It’s nearly noon at Tiny Tots’ pediatric clinic on Decarie Square in the Montreal suburb of Côte Saint-Luc, and there’s a steady line of parents holding hands or pushing strollers as they check in for their child’s appointment.
Tiny Tots is part of ELNA Medical’s growing network of family medicine and specialty clinics, with some 96 clinics in Canada, of which about 25 are in Quebec alone.
While many of the services are covered by public health insurance – in Quebec, through the Régie de l’assurance maladie du Québec (RAMQ) — the clinics are privately owned and operated.
If patients need to see a specialist, they can be referred internally to someone who works in one of ELNA’s clinics. If tests or procedures are required, a patient can have them done for free at a public clinic or have them done in-house at ELNA for an additional cost, which may be covered by private insurance.
“It’s the same concern, except in, say, better packaging,” says Dr. Benjamin Burko, a pediatrician and the chief innovation officer of the Montreal-based company.
Support for such an approach appears to be growing.
A lack of primary care physicians, long wait times for surgeries and overburdened emergency rooms have left the public thirsty for new ideas to improve Quebec’s health care system — and one of the main alternatives proposed in this election campaign is opening the network to further privatization.
Both the Coalition Avenir Québec (CAQ), which has a commanding lead in the polls, and the Conservative Party of Quebec (PCQ), a fledgling right-wing party, have put forward proposals to expand private care.
In an effort to relieve nearby hospitals, the CAQ is proposing a few new private medical centers in eastern Montreal and Quebec City. The private ‘mini-hospital’ would be open seven days a week and would have a GP post, a 24-hour emergency room for minor ailments and day treatments. All of this would be covered by public health insurance, according to the CAQ.
The PCQ wants to go further, and party leader Éric Duhaime has said the “p-word” is no longer taboo when it comes to healthcare in Quebec.
Duhaime wants private companies to be allowed to operate some hospitals and believes doctors should be encouraged to practice in both public and private health care.
Quebecers are open to idea
Proponents of more privatization argue it would take pressure off the public system and improve triage care, but many experts say doing so would siphon resources out of the public system, increasing inequality in the process.
“Having a private network that competes with the public system is not the solution to labor shortages in the public system,” said Olivier Jacques, an assistant professor in the department of health management at the Université de Montréal.
Jacques said private centers like the one proposed by the CAQ could steal doctors and nurses. It’s unclear whether such a model would lead to more effective use of taxpayers’ money, he said.
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But the ideas put forth during the campaign suggest Quebecers aren’t as attached to the idea of public health care as residents elsewhere in Canada, Jacques said.
A recent survey by Angus Reid confirms that. It found that Quebec residents are among the Canadians with the greatest need for more private care, with 40 percent saying more private care would help. (Quebecers are also among those most dissatisfied with the current system, with three in five respondents saying the care is poor.)
Similarly, 43 percent of Quebec residents who participated in TNZT’s Voice Compass survey would like to see more private health care, while 26 percent want the same amount and 31 percent less.
Importantly, Jacques noted, “Nobody is saying that people should pay more for health care themselves. So it’s not about financing the health care system, it’s about providing services, and this is very different.”
In Canada, health care spending is split between the public and private sectors with a distribution of about 75-25, according to the Canadian Institute of Health Information (CIHI).
Quebec has a slightly higher share of public care, due to its coverage of prescription drugs and other add-ons.
The CAQ and PCQ proposals have come under criticism from Quebec liberals, but they too pledge to allow more private clinics covered by public health insurance to address the surgery backlog.
The Parti Québécois and Québec Solidaire are against expanding private care. Both argue for more money for the public system.
McGill Prof. dr. Amélie Quesnel-Vallée, who holds the Canadian Research Chair on Policy and Health Inequality, pointed out that the province already has more private care than many of the public realize — starting with doctors themselves. They are largely self-employed and there are also those who have opted in whole or in part from the public system.
In the past five years, the number of specialists and general practitioners in the private system has increased by 35 percent – with more than 500 doctors in total. Private clinics are a large part of the county’s patchwork of care, enhanced by a landmark 2005 Supreme Court ruling allowing Quebec residents to have private health insurance.
Isabelle Leblanc, a general practitioner at St. Mary’s Hospital who is running for Québec Solidaire in Mont-Royal-Outremont, believes the province has already gone too far towards privatization.
A former chairman of the advocacy group Médecins Québecois pour le régime publicLeblanc is concerned about the erosion of the public health system and what this means for the most vulnerable.
“The main reason is that, you know, a private clinic is there to make a profit. It’s not there to take care of the people, and it’s going to choose its patients.”
Her party advocates investing more money in CLSCs.
“There is less and less access” to health care providers such as psychologists unless you have private insurance or the means to pay out of pocket, Leblanc said.
“In the past, 15, 20 years ago, people could very easily go to the CLSC and see a physiotherapist, psychologist or social worker, and they had access. Now access is very [limited].”
She said the money going to the CAQ’s proposed clinic in eastern Montreal should instead be used to refurbish Maisonneuve-Rosemont Hospital.
“Major renovations need to be done there,” she said.
Privatization calls for ‘different pace’
Burko started his medical career at Montreal Children’s Hospital, but said he left after becoming frustrated with what he saw as a slow and inefficient system.
He was CEO and Medical Director for 30 years at Tiny Tots, which he sold to ELNA Medical in 2017.
Private clinics operate in a market economy, which he believes promotes a better patient experience. To stay competitive, private clinics must compete for doctors and make the experience as efficient as possible to keep patients coming back, Burko said.
“Government agencies, like hospital clinics, never have that pressure,” Burko said.
“The incentives aren’t there. It’s a different pace and things are being accepted that would never be accepted in a private company.”
Given his support for the private system, it may come as a surprise that Burko, a longtime doctor, isn’t a fan of the CAQ’s proposal to build private super-clinics, which he fears will cannibalize staff.
It’s “Robbing Peter to pay Paul,” Burko said. “There aren’t enough doctors anywhere, so building a nice new building with nice furnishings isn’t going to solve anything. Either it remains unmanned, or you take staff away from other places.”
He would rather see the province invest in training more doctors and nurses to address the labor shortage.
The details of the CAQ proposal aren’t clear yet – but in general, critics say private health care providers tend to treat simpler cases, while leaving more complex care to an overloaded public system.
Still, Quesnel-Vallée said private sector involvement could be fruitful, provided it doesn’t just exacerbate the labor shortage.
“We need to have some transparency about what the government pays for these private services and how it compares to what’s currently being offered in the system,” she said.