Making Quebec a Leader in Accessibility Healthcare Services
Distinguishing Between Funding and Delivery of Services
The difference between the funding and the delivery of services must be kept in mind in any discussion regarding the healthcare system.
Funding: Doctors fees, hospital fees and other services can be paid either by the public system or by the patient (or his insurer). In Canada, governments pay for approximately 70 % of healthcare services. The other 30% is paid by group benefits or by the patient who pays out of his own pocket (for example, prescriptions, dental care, vision care, orthopaedics and cosmetic surgery).
Delivery: The nature of the public or private sector that delivers these services has nothing to do with the one paying for the services. It rather depends on the ownership and governance of the organization and the employment status of professionals who deliver these services, regardless of who pays for them. In Quebec, there are more than 3,000 private health institutions and organizations across the province (medical clinics – whether covered by the RAMQ or not –, dental, optometric, rehabilitation, physiotherapy, chiropractic and podiatric clinics, dietary services, audiology, denturology, optical, private medical laboratories, orthotics and prosthetics, and homecare, etc...).
Pay Hospitals on an Activity-Based Funding Model to Foster Competition
Most hospitals in Quebec and in Canada receive funding through overall budgets which are primarily determined by historical reasons. In an ever expanding system, this form of funding leads to rationing, and hospitals have no choice but to restrict admissions. There is no incentive for hospital managers to reform the system in order to reduce costs and to improve access and wait times.
Instead, hospitals should be paid per treatment, on an activity-based funding model as it is currently done in Scandinavian countries and in England. The amount paid to a hospital should be the equivalent of the average cost to perform the treatment in question in Quebec. This amount should be adjusted by taking into account a range of factors that are proper to each institution and patient, such as the geographical location, the individual characteristics of each patient, etc. Regular audits of at least 5% of all transactions will be performed to ensure that hospitals do not overcharge the province. Since the money will follow the patient, hospitals will be encouraged to expand their services to increase revenue. This formula also encourages hospitals whose costs are higher than average to improve their performance by adopting better practices. The growth in activity resulting from such an approach also means that patients will be treated more quickly, access to healthcare services will be improved and waiting lists decreased.
Does activity-based funding lead to cutbacks on the quality of services by healthcare institutions in order to reduce costs? Quite the contrary, insofar as revenues depend on the number of patients they attract, it is imperative for them to offer quality services and maintain a good reputation. In addition, any hospital which readmits a patient for the same condition within 30 days of his last hospital visit must do so free of charge. In due course, we will look to extend activity-based funding to other activities, such as primary care and homecare.
Establish a Ranking System of Quebec Hospitals
In a competitive environment, for consumers to make an informed decision about their hospital, they need to have access to the proper information. Hospital ratings will be compiled and made public annually. They will include performance indicators based on clinical outcomes and the quality of care and hospital services. This rating will create emulation and competition between hospitals.
Encourage New Forms of Management and Hospital Ownership
We will encourage the emergence of new ways to manage and own hospitals. These may include public hospitals whose management will be delegated following a public tender or new hospitals belonging to non-profit cooperatives and community organizations or for-profit businesses.
Change the Remuneration of the Doctors in Hospitals
Hospitals will be funded on an activity-basis and doctors who practice in hospitals will be remunerated by those hospitals. Hospitals will sign service agreements with doctors, in which both the doctor’s fees and his working conditions will be established. Such a system will encourage greater flexibility and competitiveness in the medical field.
Liberalize Medical Practices
It will be possible for doctors to work in the private sector without being obliged to disaffiliate from the RAMQ and the public system. This liberalization will occur only if certain conditions are met to ensure that the public system is not stripped of its current resources.
Contrary to common belief, there are available unused resources which can serve the private sector without affecting the public sector. For example, in 2008 it was estimated that more than half (51%) of Quebec specialists were willing to work an additional 4 hours weekly in the private sector. These same specialists agreed to be under an obligation to provide a minimum of a 35- hour work week in the public sector before being allowed to work in the private sector.
Allow Private Insurance
A ‘duplicative’ insurance is an insurance which covers medical care for people who continue to have access to the public system (and who are forced to contribute to it with their tax dollars) but also wish to have complementary treatment in the private sector. This type of insurance is currently illegal in Quebec and should be allowed so as to permit middle-class patients, who would not otherwise have the means, to have access to private treatment. This will represent additional funding for the healthcare system without being a tax or a mandatory ‘fee’ levied on taxpayers!
In Quebec, unlike the situation in the rest of Canada and the world, most nursing homes are owned by the public sector. This situation forces the government to maintain expensive real estate. In other Canadian provinces, private, community and municipal players all have a major role in nursing homes.
We will implement the following principle: healthcare should be provided through the public healthcare system while housing should be left to licensed community players, non-profit organizations, cooperatives, private companies and municipalities. In short, the role of the public healthcare system is to treat and not to house.
Before proceeding with such a change, the ministry must first adopt strict accreditation rules and procedures to ensure the safety of persons and the quality of services.
Our priorities will therefore be the following:
- To prioritize homecare;
- To ensure universal coverage of medical, nursing and housing services by the public system and, optionally, by a complementary private plan. Other homecare services for assistance in daily activities and domestic help will continue to be the subject of graduated coverage depending on the degree of dependency and of the nature of the service, and the ability to pay (in all cases, the poorest should be protected);
- To allow a patient to receive either a cash payment or a tax-credit so he can choose the provider of his choice;
- To review the sums paid or the amount of tax credits offered to recipients of home care so that they can cover a larger portion of the fees charged by intermediate resources and contracted private CHSLDs;
- To provide an expansion and diversification of accommodation and housing to intermediate or family-type resources;
- To entrust by licensing or franchising to for-profit or to non-profit organizations the management of CHSLDs within five years;
- To adjust the contributions required by persons currently accommodated according to their ability to pay in order to better reflect the real cost of food and lodging. Such an adjustment would restore fairness compared with persons who reside in their homes at their expense; and
- To allow a patient, who is not housed in a public CHSLD within a period of 72 hours after being discharged from hospital by his physician, to require a government performance guarantee to find him a place in another home other than a CHSLD, at the expense of the government.
Foster interdisciplinarity for primary care.