MQRP

MDECINS QUBCOIS POUR LE RGIME PUBLIC

(Quebec doctors for the public system)

TWO-TIER RADIOLOGY: QUEBECS CREEPING

PUBLIC-PRIVATE SYSTEM

Report of the Board of Directors to the General

Assembly of Members

Montreal, May 2, 2012

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MDECINS QUBCOIS POUR LE RGIME PUBLIC
5225 Berri St., Suite 304
Montreal, Quebec H2J 2S4
514-638-6659
info@mqrp.qc.ca
http://www.mqrp.qc.ca

Research and Writing:

Maxime Dussault-Laurendeau, director
Camille Grin, director
Marie-Claude Goulet, president
Alain Vadeboncur, vice-president
Cory Verbauwhede, secretary-treasurer

Medical Imaging Committee:

Nina Benoit, resident physician
Lucie Dagenais, associate member
Marc-Andr Fournier, researcher
Isabelle Leblanc, director
Cory Verbauwhede, secretary-treasurer

Editing and Proofreading:

Raymonde Danis, secretary

Translation:
Bob Chodos

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Contents
Privatization is underway: The case of joint public-private practice in radiology...............4

1. A historic achievement, and then a retreat........................................................................5

Medical imaging...............................................................................................................6

2. On the ground: The impact of exclusion from public coverage .......................................8

The exodus of personnel ..................................................................................................8
Wait times: Interminable and inequitable ........................................................................8
Waiting list confusion ......................................................................................................9
Hours wasted by doctors, support personnel and patients................................................9
Tests that arent optimal..................................................................................................10
Conflict of interest, marketing.....................................................................................10
and risks .....................................................................................................................10
Private tests with no quality control ...............................................................................10

3. An overview: Misuse of resources ..................................................................................12

The Quebec exception ....................................................................................................12
Radiology in Quebec : Doing more with less .................................................................15
The public-private gap ....................................................................................................16
Interregional distortions ..................................................................................................17
A distortion that damages the system .............................................................................18
Workers compensation: A special case .........................................................................19

4. The lead actors: Medical Imaging Laboratories ..............................................................21

5. What is to be done?: MQRPs positions and demands..............................................23

6. What others say.................................................................................................................26

Once bitten, twice shy: The false option of joint public-private practice..............................30

Notes......................................................................................................................................32

Appendix I: Regulation Respecting the Application of the Health Insurance Act ...............33

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Privatization is underway: The case of joint public-
private practice in radiology
The people who conceived Quebecs public health care system were concerned with protecting
it and ensuring that it would last. They suspected that if they allowed doctors to practise in both
public and private spheres, the system might be nothing more than a house of cards. Hence,
from the beginning, the Health Insurance Act banned joint public-private practice.

But they didnt foresee everything. Medical imaging presents a vivid case study illustrating the
problems that arise when doctors are allowed to practise in both spheres. Because some services
are excluded from public health insurance when they are delivered outside a hospital,
radiologists can deliver the same medically necessary services on a private and a public basis.

The result is not encouraging. Medical imaging in Quebec is in a difficult situation, which
concerns us as doctors and as citizens. While privatization is too often presented as a solution to
problems in health care, this report shows that it is a false solution, opening the door to
fundamental problems of access, organization and equity.

In this respect, private medical imaging is emblematic of what can happen in any medical
discipline, and there is much we can learn from it. Of course, this report concentrates primarily
on medical imaging, but it is also meant as a warning for all fields of medical practice, at a time
when our public system is increasingly under stress and threatened by other developments of
the same nature.

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1. A historic achievement, and then a retreat
Before the Hospital Insurance Act went into effect in 1961, only a minority of Quebecers had
access to free medical services. Quebec legislation at that time covered hospitalization costs
only for very specific groups (indigents, needy mothers, etc.), and there was no public financing
to pay doctors. Universal free diagnostic services began in Canada with the federal Hospital
Insurance and Diagnostic Services Act of 1957. With this cost-sharing legislation, Ottawa
offered to pay 50% of the cost of hospitalization and diagnostic services to provinces whose
insurance systems covered these services uniformly for all residents.

The trade union movement and the Parti Social Dmocratique, the Quebec wing of the CCF,
supported this legislation. However, it was strongly opposed by the Canadian Medical
Association, the commercial insurance industry, the Canadian Chamber of Commerce and the
Canadian Hospital Association (CHA). The hospitals recommended instead that subsidies be
granted to the poor so that they could buy private insurance.

Quebec was the last province to accept the federal offer. Once its Hospital Insurance Act came
into effect on January 1, 1961, diagnostic services and their interpretation were covered for
hospital inpatients. Hence, doctors in three diagnostic disciplines (laboratory, radiology and
pathology) were the first to receive remuneration from the province. As the volume of services
increased, these doctors quickly organized to negotiate the terms of their participation
collectively.

Conflicts broke out in some hospitals over the amount and the method of remuneration. As
Denis Goulet wrote in his history of Maisonneuve-Rosemont Hospital,

The doctors [were] uneasy about government intrusion into the management of
care and feared rapid socialization of medical practice. ... The doctors most
affected by this reform, which made laboratory analyses done in the hospital
virtually free, were the pathologists and radiologists, who rightly feared that
their work in the hospital would increase substantially. ... As a result, they
demanded additional compensation, which the ministry refused to grant them.1

In 1966, Ottawa passed the Medical Care Act and offered the provinces agreements under
which the federal government would finance 50% of the cost of medical services. To be eligible
for an agreement, a province would have to develop a service plan with the following elements:
universal accessibility; a system financed and operated on a nonprofit basis by a public agency;
and complete coverage of all medically necessary care, including medical imaging.

In 1970, Quebec extended public coverage to the whole population with the Health Insurance
Act, which included medical imaging no matter where it was delivered. Quebec also banned
joint public-private practice, extra-billing and duplicate private insurance. The Health Insurance
Act went into effect on November 1, 1970, and the vast majority of doctors quickly joined the
public system. The Regulation Respecting the Application of the Health Insurance Act was
adopted at the same time. In essence, it excluded from coverage those medical services that are
not related to prevention or cure.

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Medical imaging

Ultrasonography, computerized axial tomography (CAT) and magnetic resonance imaging

(MRI) all made their appearance around the same time, in the 1970s and especially in the
1980s. The first CAT scan machine in Canada was installed at the Montreal Neurological
Institute, followed by the first three MRI machines in 1982. At the time they were used
primarily for research purposes. The first MRI machine for clinical use was introduced at St.
Josephs Hospital in London, Ontario, in 1984. Radiologie Lannec was the first private
radiology clinic to put a CAT scan machine (1989) and an MRI machine into operation.2

In 1977, Ottawa abandoned the 50% financing formula and weakened the incentive to respect
the requirements of the Medical Care Act. While new medical imaging technologies continued
to develop, starting in 1981 Quebec began to reduce health insurance coverage. Bill 27,
introduced just before the holidays in the midst of a recession, modified the governments
power to regulate uninsured services. With this change, the government could prescribe the
cases, conditions or circumstances in which the services contemplated in section 3 [all services
rendered by physicians that are medically required] are not considered insured services for all
insured persons or those insured persons it indicates.3 Through a simple regulation, the
government could now determine that a service that was insured when it was delivered in the
hospital would no longer be insured when it was delivered outside the hospital.

Thus, starting in 1982, mammograms for screening purposes and ultrasounds were no longer
insured outside the hospital, although ordinary X-rays still were. Subsequently, as advanced
diagnostic technologies became available, the government increased the number of exclusions.
Following the example of ultrasonography, the government generally based these exclusions on
where the service was delivered.

In the 1980s and 1990s, Quebecs health and social services ministry and treasury board were
concerned about the high cost of CAT scan and MRI technology and skeptical about whether
the benefits of these technologies justified the costs. Hence, they were reluctant to proceed with
the development of CAT scan and MRI technology in hospitals. However, a number of hospital
foundations bought the machines and at the same time conducted campaigns in the media
denouncing government insensitivity in failing to meet peoples needs. Faced with a fait
accompli, the ministry of health and social services agreed to pay the cost of installing and
operating these machines. The ministrys hesitancy needs to be put in the context of the 1980s
and 1990s, a period when the political class, the government bureaucracy and health system
analysts were concerned not with improving access to services but with controlling costs.

In 1984, in reaction to the abusive practice of extra-billing prevailing in some provinces, the
federal government passed the Canada Health Act, which reiterated the definition of insured
services as medically required services rendered by medical practitioners and added a
prohibition of extra-billing. Pierre-Marc Johnson, then Quebecs health minister, had just
introduced a regulation providing for exclusions, and he worried about whether these
exclusions were compatible with the new federal rules.

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However, even with the knowledge that the exclusion of some medically necessary services
might not be in conformity with the Canada Health Act, the Quebec government continued on
its path. It excluded CAT scans in 1988 and MRIs in 1995, except when these services are
delivered in a hospital setting. In November 2011 it added optical tomography of the ocular
globe and confocal scanning laser ophthalmoscopy of the optic nerve to its list of exclusions,
refusing to cover the costs of these new technologies when they are carried out in
ophthalmology offices.4

The development in Quebec of medical imaging outside public hospitals and financed
essentially through private sources is an anomaly in Canada. The Quebec governments
hesitation in developing these new technologies in hospitals went along with a refusal to
finance their delivery in private clinics. In contrast to what has happened in other provinces,
where these services are much more extensively covered by the public system, these decisions
have opened the door to the development of a sector that is privately operated and financed, as
the new technologies have become increasingly essential in medical diagnosis.

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2. On the ground: The impact of exclusion from
public coverage
The exodus of personnel

The exclusions described above have made it possible for radiologists to establish a de facto
joint public-private practice. Many radiologists practise simultaneously in a hospital, where
they are compensated by the Rgie de lassurance maladie du Qubec (RAMQ), Quebecs
health insurance agency, and in a private clinic, where they are paid directly by patients or their
insurance.

Hence, there have been a growing number of private medical imaging clinics, which need
technologists to operate. As a result the public system has been drained of its technical and
medical personnel. Even though there are enough machines and personnel in total, the public
supply of medical imaging services has diminished and become more or less inadequate. As La
Presse reported in 2009,

In the last few years, the number of ultrasounds has continued to go down. While
40,766 ultrasounds were carried out in 2001, only 30,663 were done in 2008.
Weve lost radiologists over the years, explains Mr. Brochu, spokesperson for
Maisonneuve-Rosemont Hospital.5

Wait times: Interminable and inequitable

While patients who are hospitalized or who go to the emergency room appear to have
reasonable access to medical imaging services, such access is far more problematic in the case
of tests that are requested on an elective basis. While it is difficult to obtain complete
information to support all our conclusions, we can state on the basis of the data that do exist6
and our clinical practice that many hospitals are not managing to ensure access for outpatients
within a reasonable time frame. As La Presse reported,

The situation is so critical that the CEOs of five health institutions in the east end
of Montreal wrote to the government on June 18: We wish to inform you with
this letter that the population of the east end of Montreal currently does not have
access to diagnostic ultrasound services. We can say very clearly that
ultrasonography is no longer an insured service for the population of the east end
of Montreal.7

Longer and longer wait times in public hospitals have led some patients and their doctors to
resort to private clinics when a medical imaging test is needed. Since these services are
excluded from public coverage, the patient has to pay to have access. The paradox is that the
tests are often done by the same radiologists who work in the hospital.

Hence, access to a medical imaging test is increasingly determined not by whether the test is
medically indicated or by the patients state of health, but by the patients ability to pay.

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Different patients experience wait times that vary widely, but not in relation to their medical
condition: patients who are economically better off and those who have private insurance have
quicker access to the medical imaging tests offered by the private system. Diagnostic imaging is
often a cornerstone of medical diagnosis, which generally precedes a therapeutic decision.
Thus, patients whose access to medical imaging is delayed will also suffer a delay in the
eventual treatment of their health problems.

Waiting list confusion

In an environment of long wait times in public hospitals, and without centralized management
of waiting lists (which is difficult in the current context of dual private and public
delivery), there could be an incentive for patients to register on several public waiting lists to
maximize their chances of getting an appointment. These lists are artificially inflated by
patients who are also registered on other lists or who have already had their tests in other
hospitals. This inflation can lead to uselessly scheduled appointments, pointless calls by support
staff in radiology departments and a lack of reliable data on real wait times.

A system with exclusive public financing, such as Ontarios, would make it possible to compile
precise data on wait times, accessibility of medical imaging tests and costs of operation. By
contrast, in Quebecs joint public-private system, it is possible only to collect data that are
fragmentary or too general. The system leaves us in the dark about real wait times and
accessibility, which vary considerably both from one hospital to another and in relation to
ability to pay.

In Ontario, there has been a public oversight system in place since 2005, established by the
provinces minister of health and long-term care in the context of the Ontario Wait Time
Strategy. Anybody can go online and quickly find out how long the wait time for a CAT scan or
MRI is, in number of days, at the provincial level, for a particular hospital or by distance from a
particular postal code. The strategy also aims to standardize hospitals according to the norms of
clinical practice guidelines so as to improve the efficiency, quality and safety of tests.

Hours wasted by doctors, support personnel and patients

The difficulty of obtaining access to medical imaging tests, tied to the exclusion from public
coverage of services delivered outside a hospital, makes practice more complex for doctors and
their support staffs, who have to devote considerable time to obtaining a test in a public hospital
without an undue wait. The many hours spent on this research are hours that cannot be spent in
taking care of other patients.

In addition, many patients are referred to the emergency room to have a test done quickly.
These referrals could be avoided if there were easier access to semi-urgent medical imaging
tests in public hospitals. Many patients have spent hours on a stretcher in the emergency room,
with no clinical justification, so that they can have quick access to a CAT scan that makes it
possible to rule out a more or less acute medical condition.

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Tests that arent optimal

Paradoxically, these problems of access to appropriate medical imaging tests lead to an increase
in the number of tests ordered, which in turn leads to higher costs and further aggravation of the
access problems. This happens because many clinicians will fall back on a more accessible test
that is not as appropriate for the clinical situation. Thus, doctors will often prescribe a colon
CAT scan when they suspect a herniated disc because an MRI, which would be more accurate
and expose the patient to less radiation, is unavailable. Backup tests are often ordered, and
patients may remain on the waiting list for the optimal test several weeks or even months after
the less appropriate test has been performed.

Conflict of interest, marketing

Furthermore, radiologists may have a financial interest in a private clinic and be in a position to
reap a substantial profit from the clinic, placing them in a potential conflict of interest. This
situation could, for example, lead to an increased number of useless tests. For a substantial fee,
private radiology clinics will do preventive full-body CAT scans,8 PET scans for patients
worried about having cancer9 or 3D and 4D obstetric ultrasounds. These tests are not medically
indicated and may even be harmful as a result of the amount of radiation to which the patient is
exposed.

and risks

Overuse of diagnostic imaging also causes a number of problems. Each method has inherent
risks, such as exposure to radiation and the risk of secondary cancers for CAT scans. This risk,
while fairly small for a single test, is cumulative. Contrast agents used in CAT scans and MRIs
carry the risk of allergic reactions and kidney damage. In addition, with any medical imaging
test, there is the risk of identifying an anomaly that is not clinically significant that is, a false
positive. This can lead to needless anxiety and further tests that will overload the system and
involve additional costs.

Private financing makes it impossible to have an effective oversight system through which the
appropriateness of the tests that are carried out can be precisely evaluated. Such a system is
vital to the quality of medical practice. In contrast, coverage and delivery that are entirely
within the public sphere allow for better control of practices and more rational use of imaging
resources.

Private tests with no quality control

A recently published investigation by the Collgedesmdecinsdu Qubec(QuebecCollegeof

Physicians)onerrorscommittedinreadingmammogramsandCATscanscarriedoutinprivate
radiologyclinicsinMontrealcametothefollowingconclusions:

The inquiry ... raises issues regarding quality assurance mechanisms surrounding
the practice of medical imaging in private clinics ... Currently, there are no

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 means to ensure the quality of medical practice in private clinics along the lines
of the council of physicians, dentists and pharmacists (CMDP) in a hospital.10

It is disturbing to see that a large portion of the supply of medical imaging services is provided
by private clinics, where very little quality control seems to be in place. By contrast, care
provided in the public system is submitted to a degree of supervision that is essential in
ensuring that the entire population receives high-quality services.

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3. An overview: Misuse of resources
The situation regarding medical imaging in Quebec is unique in Canada. As we have seen,
ultrasounds, CAT scans and MRIs performed outside a hospital in Quebec are not considered
insured services, contrary to any medical logic.

The result is a de facto, but legal, joint public-private practice. Radiologists can thus provide
insured services in the hospital, and at the same time provide the same services in a private
clinic, outside the public insurance system. Material and human resources are divided between
two parallel systems, which are poorly coordinated and not necessarily complementary but
which communicate with each other. We will see that this situation leads to misuse of resources,
and hence to increased problems of access.

The Quebec exception

It is surprising to see that the number of MRI and CAT scan machines in Quebec in relation
to population is greater than the Canadian average, in both the private and the public system
(Figures 1 and 2). Per million residents, Quebec has more CAT scan machines in the public
sector alone than the public and private sectors have in total in all the other provinces (Figure
1). In the case of MRI machines, the same comparison holds true for most of the other
provinces (Figure 2). It should be noted that the proportion of CAT scan machines belonging to
the private sector is marginal everywhere, while its larger in the case of MRI machines.

Source: Canadian Institute for Health Information (CIHI), National Survey of Selected Medical Imaging
Equipment. Table on the Web: MIT 2011.

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Quebec also has more specialists in diagnostic radiology and more technologists in
radiology and radio-oncology per 100,000 residents than the other provinces (Figures 3 and 4).

Source: CIHI, Canadas Health Care Providers Provincial Profiles: A Look at 24 Health Care
Occupations.*Including technologists in radio-oncology.

However, few data are available on how human resources are divided between the private
and public sectors. Figures relating to uninsured radiology services in private clinics and those
concerning support staff in these clinics are not accessible.11 Nor are there any available data on
how radiologists divide their time in relation to CAT scans, MRIs and ultrasounds between their
activities in the hospital and their private activities. De facto joint public-private practice means
that radiologists who operate private clinics are also responsible for radiology tests in the
hospital. The Association des radiologistes du Qubec alleges that there is a shortage of
technologists in the public sector, but in this context the shortage is difficult to identify
precisely.

The number of CAT scans per resident is also higher in Quebec than in the other provinces
(Figure 5). Quebecs total is 18% higher than the Canadian average. However, the number of
MRIs in Quebec is 9% lower than the Canadian average and 22% lower than Ontarios number
(Figure 6), even though Quebec has more MRI machines and more total personnel.
Unfortunately, no data are available comparing rates of use of machines in the public and
private sectors.

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 Source: CIHI, National Survey of Selected Medical Imaging Equipment. Table on the Web: MIT 2011.

Therefore, despite greater human resources, intensity of use of machines is lower in Quebec,
especially in the case of MRIs (Figures 7 and 8). Quebec differs from the other provinces in its
larger proportion of private clinics, private financing of tests performed outside hospitals and de
facto joint public-private practice.

Source: CIHI, National Survey of Selected Medical Imaging Equipment. Table on the Web: MIT 2011.

According to a 2008 study by Bercovici and Bell of public hospitals and private clinics offering
MRIs in several provinces, including Quebec, the rate of use of machines is about 50% higher
in hospitals than in private clinics: an average of 14.7 hours of operation per day during the
week and 11.8 hours per day on weekends for hospital machines, compared to 9.7 hours per day
during the week and 8.2 hours per day on weekends for machines in clinics.

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Radiology in Quebec: Doing more with less...

Given that there are more machines and professionals in Quebec, it is hard to attribute the
problems of access that are reported to a lack of human or material resources. While there may
be more professionals in Quebec, they are unavailable in the public system when they are busy
with tests carried out in private clinics this is undoubtedly part of the explanation for the
lower rate of use. It is also possible that professionals work fewer hours on average in Quebec.
However, it is still true that the draining of human resources by the private sector is detrimental
to the operation and accessibility of public medical imaging.

The public-private gap

At the Centre hospitalier de lUniversit de Montral (CHUM), patients have to wait much
longer than the medically acceptable wait times for MRIs and CAT scans. Wait times vary
between 6 and 22 weeks for an MRI and between 9 and 23 weeks for a CAT scan.12 In contrast,
the wait time for an MRI in a private clinic such as Medisys is one business day, and there is no
wait for a CAT scan.13 This mismatch is a black-and-white demonstration of the oversupply of
radiology in the private sector, with resources mobilized uselessly to carry out tests that are not
urgent and may be less medically appropriate. This oversupply has an impact on access for the
majority of the population.

Sources: Direction de lvaluation des technologies et des modes dintervention en sant, CHUM, and Technology
Assessment Unit, McGill University Health Centre, Les temps dattente au CHUM: I. Imagerie diagnostique,
arthroplastie, chirurgie cardiaque, soins du cancer et restauration de la vue, May 2007; www.medisys.ca/

The data for ultrasounds lead to equally striking conclusions. As an example, let us look at the
Sherbrooke area, where private ultrasounds are available near the hospital. Wait times are
considerably longer at the Centre hospitalier Universitaire de Sherbrooke (CHUS) than at the
neighbouring private clinics. They are also longer at CHUS than at most other health and social

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services centres (CSSS) in the Eastern Townships where no private service of that kind is
available.

Source: Agence de la Sant et des Services Sociaux de lEstrie, Sommaire des dlais moyens et liste
dattente en imagerie mdicale.

Private delivery of radiology not only sets up an ethically questionable two-tier system but
also harms the public system by draining material, human and financial resources. The media
too often tend to conclude that quick access to private radiology is proof of its efficiency.
However, what is really involved is an imbalance of supply between the private and public
sectors, and another instance of poor use of resources.

Interregional distortions

On the whole, private radiology laboratories are concentrated in major urban centres, where
there is a market for these services.

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 Source: Ministre de la Sant et des Services Sociaux du Qubec.

Only four regions have privately operated CAT scan machines: Quebec City, Montreal, Laval
and Montrgie (the area surrounding Montreal except for Laval). In these regions, a large
proportion of machines are privately operated. The concentration of these services primarily
around the major centres suggests that the draining of personnel and resources to these
laboratories is not only harming the public system but also working against interregional equity.

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 Source: CIHI, National Survey of Selected Medical Imaging Equipment. Table on the Web: MIT 2011.

Privately operated MRI machines are more broadly distributed around Quebec than privately
operated CAT scan machines, but they also represent a larger proportion of the total number of
machines. The same overall tendency towards concentration around the major centres, where
there is a market for VIP tests, can be seen in the case of MRI machines.

A distortion that damages the system

Within Canada, it is only in Quebec that there are a large number of medical imaging machines
(MRI and CAT scan) owned and operated by private clinics, delivering tests paid for by patients
or their private insurance and contributing to the profits of private interests. While no numerical
data are currently available for ultrasound machines, the reality on the ground undoubtedly
includes substantial private delivery of ultrasonography and is comparable to what we have
seen in the case of MRI and CAT scan machines.

While it has more material and human resources, Quebec is less effective than Canada as a
whole in providing accessible medical imaging services. The exclusion from public coverage of
CAT scan, MRI and ultrasound tests performed outside a hospital leads to joint public-private
practice that has the effect of draining resources from the public to the private sector. This
damaging distortion leads to problems of access to medical imaging for most patients and is a
fundamental issue that needs to be taken into account in the search for solutions to these
problems.

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Workers compensation: A special case

In the case of a work accident or occupational disease, Quebecs workers compensation

agency, the Commission de la sant et de la scurit du travail (CSST), not only must pay for
health care but must also provide income replacement. Any delay extends the period of income
replacement, and hence the direct cost to the CSST. In addition, delays can lead to higher costs
if the injury is not treated in time. If the delay compromises the patients rehabilitation or makes
it more difficult, it may mean a longer period before the patient can return to work and therefore
additional costs to the insurer. Hence, acting as a responsible insurer, the CSST provides its
beneficiaries with privileged access to medical imaging tests.

Thus, the CSST reimburses patients for medical imaging services ultrasound, CAT scan and
MRI whether they are delivered in a hospital or in a private clinic, and whether or not they
are insured by the RAMQ. It has signed agreements with private imaging laboratories
throughout Quebec. These agreements cover ultrasounds (six agreements), nuclear medicine
(three agreements), CAT scans (16 agreements) and above all MRIs (25 agreements). The CSST
requires guaranteed access to the test within ten days and to the results within five days after
that.

This situation raises the question of equity and its abuse. From an ethical point of view, treating
occupational injuries preferentially in relation to all other health problems not related to work is
difficult to justify. A just and equitable system treats patients according to their needs and not
according to their (or their insurers) ability to pay.

As a result of this way of operating, private medical imaging laboratories receive substantial
financing from the CSST, and this money is not available to public hospitals. No doubt, the
private laboratories offer quick service, but this service exists at the expense of the public
system since personnel are quite simply drained to the private system. In the case of the CSST,
financial resources are drained as well.

MQRP does not object to access to private clinics run by doctors participating in the public
system for cases insured by the CSST and the automobile insurance agency, the SAAQ far
from it. Rather, MQRP maintains that this access should be extended to the population as a
whole by bringing these clinics into the public sector. Rights have often been initially won by
and for organized workers and then extended to the whole population.

The same medicine needs to apply in all situations. A mother who suffers a fall while picking
up her child from daycare after work should have the same right to a test as she would if her
accident had happened at work she should have the test as quickly, and without paying a
private clinic.

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4. The lead actors: Medical Imaging Laboratories
Like Specialized Medical Centres (SMCs), Medical Imaging Laboratories (MILs) can be owned
by shareholders who dont practise in the clinic. This distinguishes them from traditional group
practices operating by agreement with the government, in which doctors who work there pool
their resources. Most MILs are well integrated into the public system and perform insured tests.
However, a few large clinics whose practice is based on exclusions from the public system and
on money from public insurers such as the CSST and the SAAQ can have an impact on the
overall picture.

Only a radiologist may operate a Medical Imaging Laboratory. However, the only constraint
placed on the company for which the operator acts is that more than 50% of the shareholders
have to be radiologists. In other words, a specialists certificate in radiology is a licence for
unlimited investment in the MIL market. In an extreme case, a certified radiologist could hold
100% of the shares of all the MILs in Quebec. If lack of money was a problem, the radiologist
could sell just under half of the shares in each laboratory to financial backers.

MILs that operate under this structure are motivated to provide their shareholders with a return
on their investment. The law requires a majority of an MILs internal management board to be
made up of radiologists working in the laboratory. However, this is not adequate protection
against possible pressures coming from outside shareholders. Recent reports of RAMQ
inquiries into RocklandMDs SMCs and the Clinique Chirurgicale de Laval are enough to
convince a reader that these concerns are solidly grounded.14 These clinics found ways around
regulations so that they could satisfy their shareholders desire for profits. RocklandMD
imposed compulsory fees for access to a participating doctor and billed for services for which it
had already been paid by the RAMQ two practices that are against the law. For its part, the
Laval clinic took advantage of a little-known exclusion allowing it to bill an employer or an
association for services in very particular circumstances. Using this exclusion, it required
patients to pay for services through a third party that took care of billing.15 In MQRPs view,
since these clinics appear to have used dubious means to collect substantial sums of money, the
RAMQ should have imposed substantial penalties. The law provides for severe penalties for
this kind of infraction, but a law is effective only when it is enforced.

MILs are different from SMCs by virtue of the exclusions criticized in this report. Since
radiologists currently enjoy the right to be compensated both by the RAMQ and by patients,
commercial practices that are illegal in SMCs are legal in MILs. However, the law provides for
two kinds of MILs. One kind is made up exclusively of doctors who participate in the Quebec
health insurance system, while the other is made up exclusively of non-participating doctors.
But because the exclusion of a significant portion of medical imaging from public insurance
effectively allows a radiologist to operate a joint public-private practice, there is no reason for a
radiologist not to participate in the public system and there are, in fact, no non-participating
radiologists in Quebec.

MQRP has long demanded that the services that are currently excluded be completely covered.
However, even if this were to happen, the lucrative nature of MILs for shareholders would still

20
be highly problematic. In similar cases in Ontario, this model was rejected because of the waste
of public funds to which it led:

The for-profit clinics siphoned scarce radiologists and technologists from public non-
profit hospitals, reducing the number of scans the hospitals were able to do;
The for-profit clinics cream-skimmed the fastest, lightest-care patients, leaving the
more complex heavy-care patients for public nonprofit hospitals;
The for-profit clinics siphoned revenues from public nonprofit hospitals;
The contracts with the for-profit clinics were, and remain, secret and unaccountable;
The clinics reported selling medically unnecessary scans, wasting resources and
compromising health for profit, in contravention of clinical treatment protocols.16

Finally, while there are many similarities between the rights and obligations of SMCs and those
of MILs, there are also enormous differences, especially in terms of the publics right to
information. For example, the health and social services ministry is not obligated to publish
regularly the information required to obtain and renew licences.

21
5. What is to be done?: MQRPs positions and
demands
First of all, MQRP demands complete public coverage of medically necessary medical imaging,
whether services are provided in a hospital or in a private radiology clinic.

To accomplish this, the Regulation Respecting the Application of the Health Insurance Act will
need to be amended to abolish the exclusion of ultrasounds, CAT scans and MRIs when they
are delivered outside a hospital (see Appendix I). These exclusions, unique in Canada, are
contrary to the principle of universal access to medically necessary services.

The absence of public coverage for these tests, which are essential in contemporary medical
practice, is the source of many problems. Hospitals cannot always provide their free services
within a reasonable time frame, largely because of the impact of private radiology services on
human resources. As a result, if patients cannot pay to have these tests, their diagnoses are
delayed, their suffering is needlessly prolonged, their incapacities get worse and their lives may
even be endangered. These medical developments inevitably have harmful economic and social
consequences as well.17

For the health system, the presence of a substantial supply of private medical imaging services
leads to longer waiting lists in hospitals, higher costs, lack of information on the overall picture,
difficulty in planning services and a lack of quality control. The policy of commercializing
services also encourages the development of the private complementary insurance market.

Once the delivery of medical imaging services that is currently excluded from public insurance
is brought into the public system, better planning of these services will become possible. This
will mean giving preference to delivery in public outpatient clinics in hospitals.

For all these reasons, we consider it essential to extend public coverage immediately to all
medically necessary medical imaging tests, in the following manner:

1. Eliminate the exclusion from public coverage of medical imaging tests (ultrasound, CAT
scan and MRI) performed outside a hospital through an amendment to the Regulation
Respecting the Application of the Health Insurance Act and not through piecemeal
agreements that will not ensure the same services in uniform conditions. (See Appendix I:
Regulation Respecting the Application of the Health Insurance Act).

2. When this exclusion is eliminated, medical imaging tests performed outside a hospital will
become insured services, like all other services delivered by doctors.

3. Once these services are insured, the prohibition of duplicate private insurance will apply
to them, just as it applies to all other medically insured services. Providing tests linked to
private insurance will no longer be a valid option. As a result, the share of the market held
by private medical insurance will erode, giving way to public insurance that is more just and
equitable.

22
4. The problematic situation of joint public-private practice by radiologists, tied to these
exclusions, will also be eliminated, because a doctor is not allowed to provide services
insured by the RAMQ in both the private and the public sector. Hence, radiologists will
have to choose between the status of participating physician and that of non-
participating physician. Since the market for private medical imaging will be limited by
the ban on duplicate private insurance, the vast majority of radiologists will continue to
be doctors participating in the public system, like other doctors working in Quebec.
Radiologists will be devoting most or all of their time to a much more adequate public
system that will be better able to meet all the needs of Quebecers.

5. As with all medically necessary services covered by health insurance, equitable and
reasonable rates will be negotiated between the health and social services ministry and
the medical specialists federation to provide for the remuneration of radiologists
performing medical imaging tests outside hospitals.

We are aware that reestablishing public coverage of medical imaging tests performed outside a
hospital will require additional public financing for private delivery in MILs, some of which are
for-profit enterprises. This situation appears to us inevitable in the short term, although it should
not be encouraged in the future. We believe that the public investment required to ensure more
complete coverage of medical imaging is appropriate, to the extent that it will lead to improved
service and equity of access and shorter wait times. For services delivered outside hospitals, a
return to the model of nonprofit group practices operating by agreement with the government
should be encouraged as much as possible.

Hence, it will be essential A) to set the parameters of public coverage of this private service
and B) to encourage the improvement of public provision of medical imaging over the
medium and long term so that private delivery will lapse.

A) Setting the parameters of public coverage of a private service

6. We continue to demand the abolition of corporate structures with private investors.

Once these structures are abolished, the MILs will become private medical imaging clinics
operating by agreement with the public system, along the same lines as private offices of
family doctors.

7. We also reaffirm the importance of maintaining the prohibition on participating and non-
participating doctors practising together under the same umbrella (SMC or MIL).
According to the law, an SMC or an MIL must be made up either of doctors participating in
the public system or of non-participating doctors, but not of both at the same time. MQRP
also demands that this prohibition apply to the whole public health care system. Without
this condition, conflicts of interest are inevitable.

8. To regain public control of medical imaging, it will be necessary to apply the prohibition
on extra-billing rigorously and abolish ancillary fees.

23
B) Aiming for complete public provision of services

9. The return of radiologists and radiology technicians to public hospitals, along with
better use of medical imaging machines, will make it possible to provide more adequate
public delivery of medical imaging services in hospitals. Meanwhile, the ministry should
suspend the granting of new licences.

10. As Ontario did a few years ago, the government could also, if necessary, buy some private
medical imaging clinics to fill the gaps in the provision of services and thus provide
medical imaging services equitably to all the people of a particular area. MILs would then
become nonprofit public outpatient medical imaging clinics, integrated into the public
system.

24
6. What others say
Dr. Marc-Andr Asselin, president of the Association des mdecins omnipraticiens de
Montral (Montreal association of general practitioners):

Its easy to say that we have a free and universal health care system in Quebec.
But in fact, thats not the case, the vice-president of the Fdration des
mdecins omnipraticiens du Qubec [Quebecs federation of general
practitioners], Dr. Marc-Andr Asselin, says regretfully. To correct the
situation, Dr. Asselin believes that the government should insure
ultrasounds both in hospitals and in private offices: People need ultrasounds
every day, but dont have access to them within a reasonable time frame. The
government should tell us whether it insures health care or not. If it does,
ultrasounds should be insured.18

MQRP not only comes to the same conclusion as Dr. Asselin but ups the ante, maintaining that
the situation is similar for CAT scans and MRIs. These three kinds of tests should be publicly
insured outside of hospitals.

Dr. Gatan Barrette, president of the Fdration des mdecins spcialistes du Qubec (FMSQ,
Quebec specialists federation), would not be opposed to government insurance of radiology
in private offices:

If the government decides to cover it outside the hospital, which it can do

any time, then it does it and we negotiate a fee and its finished. I have no
problem with that. The bargaining surrounding that would last a month.
Its a simple budgetary calculation, Dr. Barrette indicated.

In his view, its the government thats responsible for the situation and not the
radiologists, who are offering a completely legal service in private clinics. Its
because the hospital doesnt develop that the private sector develops. The
financing of services outside the hospital is a subject that is major and will
get bigger with time, and its a subject that governments have intentionally
refused to address for one simple reason, he suggested.19

MQRP agrees that the government and underfinancing are primarily responsible for the
situation. That said, if medical imaging were covered publicly, MQRP is concerned about the
possibility that the fee paid to radiologists would be higher than is warranted by the costs. This
would lead to a larger exodus of radiologists to private clinics. If public delivery of services is
to be encouraged, remuneration from the public purse should not be more advantageous outside
hospitals.

Dr. Frdric Desjardins, president of the Association des radiologistes du Qubec:

The president of the FMSQ had suggested last week that radiologists could
perform between 800,000 and a million more ultrasounds each year, without any

25
 additional resources, if the government decided to cover the costs of ultrasounds
in private clinics. Dr. Barrette had estimated that it would cost the Rgie de
lassurance maladie du Qubec about $30 million a year to cover these tests in
private offices ...

[Dr. Desjardins] also said he was surprised to hear the president of Mdecins
[qubcois] pour le rgime public, Dr. Marie-Claude Goulet, suggest that the
costs of medical imaging tests (ultrasounds and MRIs) in private offices should
be included in the services covered by health insurance.

I fell out of my chair when I read that. If the government really has some $30
million a year for ultrasounds, it should put the money into hospitals, not private
offices, maintained Dr. Desjardins, who holds shares in private clinics. He said
he is prepared to sit on a committee that would see to the best use of these funds.

And I will put forward lots of ideas about how to invest in the public system to
improve access, he added.20

MQRP completely agrees that investment should be in public hospitals rather than private
medical imaging clinics. Indeed, our demand is that medical imaging should eventually be
completely integrated into the public system. It also seems very clear to us that as long as
medical imaging tests performed outside of hospitals are excluded from health insurance, it will
be impossible to solve the problems of inequitable access to these tests, as the waiting lists in
the public system are directly linked to human resources (radiologists, technologists) being
drained to the private sector.

Dr. Claude Blanchard, medical consultant to the ministry of health, responsible for the licensing
of Medical Imaging Laboratories (MILs) and of radiology:

Radiology, a developing sector?

Even if the health ministry doesnt know exactly how many tests are
performed in private radiology clinics each year, because its not required to
answer that question, Dr. Blanchard believes that private delivery is more
common in radiology than in any other medical specialty. Most other medical
specialists practising in private offices provide consultation or expertise, but they
havent pushed the technological dimension as far as the radiologists have.
However, the phenomenon is beginning to spread in other disciplines,
especially with the establishment of private endoscopy clinics.21

MQRP also notes the disturbing trend towards more widespread private delivery and repeats
that the radiology model should absolutely not be exported to other specialties. The health
ministry and the RAMQ should be much more aggressive in implementing the prohibition of
extra-billing and other illegal practices that are becoming more widespread as a result of these
new clinics. In this context, our fear is that digestive endoscopy performed outside a hospital
will be the next procedure excluded from public coverage.

26
Dr Jean Rodrigue, assistant deputy minister for medical and university affairs at the ministry of
health and social services:

So, is a radiologist who practises in a hospital and has an interest in a

private clinic in a position of conflict of interest? Dr. Rodrigue emphasizes
that in the vast majority of cases a radiologist cannot determine the demand for
tests, insured or uninsured, coming from an attending physician. Its often
patients who determine where they will have their tests done. The assistant
deputy minister also notes that radiologists are subject to their code of ethics and
that their behaviour can be examined by their hospitals council of physicians,
dentists and pharmacists if there is a violation.22

A radiologist who has an interest in a private clinic and can choose where to practise, with one
location being more remunerative than the other and each location having its own waiting list,
has a potential conflict of interest. In effect, radiologists who on their own initiative transfer
part of their practice to the private sector contribute to widening the gap between public supply
and demand. Its not always true that patients determine where they will have their tests.
Patients are very often held hostage and faced with the dilemma of paying to have their tests
more quickly or putting themselves on a waiting list in the public hospital.

Dr. Rodrigue believes that the public systems resources are underused and
need to be further optimized. Although there are waiting lists, especially for
MRIs, the ministry takes the view that currently we need to work first and
foremost on access to medical imaging and on processes for improving access in
the public system, he emphasized.

According to our assessment of scanners and MRI machines, its clear that
the public system has the infrastructure to meet the needs of Quebecers and
that there are adjustments to be made. We think there are enough machines
in the public system to meet the needs of Quebecers.23

MQRP completely agrees that there are enough machines in the public system to meet the
needs of Quebecers and that the public systems resources are underused and need to be
further optimized. We have shown that Quebecs number of MRI and CAT scan machines is
higher than the Canadian average in both the private and the public sector.

The idea that the problem can be solved without abolishing the exclusions from public
insurance is an illusion. In our view, the exclusions are the source of problems of access in the
public system. As long as the development of private medical imaging clinics is allowed and
encouraged through the exclusions and through private insurance, the human resources that the
public system needs to function well will be drained towards the private sector. In addition,
radiologists who are investors will have no interest in resolving the question of waiting lists
because they draw their clientele directly from those lists.

27
 There is also the question of the appropriateness of the tests. We have to be
careful. When a technique is made more accessible, is there any assurance
that its use will be effective and efficient?24

As we see it, better access to all medical imaging tests through public coverage will make
possible more rational use of these tests, along with better control of their quality and
appropriateness.

28
Once bitten, twice shy: The false option of joint
public-private practice
Fundamental social advances have been made possible through public coverage of health care.
However, for some medical imaging procedures, the struggle for public coverage has also
experienced some reverses and is therefore not over. This report has cast light on some of the
mechanisms operating to privatize our public health care system and has provided a glimpse of
what awaits us if nothing is done to stop this process.

Since the initial legislation integrating medicine into Quebecs social safety net was passed,
many doctors have supported this new way of encouraging access to health care. However,
there have also been many areas of resistance within the medical profession. A fragile balance
built on compromises between the public and private sectors has led to the system that we know
today.

This compromise is based on the fundamental principle that a doctor has to choose his or her
camp: to be exclusively participating or exclusively non-participating. Participating physicians
are forbidden to receive any money for medically necessary services other than the fees
negotiated between the health ministry and the doctors federations. Non-participating doctors
have to get by according to the rules of the market.

Within the public system, fees are the subject of constant bargaining, for services both inside
and outside of hospitals. In hospitals infrastructure is paid for by the ministry, while in other
locations doctors receive compensation for their overhead. The bargaining is centralized: in
principle, all doctors should be paid in the same way for the same service, in an effort to
provide equal access and quality for all citizens.

However, over the years, as the government has dealt with budgetary restrictions, it has
hesitated to cover some new technologies. This hesitation has left holes in public coverage,
affecting medically necessary services. As a result, the public system has gradually given up
hard-won ground, and a parallel private system has taken shape. Pressure from the private
system has widened the gaps in public coverage and threatened other areas under public
control. In this way, the mutually agreed-on bargaining mechanism has been sidestepped.

Radiologists have been the first to benefit from legal joint public-private practice. They can be
compensated both by the RAMQ and by private sources (insurance companies and individuals)
for medically necessary services. This dual source of revenue has made possible the
development of for-profit companies with an ever broadening scope of activity. As these
companies grow, they become able to compete with the public system, and then to weaken it,
primarily by draining its human resources (radiologists and technologists), with consequences
that we have explored in this report.

Other specialties are looking covetously at joint public-private practice, which allows doctors to
negotiate a guaranteed base income coming from the RAMQ and then to supplement it with
income from private sources. Thus, in November 2011, legally dubious billing for substantial

29
ancillary fees not covered by the agreements with the ophthalmologists led to a new exclusion
of medical imaging services delivered in offices. We can anticipate the same thing happening in
gastroenterology, where it is becoming more common to charge illegal ancillary fees for
digestive endoscopies, and in other specialties.

The exclusion from public coverage of medically necessary services is not the only reason that
the principle of coherent, centralized bargaining is being weakened. In addition to the
agreements between the health ministry and the federations, agreements for specific services
negotiated by the regional agencies and the health and social services centres have created a
parallel system of financing. The exact amount of the supplementary profits being made under
these agreements is not made public. Meanwhile, all sorts of illegal billing practices are
becoming more common throughout the system.

Fortified by this new income, commercial health care companies are building a position of
power relative to the government and are becoming more and more invasive. In this vicious
circle, the development of a parallel private system has weakened the governments bargaining
power, which is the foundation of our public system. Thus, the parallel private system is
engaging in unfair competition with the public system.

This is what needs to end, and that is why we are proposing that medical imaging currently
excluded by regulation be covered by public insurance.

30
Notes
1
Denis Goulet, LHpital Maisonneuve-Rosemont : une histoire mdicale,19542004 (Quebec City: ditions du
Septentrion, 2004).
2
Retrieved April 29, 2012, from www.santeprivee.ca/Tomodensitometrie/Radiologie_Laennec_Inc.50-
80-0-0.html
3
Health Insurance Act, s. 69, para. b.1.
4
Regulation Respecting the Application of the Health Insurance Act, s. 22, para q.3.
5
Ariane Lacoursire, chographies : des patients dirigs vers le priv, La Presse, July 23, 2009.
6
For example, Dlais dattente et liste dattente aux examens dimagerie mdicale dans les tablissements publics
et privs de lEstrie, retrieved April 27, 2012, from aspnet.transitserver.net/microage/frm_aspx/index.aspx
7
Lacoursire, chographies.
8
Natalie Mehra, Eroding Public Medicare : Lessons and Consequences of For-Profit Health Care across Canada,
October 2008, retrieved April 27, 2012, from www.web.net/ohc/Eroding%20Public%20Medicare.pdf
9
Heard on the radio, March 18, 2009.
10
Huguette Blanger and Louise Charbonneau, Rapport denqute : rvision des mammographies et des
tomodensitomtries effectues dans les cliniques de radiologie Fabrevillle, Jean-TalonBlanger et Domus
Medica, 20082010, presented to the executive committee of the Collge des Mdecins du Qubec March 26,
2012, retrieved April 27, 2012, from
www.cmq.org/fr/Public/Profil/Commun/Nouvelles/2012/~/media/Files/PesseEvenements/Rapport-
mammographies-mars2012-DEF.ashx?41227
11
According to figures from the Alliance du Personnel Professionnel et Technique de la Sant et des Services
Sociaux, about 14% of radiodiagnostic technologists work in the private sector.
12
Direction de lvaluation des technologies et des modes dintervention en sant, CHUM, and Technology
Assessment Unit, McGill University Health Centre, Les temps dattente au CHUM: I. Imagerie diagnostique,
arthroplastie, chirurgie cardiaque, soins du cancer et restauration de la vue, May 2007, retrieved April 27, 2012,
from www.chumtl.qc.ca/userfiles/Image/DETMIS/rapport_temps-attente.pdf
13
Retrieved April 28, 2012, from www.medisys.ca/
14
Enqute de la Rgie de lassurance maladie du Qubec sur le Centre de chirurgie et de mdecine Rockland inc.,
February 2012, retrieved April 26, 2012, from
www.ramq.gouv.qc.ca/fr/regie/sallepresse/actualites/2012/Pages/rapport-rockland.aspx; Enqute de la Rgie de
lassurance maladie du Qubec sur la Clinique chirurgicale de Laval, March 2012, retrieved April 26, 2012, from
www.ramq.gouv.qc.ca/SiteCollectionDocuments/citoyens/fr/rapports/rappenq-cliniquelaval-fr.pdf
15
Ibid.
16
Mehra, Eroding Public Medicare.
17
J. McGrurran, T. Noseworthy and the Steering Committee of the Western Canada Waiting List Project,
Improving the Management of Waiting Lists for Elective Healthcare Services: Public Perspectives on Proposed
Solutions, Hospital Quarterly, Spring 2002, pp. 2832.
18
Lacoursire, chographies.
19
Pierre Pelchat, chographies en clinique prive : la gratuit, une solution?, Le Soleil, July 3, 2011.
20
Pierre Pelchat, Gratuit des chographies : les radiologues surpris, Le Soleil, July 6, 2011
21
Denis Mthot, Imagerie mdicale : le Ministre veut optimiser lutilisation de lquipement public plutt que de
recourir au priv, Lactualit mdicale, October 5, 2011.
22
Ibid.
23
Ibid.
24
Ibid.

31
Appendix I: Regulation Respecting the Application
of the Health Insurance Act
Enabling act:
Health Insurance Act
(R.S.Q., c. A-29, s. 69)

DIVISION V
SERVICES NOT CONSIDERED INSURED

22. The services mentioned under this Division shall not be considered as insured services for
the purposes of the Act: ...

(q) ultrasonography, unless this service is rendered in a facility maintained by an institution

which operates a hospital centre or is rendered for obstetrical reasons, in a facility maintained
by an institution which operates a local community service centre referred to in Schedule D, or
is required for the purposes of medically assisted procreation in accordance with section 34.4,
34.5 or 34.6;

(q.1) computer tomography, unless the service is provided in a facility maintained by an

institution which operates a hospital centre;

(q.2) magnetic resonance imaging, unless the service is rendered in a facility maintained by an
institution that operates a hospital centre;

(q.3) optical tomography of the ocular globe and confocal scanning laser ophthalmoscopy of the
optic nerve, unless those services are rendered in a facility maintained by an institution that
operates a hospital centre or they are rendered as part of an intravitreal injection of an
antiangiogenic drug for treatment of age-related macular degeneration;

32