law and the Department of Health Policy, Management and Evaluation,UniversityofToronto.
For more workshop information, please go to our web site at http://www.law.utoronto.ca/healthlaw/index.htm or contact Nadia Gulezko at n.gulezko@utoronto.ca
