Montréal clinic uses public–private payment scheme
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* Margot Andresen

*   © 2007 Canadian Medical Association or its licensors

Controversy has erupted over a new “semi-private” medical clinic in Montréal that many believe crosses the line to create a two-tier medical system in Quebec.

The clinic, critics say, violates provisions of both the Canada Health Act and Quebec's Bill 33, which, although not yet enacted, allows for the creation of specialized medical centers that contract with public hospitals to provide hip and knee replacement, as well as cataract surgery, in cases where they haven't been performed within established wait time guarantees. The centres can bill the provincial health plan for the surgeries, as well as charge fees for items and services that aren't covered by medicare.

Bill 33 was passed by the Quebec legislature in December 2006 in response to the landmark Supreme Court of Canada ruling (*Chaoulli and Zeliotis* v. *A G Quebec et al*.) in 2005 that the province's ban on private health insurance for medically necessary services violated human rights law. While Bill 33 has not yet come into force, it states that physicians in permitted clinics must “post in view of the public … the rates for services, supplies and accessory fees.”

It's unclear, though, exactly what accessory fees will be allowed and that won't be known until the provincial government completes negotiations with medical federations.

In the interval, though, the newly-minted 50 000 square foot Rockland MD Medical and Surgical Centre opened its doors on Jan. 22 to conduct knee arthroscopies, hernia repairs and other day surgeries, including varicose vein, hemorrhoids, orthopedic, and diagnostic endoscopies. The province's health plan is billed for the surgeries, while patients are being charged $1300 for the use of the facilities and equipment.

Critics are concerned the wider range of surgical procedures available at the clinic contravenes the Canada Health Act and that the lack of clarity regarding accessory fees contravenes a provincial Health Insurance Act provision that says “no person may exact or receive any payment from any insured person for a service, the supplying of something or costs accessory to an insured service.” The provincial government's health insurance board has been asked “to clarify the question of the incidental expenses,” provincial health minister Phillippe Couillard said.

Couillard also expressed concern about doctors who've opted out of medicare and physicians who are still part of the government health plan operating under the same roof. “It is not allowed to have participating doctors and non-participating doctors under the same roof,” Couillard said. “It is clearly indicated in the law.”

Former family physician and Rockland's president, Dr. Fernand Taras told *CMAJ* that the clinic “will benefit not only the patient, but the public system, by allowing it to offload some of the work.”