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Round the World

QuebecTHE DISPUTE BETWEEN GOVERNMENT AND

MEDICAL SPECIALISTS

IN Canada the evolution of a comprehensive system of" prepaid " and universally available medical care is welladvanced. This has come about through insurance plansproviding for the costs of hospital services, complementedby independent insurance plans providing payment forthe services of doctors. These developments have beenencouraged and supported by cost-sharing arrangementsbetween the federal and provincial Governments, thelatter being responsible for health services. In this wayuniversal cover for hospital services and services of doctorswas established in all the provinces of Canada by Jan. 1,1971. In Quebec the hospital insurance scheme has beenoperating since 1961. This province was the seventh of theten to institute an insurance plan covering the services ofphysicians and surgeons: the plan went into effect onNov. 1, 1970, and in the process there was a bitter disputebetween the Government and medical specialists.The federal programme supporting insurance cover for

the services of doctors dates from legislation which hasbeen in effect since 1968. In this programme the federalGovernment undertakes to contribute about half of thenational average per-head cost to agencies of provincialGovernments. In order to qualify for support a provincialplan must provide comprehensive cover for all medicallyrequired services rendered by physicians or surgeons.Benefits must be available to at least 90% of the popu-lation from the outset, and the proportion must rise to95% after five years. Benefits must continue duringtemporary absence from the province anywhere in theworld. Finally, the plan must be administered on a non-profit basis by a public authority accountable to theprovincial Government. From the date such a plan beginsprivate insurance covering the fees of doctors is prohibited.

In 1962, before the start of the federal programme, theprovince of Saskatchewan led the way into this type ofinsurance with a scheme which later qualified for federalsupport. In the beginning there were major disagreementsbetween the provincial commission and the medical pro-fession in that province. These disagreements were

resolved and the conditions for participation of doctorsfinally settled in Saskatchewan are similar to those agreedin the five further provinces recruited to the programmeduring 1968 and 1969, where agreements were nego-tiated smoothly. The provincial contributions to the costof the plans are raised by premiums or by direct or indirecttaxation, and doctors are paid fees for services accordingto schedules agreed between provincial authorities and pro-fessional organisation. Doctors may choose not to partici-pate and the fees of these doctors are not restricted. Thenumber of doctors opting out of the plans has proved sofar to be small. In most provinces the patients of non-participating doctors can recover in whole or in part theagreed fee from their provincial commissions. In someconditions participating doctors are permitted to chargefees which exceed the insured benefits. The powers of

regulation of the practice and the standards of medicineremain with the College of Physicians and Surgeons inthe provinces. These arrangements led doctors to expectsimilar developments in other provinces as they too

moved towards comprehensive insurance plans.

Rapid MovesIn 1969 the Government of Quebec established a:Health

Insurance Board to prepare the ground for comprehensivemedical insurance which would meet the federal require-

ments. During its last weeks in power the National UnionGovernment gave first reading to a Health Insurance Act,but this died on the order book with the change of Govern-ment in April, 1970. The new Liberal Government wascommitted to the rapid implementation of a similar insur-ance plan. In June, 1970, legislation was passed definingarrangements other than those for the remuneration ofdoctors, and it was intended that this would go into effectupon conclusion of agreements with the professional organ-isations concerned. In Quebec the College of Physiciansand Surgeons fills the traditional role. However, for thepurposes of action in the social and economic interests ofthe profession, the Federation of General Practitioners andthe Federation of Medical Specialists had been formed onthe initiative of the profession in 1966. These federationsare legally constituted as so-called syndicates and are sub-ject to provisions of the labour code; in this respect the

organisation of the profession differs from that in the restof Canada, where these matters are dealt with by the pro-vincial branches of the Canadian Medical Association.The Federation of Medical Specialists objected that theHealth Insurance Act gave the power to regulate medicalpractice to a committee of the provincial health commission,with a majority of non-medical members, so that thecommission would usurp the major function of the College.The specialists were also opposed to provisions of the Billwhereby a limit of 3% of physicians and surgeons in eachof the recognised specialties within regions was set to thenumber of non-participating doctors whose patients wouldbe entitled to benefits. These clauses were later modified,possibly as the result of strong pressure exerted by theQuebec labour movement, so that the patients of all non-participating doctors were excluded from benefits. The

specialists objected to these features of the plan, on thegrounds that they limited their freedom and effectivelyrestricted access of patients to doctors of their choice.Meanwhile the Federation had presented their current

schedule of fees, which approximated those agreed in theHealth Insurance Plan in the province of Ontario. On

July 31 the Government revealed a proposed budget forthe plan. When this was translated into fees for servicesand into individual earnings, widely divergent inter-

pretations were made by the parties concerned. It wasunfortunate that discussion of remuneration between theGovernment and the profession had hitherto been cursory.What really amounted to preliminary exchanges in bargain-ing now took place in public, and attention in the newsmedia was focused on this aspect of the problem. The

specialists were not prepared to negotiate further with theGovernment unless it conceded that the legislation affectingthe control of medical practice and the freedom of doctorsto opt out of the plan would be modified. A mediator wasappointed, but this attempt at conciliation failed.

Withdrawal

In an atmosphere of growing mistrust the medicalspecialists pressed their demand for amendment of thelegislation and made preparations for a partial withdrawalof their services. The withdrawal of services began onOct. 8, and by Oct. 15 three-quarters of the specialistshad ceased to practise. Many of these left the provincetemporarily, while their colleagues operated a plan pro-viding emergency services in the hospitals. In the secondweek of October the Department of Health and the Collegeof Physicians and Surgeons reported that the emergencyservice in some areas was under strain. Concern over

possible deterioration of medical services was heightenedin the crisis which followed the kidnapping by terroristsin Montreal of Mr. James Cross, the British Trade Com-missioner, on Oct. 6, and of Mr. Pierre Laporte, the QuebecMinister of Labour, on Oct. 10. In the atmospherecreated by these events the National Assembly in Quebec

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legislated on Oct. 15 and 16 to amend the Health InsuranceAct and to ensure the coming into force of the InsurancePlan on Nov. 1. The amendment of the Act met one ofthe demands of the specialists by effectively restoringcontrol of medical practice to the profession. However,the new legislation did not restore benefits to the patientsof non-participating doctors; it established fees for ser-vices at rates very substantially below those suggested bythe Federation; and it precluded the charging of fees inexcess of this tariff by participating doctors. A further Actwas passed at the same time, requiring the specialists totake up or to continue the usual practice of their profession(Bill 41). This Act applied to every specialist who held alicence in Quebec within the preceding three months; itcarried severe penalties to those who might default; itdid not exempt doctors who were absent from the pro-vince ; and the practice of medicine outside the plan wasnot permitted to any doctor until expiry of a 90-day periodafter individual notice. On the same day in reaction to thesituation created by the terrorists the War Measures Actwas invoked by the federal Government. On Oct. 17 it

appeared that the majority of the medical specialists haddecided individually to defy Bill 41.Return to Work

Overnight, the shocking murder of Mr. Laporte wasdiscovered. Next day 1600 specialists met in Ottawa anddecided to return immediately to their practices; theexecutive of the Federation, in compliance with Bill 41,requested all its members to follow suit. The President ofthe Canadian Medical Association, a national body whichwould not normally become involved in a dispute betweena provincial segment of the profession and its Government,voiced the resentment engendered in the profession bythis legislation. He emphasised that the medical special-ists, who were muzzled by provisions of the Bill, had beenswayed in their decision by the existence of the state ofemergency. The Minister of Health claimed that Bill 41followed precedents set in disputes with organised labour,and that it was not intended to use it in dealing withindividual doctors. On Nov. 1 the Health Plan went intoeffect. The Government had made it clear that the tariff

imposed by legislation was negotiable, and discussionswith the specialists were resumed. A tariff was arrived atand an agreement was signed, in spite of the continueddissatisfaction of the Federation of Specialists with theclauses relating to opting out. The scale of fees suggestedby the specialists was closely similar to that accepted byGovernment in Ontario. In that province doctor’s chargesexceed the insured benefits by 10%. The insured benefitsagreed in Quebec are about 5% below those in Ontario;but according to the Health Insurance Act doctors are notpermitted to charge fees exceeding the insured benefits.Thus doctors in Quebec receive fees approximately 85%of those received in Ontario. The Federation of GeneralPractitioners had not been in active dispute with theGovernment, and their agreement had already been signed.The controversial Bill 41 lapsed on Nov. 15.The Aftermath

It is clear that communication between Governmentand the medical profession before and after the generalelection of April, 1970, was lamentably poor, and that thiscontributed to the impasse reached in October. It is clearalso that the attitudes of Government, of doctors, and ofthe public were affected by the national emergency whichdeveloped at the same time. Whatever the effects of theemergency on the actions of Government and of thespecialists, the issues of control of medical practice andrates of remuneration were rapidly settled when seriousnegotiations were undertaken. The question of the effec-tive freedom of doctors to opt out of the plan remains animportant one. In addition to being a bone of contention

in itself this freedom is seen by the Federation of MedicalSpecialists as a potential means of expression of discontent,should they again find themselves in disagreement withthe Government: they see restrictions on this recourse inthe unfavourable conditions created for non-participatingdoctors and in the precedents for legislation prohibitingmoves which could be viewed as concerted actions of themembers of a syndicate. The weapons employed in therecent dispute were crude and distressing to all parties,and it is extremely doubtful whether their use contributedto the settlement. The results can only have emphasisedthe importance of continuing discussion between Govern-ment and the medical profession. This dialogue is one ofthe factors which will determine whether the province ofQuebec can maintain the quality of its medical manpowerin equilibrium with the rest of North America, wheredoctors, French-speaking and English-speaking, are

potentially highly mobile. It is not yet possible to assessin detail the effect of the Health Plan on members of themedical profession, but it is apparent that the number ofdoctors leaving the province in the short term as a resultof its introduction is small. Nor is it yet possible to deter-mine the response of the public, but there are signs thatthe expected increase in the volume of demand for medicalservices has begun. In the medical schools the need to

recompense the large number of clinical teachers who arepart-time members of faculties, and who contribute sub-stantially to the training of interns and residents, has beenpointed out by the deans and recognised by the Minister.Meanwhile, the reports of inquiries into health matters,commissioned by the Government in Quebec, have stimu-lated discussion on improvements in the system for deliveryof health care, on alternative arrangements for paying forthese services, and on methods for teaching the necessaryskills.

United States

THE BUSINESS OF DEATH

The American way of death has provided much amuse-ment to the satirists Waugh and Mitford, and concern tomany thoughtful people in this country. The undertakers,the embalmers, and all the other interests concerned withdeath comprise a very strong lobby whose promotion ofand pandering to certain public feelings have made deathvery expensive, indeed nearly as expensive as dying. Re-strictions on necropsies, movement of bodies, and otherdifficulties hamper scientific progress and make muchscientific work impossible. Moreover, often the graveyardscomprise almost the only open space still existing in acommunity, many of which have neglected to providepublic parks and open spaces. They do provide masses ofstone which may one day have other uses, as other civilisa-tions have found.

But there are indications of change. Transplants, theremoval of organs and tissues for-the use of other sufferers,decline in religious orthodoxy, increased population move-ments inside the country, and a difference in the attitudesto family life may all be factors. An increasing number ofpeople wish to leave their bodies for medical research orteaching purposes. Another change is the increasinginterest in cremation. The practice seems to be spreading,especially in the West, and the young are now taking aninterest as the shortage of recreational space is borne in

upon them. The attitude of the churches is changing; in1963 the Roman Catholic church decided to tolerate crema-tion. Finally, there is the cost. Cremation is still enor-

mously cheaper, even if one is talked into the purchase ofan expensive coffin or urn to preserve the ashes. The move-ment is slow: only a 10 ° increase in the last 10 years (NewEngland is the most backward area in this respect), but it isdiscernible, and will probably gain momentum.