Policy changes and physicians opting out from Medicare in Quebec: an interrupted time-series analysis

BACKGROUND:In all Canadian provinces, physicians can decide to either bill the provincial public system (opt in) or work privately and bill patients directly (opt out). We hypothesized that 2 policy events were associated with an increase in physicians opting out in Quebec.METHODS:The 2 policy events of interest were the 2005 Supreme Court of Canada ruling on Chaoulli v. Quebec and a regulatory clampdown forbidding double billing that was implemented by Quebec’s government in 2017. We used interrupted time-series analyses of the Quebec government’s yearly list of physicians who chose to opt out from 1994 to 2019 to analyze the relation between these events and physician billing status.RESULTS:The number of family physicians who opted out increased from 9 in 1994 to 347 in 2019. Opting out increased after the Chaoulli ruling, and our analysis suggested that between 2005 and 2019, 284 more family physicians opted out than if pre-Chaoulli trends had continued. The number of specialist physicians who opted out rose from 23 in 1994 to 150 in 2019. Our analysis suggested that an additional 69 specialist physicians opted out after the 2017 clampdown on double billing than previous trends would have predicted.INTERPRETATION:We found that the number of physicians who opted out increased in Quebec, and increases after 2 policy actions suggest an association with these policy interventions. Opting out decisions are likely important inputs into decision-making by physicians, which, in turn may influence the provision of publicly funded health care.

In all Canadian provinces, most physicians work as part of a private business. Whether they are solo practitioners or part of larger group practices, physicians can bill the provincial public Medicare system, or work privately and bill patients directly. Engaging in both is referred to as “dual practice,” and evidence exists to suggest that it can negatively affect the accessibility of care in the public system where it is permitted.¹ As a result, most provinces have enacted legal barriers designed to prohibit or discourage dual practice.² In Quebec, British Columbia, Alberta, Saskatchewan and New Brunswick, physicians have to opt out formally from the public system to be able to bill patients for publicly covered services. In Ontario, Manitoba and Nova Scotia, physicians who decide to rely on private billing are not permitted to bill their patients more than the public fee schedule. Given these regulations, it is widely thought that only a small proportion of Canadian physicians choose to work outside of the public funding scheme for medical care. Nevertheless, private out-of-pocket payment to physicians still accounts for hundreds of millions of dollars per year in Canada³ and, in Quebec, the number of physicians who opt out has been steadily growing for the past decade. However, our understanding of how policies and legal events have affected these rates in Quebec or other Canadian provinces is limited. Over the past 20 years, 2 important policy events directly related to dual practice have occurred in Quebec.First, in 2005, in its ruling for Chaoulli v. Quebec, the Supreme Court of Canada concluded that Quebec’s prohibition of private insurance for publicly insured medical services violated Section 1 of the Quebec Charter of Human Rights and Freedoms.^4–6 Quebec’s government was granted 1 year to adjust its laws to the ruling, during which time there were intense policy debates about the private system.^7–9 Many argued that there was a demand for out-of-pocket privately financed medical services, pushing many private investors, physicians and patients to debate the role of private delivery of health services.^7,10–12 Second, in the years following this ruling, Quebec witnessed substantial interest and investments in private facilities for elective medical interventions. In many specialties with a high volume of outpatient elective interventions (e.g., ophthalmology, dermatology and orthopedic surgery), a certain level of double billing became the norm. Patients were routinely asked to pay out-of-pocket to cover things like eye drops, anesthetics, use of the intervention room and record management — so-called “frais accessoires” [“incidental expenses”]. Faced with increased public and media scrutiny of the legality of those fees and strong pressures from Ottawa, Quebec started, in January 2017, to enforce a new regulation that clearly outlawed double billing for publicly funded medical services.¹³ Because many clinics had come to rely on these added fees, this clampdown threatened their business model, which may have pushed some physicians to opt out of the public system altogether.As physicians who have opted out are not available to deliver services for publicly insured patients, any trend toward more privately delivered care will have obvious implications for delivery of publicly funded health care in Canada. Furthermore, international evidence suggests that dual practice is associated with challenges to equity and efficiency.^14–16 Therefore, we analyzed the association of these 2 policy events with physicians’ decisions to opt out in Quebec.