activity-based funding

LE
SPÉCIALISTE
LE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC
Vol. 15 no. 3 | September 2013
ACTIVITY-BASED
FUNDING:
A PANACEA?
DAY-TO-DAY
MYTHS AND
REALITIES
See text p. 36
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TABLE OF CONTENTS
7
Le Spécialiste is published 4 times per year by
the Fédération des médecins spécialistes du Québec.
PRESIDENT’S EDITORIAL
O Canada, in Canada
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Unemployed medical specialists,
is it possible?
11 FEDERATION AFFAIRS
12 DID YOU KNOW...
15 LEGAL ISSUES
DOSSIER
16
ACTIVITY-BASED FUNDING:
A PANACEA?
• T2A: the French Model
18
• Other Experiences Around the Globe
25
• Activity-Based Funding in Quebec:
At What Cost?
28
32 GREAT NAMES IN QUÉBEC MEDICINE
Dr Brian Bexton, psychiatrist
34 CONTINUING
PROFESSIONAL EDUCATION
35 PROFESSIONALS’ FINANCIAL
36 SOGEMEC ASSURANCES
38 L’ÉDITORIAL DU PRÉSIDENT
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PRESIDENT’S EDITORIAL
DR GAÉTAN BARRETTE
O Canada, in Canada
So, why don’t we have a conversation about this big country? In this period of emotional identity
crisis, isn’t this a good idea? Especially since the FMSQ was invited by the Quebec Medical
Association (QMA) to be present at the Annual Meeting of the Canadian Medical Association (CMA)
held in Calgary in August.
F
irst, a few words about the people. Nice, very welcoming,
very proud of their work, not at all pretentious in spite of their
wealth. “We worked hard to get to where we are,” we heard
them say. “We” as in “the population of Alberta.” They are right.
Especially since we also benefit from it!
So much for our hosts. But the CMA covers all of Canada, Quebec
as well as the ROC. Never has this difference seemed so large to us.
Let’s look at two subjects bitterly debated: medical unemployment
and end-of-life care.
First, medical unemployment. In English, the topic was “medical
underemployment” and it was the subject of a strategic debate
session. At the CMA, such a debate leads to a vote on one or more
resolutions that form the basis of positions that are then defended
by the CMA. To launch the debate, the CMA had invited a speaker
introduced as an expert on the issue. Imagine the scene. In his
mid-forties, he declares having been interested by the matter since
his residency and, for this meeting, to have surrounded himself with
a multitude of experts to analyze and account for the pan-Canadian
situation on this subject. What a surprise! From the start of his
presentation, we heard him affirm, with insistence, that nowhere
in Canada - yes, your eyes haven’t deceived you - nowhere had
there been any evaluation or planning for medical manpower
commensurate with the needs of the population and, worse yet,
that nowhere in Canada was there any mechanism aimed at
ensuring the distribution of physicians throughout the territory!!!
The CMA meetings being very formal, the assistance of the QMA
was required to allow us to address the meeting and inform the
so-called “Canadian national expert” that Quebec existed and that,
in his Canada, there was a province, visible on the radar screen,
where, for more than 10 years, not only was all this being done,
but that such projections were extended over the next 25 years!!!
In spite of everything, this brings up a very real political problem.
The problem surfaces when observations are deliberately biased.
In the ROC, just as in Quebec, resident physicians are worried. In
the ROC, there are no PREMs, PEMs, etc. As a result, it’s a free
market in which all graduates try to find a position in downtown
Toronto, Calgary or Vancouver. It’s even said that it makes for the
complete happiness of senior physicians in practice who want to
take six months off: candidates fight to determine who will replace
the top guys and they have the competence to do it! However, this
is neither medical underemployment nor unemployment. It’s simply
refusal, avoidance. Because, one day, the whole territory will have
to be covered…
Unfortunately, starting off with an erroneous statement of fact can
devolve into a very dangerous game. Such an observation leads
directly to proposing a reduction in the number of acceptances
into medicine. These were exactly the same observations we heard
here at the beginning of the 90s. We know what happened as a
result. We’ve discussed it previously among ourselves. But rational
planning does exist in Quebec, and we all collaborate. Yes, there
are a few specialties where full employment seems to be at hand.
But not medical unemployment. It’s a shame that the “Canadian
national experts” are not bilingual.
Then, we assisted at another “strategic debate” on end-of-life care.
What we witnessed was an extremely high level of artistic... skating!
First off, there was the opening speech, which is always given by
the federal Minister of Health. This year, the speaker was Madam
Rona Ambrose, herself originally from Alberta. She knew that the
subject would be addressed later and, before even being asked, she
stated her position clearly: no to assisted suicide! Exit the debate
on end-of-life care, focus on assisted suicide! Later on, there was
the debate itself where everything was done to avoid the subject,
to even say the name out loud. And so, the discussion veered to
palliative care. As long as they were at it, it was even suggested
that a palliative care specialty in family medicine be instituted. One
of the good doctors from the ROC compared Quebec’s Bill 52 (see
page 9) to supervised injection facilities and stated that medicallyassisted dying was just as immoral. You read it here!
Later on, in a less formal session, Madam Chantal Hébert, a
media personality had been invited to talk about the subject. Very
politely, she explained that if they (the physicians) thought they could
avoid the debate, then they were wasting their time because, she
reminded them, they were there to serve the people and, on the
subject of end-of-life care, including euthanasia, the choice would
be made by the people.
I was laughing. If I’d been in their shoes, I would have been
embarrassed to read André Picard’s reporting of these debates
in the Globe and Mail: “With doctors ducking the issue [...] That is
unsatisfactory, and it’s no way to show physician leadership. We
trust doctors with our lives, and with our deaths. Physicians make
tough decisions every day at the bedside. They should be willing
and able to do so on the convention floor as well.”
In any case, at the FMSQ, we have never been afraid of debates
and, when we take part, we say things as they are, whatever the
right-thinkers may think!
In all solidarity !
S
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Comparaison Québec – Canada, 2012
LES DIX RAISONS PRINCIPALES POUR LES VISITES AUX MÉDECINS EN 2012
QUÉBEC
CANADA
NOMBRE DE CONSULTATIONS (EN MILLIERS) : 74 992
NOMBRE DE CONSULTATIONS (EN MILLIERS) : 323 195
Hypertension
4 166
1
Hypertension
19 306
Bilan de santé
2 762
2
Bilan de santé
10 186
Diabète sans complications
2 433
3
Diabète sans complications
Dépression
Anxiété
Hyperlipidémie
PUBLICITÉ
PLEINE PAGE
Infection aiguë des voies respiratoires
Trouble de déficite de l’attention
Otite moyenne
Oesophagite
9 823
1 739
4
Dépression
8 175
1 671
5
Anxiété
6 425
1 283
6
Surveillance normale de la grossesse
5 355
1 161
7
Infection aiguë des voies respiratoires
5 230
971
8
Hyperlipidémie
4 195
964
9
Oesophagite
3 866
959
10
Otite moyenne
3 412
LES VINGT MÉDICAMENTS LES PLUS PRESCRITS EN 2012
QUÉBEC
TOTAL DES ORDONNANCES
EN 2012 (000S)
% VARIATION
2011 À 2012
TOTAL DES ORDONNANCES
EN 2012 (000S)
% VARIATION
2011 À 2012
SYNTHROID
8 303
5,6
1
SYNTHROID
14 788
7
CRESTOR
3 515
-25,2
2
D-TABS
2 587
44,2
3
CRESTOR
6 906
-39,1
APO-ATORVASTATIN
5 473
NEXIUM
2 182
-7,9
4
0,5
APO-FUROSEMIDE
4 222
11,5
PRO-AAS EC-80
2 154
5,6
5
LYRICA
2 146
COVERSYL
3 832
15,7
19,2
6
CIPRALEX
3 243
ATORVASTATINE
27
1 900
24,3
7
APO-HYDRO
3 179
-5,7
ATIVAN
1 634
0
8
ELAVIL
3 040
13,7
COUMADIN
1 497
-8,8
9
NEXIUM
3 023
-17,8
RATIO-ATORVASTATINE
1 454
154,7
10
TEVA-AMOXICILLIN
2 920
-16,9
PRO-METFORMINE
1 443
7,1
11
LYRICA
2 911
16,9
CANADA
IMS Brogan
APO-ATORVASTATIN
1 431
-0,7
12
TARO-WARFARIN
2 890
5,9
COVERSYL
1 395
14,4
13
ATIVAN
2 849
0,9
SANDOZ-BISOPROLOL
1 283
-18,4
14
TEVA-VENLAFAXINE
2 836
61,7
AMLODIPINE
1 226
15,2
15
ZYLOPRIM
2 710
17,8
PMS-AMLODIPINE
1 159
13,1
16
CELEBREX
2 679
-1,9
CELEBREX
1 126
1,8
17
D-TABS
2 675
47,5
PANTOPRAZOLE
1 116
23,1
18
APO-SALVENT CFC
2 540
15,1
ELAVIL
1 106
47,3
19
VENTOLIN HFA
2 530
-10,8
ALESSE
1 102
5
20
ELTROXIN
2 464
-1,5
Source : IMS Brogan et l’Index canadien des maladies et traitements.
POUR DE PLUS AMPLES RENSEIGNEMENTS : 1-888-400-4672 | www.imsbrogan.com
Une importante source d’information, d’analyse et de consultation pour les secteurs de la santé au Canada
IN THE NEWS
On the Political Front
FROM QUEBEC’S NATIONAL ASSEMBLY
Fall will be quite busy on Quebec’s parliamentary scene. The National
Assembly will resume work on Tuesday, September 17, and we already know
that two important consultations will take place during the fall. To start with,
the Committee on Health and Social Services will hold public audiences on
Bill 52, an Act respecting end-of-life care. The FMSQ was invited to attend in
view of its interest and implication in the subject, as the Federation was the
first physician organization to publicly comment on the question of Dying With
Dignity. It must be recalled that Véronique Hivon, Minister for Social Services
and Youth Protection, proposed this bill on June 12th. After this first round of
consultations, the bill will undertake its legislative process.
Another consultation to keep an eye on will deal with the white paper on the
creation of an autonomy insurance plan which was made public last April 30th
by the Minister of Health and Social Services, accompanied by the Premier.
The government intends to submit a bill that it would like to see adopted
before the end of the current year. What remains to be seen is the welcome
this white paper, and the legislative bill that would eventually follow, will garner
from opposition parties, who have the majority. The FMSQ will surely makes
it position known when the time comes.
With each parliamentary session carrying its load of bills, the Federation is
constantly on the alert for any health-related issues.
FROM THE HOUSE OF
COMMONS IN OTTAWA
There has been a reversal of the situation with regards
to C-377, the controversial bill piloted by Conservative
MP Russ Hiebert, aiming to force union organizations
to make public a slew of information on their activities, in particular the names of beneficiaries of any
transaction of $5,000 or more and any salary paid in
excess of $100,000. Tabled on December 5, 2011, the
bill, having left the House of Commons and already
having passed the stage of first reading in the Senate
in December 2012, has finally been substantially
modified by the adoption of a series of amendments
on third reading, supported by a majority of Liberal
senators and 16 Conservative ones.
The bill was thus adopted as modified by the Senate
on June 26th and must, de facto, return to the House
of Commons. Two options are then possible: either the
House of Commons adopts the bill as amended by
the Senate or it modifies it again, in which case it will
have to be returned to the upper chamber. Bill C-377’s
saga will continue when parliamentary work resumes.
S
L
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A WORD FROM THE VICE-PRESIDENT
DR DIANE FRANCŒUR
Unemployed medical specialists,
is it possible?
A nitty-gritty subject in the news, fed into from all directions, medical unemployment is on the
program for Canadian medical organizations. The topic was even part of the proposals at the
146th Annual Meeting of the Canadian Medical Association in Calgary. Should we be worried?
Quebec is the only province with rigorous medical manpower plans
(PEMs) which were implemented in cooperation with the medical
federations and the department of health and social services
(MSSS). A necessary evil or making managers responsible, the
opinion varies according to whether one is a citizen of a remote
region or a physician at the end of his or her residency who wants
to set up in downtown Montreal... Times have changed a lot, but
we had to act before finding ourselves in the same situation as
our colleagues in the other provinces of Canada where those
who are finishing up their residency take up one fellowship after
another while waiting for a white-haired colleague to give up his
place downtown.
We don’t have this problem with regard to those who are finishing
up their residency in Quebec. However, the grass is not all that
green in “la belle province”! On the one hand, the deployment of
technical platforms announced for Montreal’s outlying suburbs
(area code 450) did not materialize and, on the other, the issue of
extra fees makes newly graduated physicians leery of setting up a
practice to perform procedures, especially when the current health
minister seems to be tempted by discounted financing. And yet,
recent history has shown (as exemplified by the medically-assisted
procreation issue) that when they are adequately financed, medical
clinics can offer services and procedures without limits, contrary
to hospitals, thus contributing to shorter waiting times.
Another reality that limits access for new graduates: physicians
who put off their retirement thus keeping their PEM and their
technical platforms. Unfortunately, the economic highs and lows
in recent years have also strongly inspired them to keep in shape
and continue to work!
So, what are we going to do with all these graduating residents?
The latter have suggested that we reduce the number of students
in medicine. After long discussions with representatives of the
universities and of the MSSS, we cannot support this proposal.
It takes 10 years to train a medical specialist. The feminization of
the medical profession has brought about changes to the profile
as much for men as for women of all generations. We need more
physicians now to do the same work as before. Young physicians refuse to settle alone in remote areas. And, by the way, they
stay longer when on-call schedules are less demanding, which
is reflected in service cut-backs that are much rarer these days.
10
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Should part-time work be allowed? This issue, generating a lot of
emotion, will be dealt with calmly in little doses. No one wants us
to find ourselves with a shortfall from one day to the next, or with
a surplus if all these “part-timers” were to return to work full-time.
The loss of expertise in specialties with a significant technical
component is a reality: one must see patients to retain one’s skills.
Simulations are not enough to allow us to preserve all our reflexes.
At present, the MSSS gives permission much more easily than
before, for the pairing of physicians at the end of their careers
with newcomers, and this for a period that is much less difficult
to accept than the traditionally obligatory year, which was the
rule previously. Evidently, when these files are well prepared and
when population needs justify it, it is a lot easier for us to defend
our members.
YOUR AFFILIATED MEDICAL ASSOCIATIONS
MUST KNOW YOUR PRESENT AND FUTURE
NEEDS FOR THE MEDICAL MANPOWER
PLANS FOR 2016-2020 ON WHICH WE
WILL START WORKING IN THE FALL.
In association with certain other medical associations, we have
even reduced the number of positions in residency to avoid
creating unemployed physicians. Residents have been clearly
advised to reserve their positions and to start the process early
during training especially in certain regions where their notices
of conformity take an eternity to get there. They have also been
warned that they can’t take off like kamikaze pilots into fellowships
without having organized their PEM beforehand... otherwise they
might have to learn English upon their return. Exceptions to additional training are far from automatic and an impressive curriculum
vitae does not open all doors without fail. We are also working on
a concrete definition of “full-time equivalent”, since the one based
on revenue alone is obsolete: certain obligations, like on-call duty
and involvement with hospitals, are included in this package.
Be assured though: there are no unemployed specialists on the
horizon, but we will keep a careful watch! Being without access
to technical platforms in spite of long waiting lists is much more
worrisome in this period of reductions and it can represent a form
of disguised unemployment.
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FEDERATION AFFAIRS
The respite that makes a difference
What would you pay for a restored smile? What is a good night’s sleep worth? For many people,
happiness does not have a price... cannot be bought... can only be given! It’s been more than
a year now since the FMSQ, through its Foundation, has warmed the hearts of thousands of
caregivers and care receivers. The bottom line of medical specialists’ involvement in this cause is
incredibly significant.
On April 23, 2012, the day on which its activities officially started,
the FMSQ Foundation (FFMSQ) donated an initial amount of
$100,000 to The Brome-Missisquoi Caregivers Support Group to
complete the interior and exterior installations of Maison Gilles-Carle,
in Cowansville.
During this first year, the Foundation came
to the aid of respite organizations that had
qualified in one or the other of the targeted
categories: either to maintain a respite
service or to create new ones; to improve,
renovate or even procure installations that
were essential to the well-being of their
users. The Foundation started the year 2013
with the same energy.
CAREGIVERS IN QUEBEC
More than a million individuals in Quebec dedicate themselves totally
to supporting someone close to them who suffers from temporary
or permanent disability as a result of an illness, a handicap, an
accident or a degenerative disease. One person out of seven is
likely to be a caregiver to a loved one or a neighbour.
With its Foundation, the FMSQ salutes
the important role of those who are,
in some fashion, the extension of
the professional resources of the
healthcare system. Without them,
a large section of society would be
deprived, even to the point of despair.
“Caregivers act in such complete
selflessness that they forget to take
time for themselves, to rest, to the point of neglecting their own
health. We have to realize that without them the public healthcare
system would not be up to the task of looking after the most vulnerable members of our society,” says Dr Barrette.
At the time we took this vacation,
our son […] wasn’t doing well. He
had his 17th birthday in August
and was in full crisis […]. We were
tired out and at the end of our rope.
The Foundation receives requests from all over the Province. For
each of these, a complete file was compiled: decisions were made
based on solid grounds. The Foundation makes sure that each
dollar invested is in fact spent to allow some respite and make a real
difference in the lives of caregivers. Each organization receiving aid
from the Foundation undertakes to provide a rendering of accounts
until the end of the project.
Projects varied greatly from one organization to another: relaxation
workshops for exhausted caregivers, short-term respites with or
without sleepovers, activity days for care receivers or caregivers,
purchase of specialized furniture or equipment for respite centres,
drop-in centres for caregivers and care receivers, etc.
In total, the Foundation has financially supported some thirty organizations to make their respite activities a reality.
We wish to remind you that the FMSQ Foundation is a charitable
organization, recognized under the Income Tax Act, whose objective
is to support the cause of caregivers in Quebec. It has set aside
an annual budget of $1 million taken directly from the FMSQ’s
regular budget.
Organizations wishing to apply for financial support can look up
the section of the FMSQ portal (fmsq.org/fondation) dedicated
to the Foundation. This section contains all the details, eligibility
criteria, documents required, terms and conditions for presenting
a request as well as the application form.
LAC-MÉGANTIC: A BIT OF RESPITE AFTER THE DISASTER
July 6, 2013 will forever remain a black day in the history of Quebec
as a whole, but in particular in that of Lac-Mégantic, because of the
train accident that caused considerable and irreversible damage.
Hand-in-hand with their colleagues in general practice, the medical
specialists working in the region all signed a letter asking municipal
authorities not to authorize the reconstruction of train lines within
the perimeter of the city and to prevent the construction of housing
near any future train tracks that would bypass the urban area. The
medical specialists who were signers include Denys Breton and
Paul E. Paradis, general surgeons; Yves Marmen, radiologist;
Adrian Pusca and Wadith Pierre Saad, internists.
Their letter was submitted to the municipal council meeting on
July 17th from the perspective of social and preventive medicine
– the signers wanting to avoid other accidents, but also invoking
the opinion that the presence of train tracks would awaken and
maintain the pain associated with the loss of loved ones. The
signers asked instead that a dignified and pacifying memorial be
built in memory of those who disappeared.
As for the FMSQ, right from the start, the FMSQ Foundation took
steps to come to the aid of relief organizations in the immediate
region so as to identify their needs. Responding to the Foundation’s
invitation, the organization Les Soupapes de la Bonne Humeur
proposed two respite projects within the scope of their organizational capacity in the circumstances. Some thirty families were
thus able to take advantage of moments of respite thanks to the
Foundation’s contribution.
Moreover, medical specialists were invited, in particular by their
respective medical associations, to give generously to the fund
raising organized by the Red Cross.
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DID YOU KNOW...
PRIZES, AWARDS AND NOMINATION
AMPQ AWARD
Dr Pierre Vincent, who works at the Institut
universitaire en santé mentale de Québec,
received the Heinz E. Lehmann Prize for
Excellence in Psychiatry from the Association
des médecins psychiatres du Québec. This
prize was presented to him to highlight his
exceptional contribution to the advancement
and reputation of psychiatry.
AMEQ AWARD
Dr Jana Havrankova, an endocrinologist in
practice in Saint-Lambert has been named
endocrinologist emeritus in 2013 by the
Association des médecins endocrinologues du Québec. She received this award
in recognition of her commitment throughout
her career.
HEART RHYTHM SOCIETY AWARD
Dr Stanley Nattel, a cardiologist and the
director of electrophysiological research at
the Montreal Heart Institute Research Centre
has received the 2013 Founders Lectureship
Award from the Heart Rhythm Society. The
distinction honours the scientist who has
contributed in a unique and significant
fashion to the field of heart rhythm.
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Vous méritez ce qu’il y a de mieux !
DOUBLE RECOGNITION FROM THE AMERICAN
SOCIETY OF HYPERTENSION
The American Society of Hypertension has honoured one of its
oldest members, Dr Ernesto L. Schiffrin, Physician-in-Chief
of the Jewish General Hospital in Montreal, by naming him the
2013 ASH Distinguished Scientist and conferring on him the
Robert Tigerstedt Award, in remembrance of the physiologistresearcher known for his discovery of the renin-angiotensin
system. Dr Ernesto L. Schiffrin has dedicated a great portion
of his career to research on the renin-angiotensin-aldosterone
system and hypertension.
CHU SAINTE-JUSTINE AWARD
On the occasion of the Gala reconnaissance, the Prix SainteJustine was presented to Dr Normand Lapointe, a pediatrician,
in recognition of the work he has done with women and children
affected by HIV. Since 1988, Dr Lapointe has dedicated a large
part of his professional activities to the development of the Unité
hospitalière de recherche, d’enseignement et de soins sur le
SIDA (UHRESS) at the CHU Sainte-Justine of which he is still
co-director.
In addition, Doctors Arielle Lévy, a pediatrician; Andrée
Sansregret, a gynecologist and obstetrician; France Gauvin,
a pediatrician; Sandra Lesage, an anesthesiologist; Nancy
Robitaille, a pediatric hematologist and Géraldine Pettersen,
a pediatric intensive care specialist, received the Prix Excellence
Innovation. This prize recognizes the excellence and innovative
nature of care given to mothers and children. The group not only
evaluated the application of a protocol for massive hemorrhaging
via a simulation in an interdisciplinary team, but was also able to
apply this protocol during an intervention that saved the lives of a
mother and her newborn when severe complications manifested
themselves a few hours after giving birth.
Offrez-vous
l’expérience
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Le programme Jet-Set de Vacances TMR s’adresse particulièrement aux voyageurs
en quête d’une expérience de voyage améliorée. Localisés dans les plus beaux endroits, les hôtels rattachés au programme ont été triés sur le volet afin de procurer
à cette précieuse clientèle un confort supérieur, des attentions particulières et des
privilèges distinctifs.
En choisissant un hôtel Jet-Set de Vacances TMR, vous bénéficiez
des avantages suivants, sans aucun frais supplémentaires:
• Stationnement à l’aéroport au Valet
Parking de Park N’ Fly (Montréal) et
au Self Park (Ottawa)
• Accès au salon VIP à l’aéroport de
Montréal (Salon World MasterCard
Banque Nationale)
• Transferts privés à destination
• Meilleure localisation à l’hôtel
sélectionné
• Excursion gratuite à destination
(une par personne)
Nous vous invitions à consulter la brochure Soleil 2013.2014 de Vancances TMR pour connaître la liste complète des
inclusions exceptionnelles de chaque partenaire hôtelier. Vacances TMR situé au 1180, rue Drummond, suite 330, à
Montréal, Québec, H3G 2S1 est titulaire d’un permis du Québec.
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Club Voyages est une division de Transat Distribution Canada Inc. Permis No 753141 au Québec.
Siège Social : 300, rue Léo-Pariseau, bureau 1601, Montréal, Québec H2X 4B3
Vmd/mc Marque déposée/de commerce d’AIR MILES International Trading B.V., employée en vertu d’une licence
par LoyaltyOne, Inc. et Transat Distribution Canada Inc.
DOCTORS WITHOUT BORDERS
Dr Joanne Liu, a pediatrician at SainteJustine University Hospital Centre has
accepted the position of President of the
humanitarian aid organization known as
Doctors Without Borders. An associate
member of this organization for close to
twenty years, she will assume her functions
in Geneva in October.
DID YOU KNOW...
8TH EDITION OF
THE MEDICAL FEDERATIONS’ GOLF
ARMAND-FRAPPIER FOUNDATION OF INRS
UNIVERSITY AWARD
TOURNAMENT
Dr Jacques Montplaisir,
a psychiatrist and the
founding director of the
C e n te r f o r A d v a n c e d
Research in Sleep
Medicine ( CARSM ) at
Hôpital Sacré-Cœur in
Montreal was awarded the 2013 Bell Award
of Excellence in Health for the CARSM. This
state-of-the-art research centre was created
in 1977 by Dr Montplaisir.
IN AID OF THE QUEBEC PHYSICIANS’ HEALTH PROGRAM
This annual edition of the Medical Federations’ Golf Tournament, the 8th one,
in aid of the Quebec Physicians’ Health Program which took place at Le Mirage
Golf Club, amassed a total of $117,000. Close to 125 participants took advantage
of a beautiful day to meet their colleagues in this magnificent environment and
to compare their golfing talents.
The organizers wish to thank sponsors, participants, donors as well as everyone
who made this day such a great success.
The date for the 2014 edition will be decided upon shortly.
Photo: Judith Gauthier
Dr Marie Plante, an oncological gynecologist at the
CHU de Québec is the
winner in the Women of
Merit contest, in the Health
categor y. This contest
seeks to promote women
who transform their environment and distinguish
themselves through their commitment, leadership, creativity and determination. Dr Plante
took an active part in the development of the
radical trachelectomy.
From left to right: Mr Christopher Lemieux from the Fédération médicale étudiante du Québec;
Dr Louis Godin, President of the Fédération des médecins omnipraticiens du Québec; Dr William
Barakett, President of the Quebec Physicians’ Health Program; Dr Charles Dussault, President
of the Fédération des médecins résidents du Québec, and Dr Gaétan Barrette, President of the
Fédération des médecins spécialistes du Québec.
SOCIÉTÉ QUÉBÉCOISE DE RHUMATOLOGIE
AWARD
Dr Jean-Pierre Pelletier,
a rheumatologist, and
Johanne Martel-Pelletier,
P h . D., b o t h r e s e a rchers at the Centre de
recherche du CHUM, have
jointly received the 2013
Roger Demers Prize at the 44th Laurentian
Conference of Rheumatology. This award
seeks to highlight their exceptional contribution to their area of research.
Photo: Judith Gauthier
Photo: Édith Prudhomme
WOMAN OF MERIT AWARD FROM THE YWCA
IN QUEBEC CITY
This year, it was the FMSQ foursome who won the Tournament honours. The trophy was presented
by Dr William Barakett to the foursome: Dr Roger Grégoire, Dr Raynald Ferland, Me Sylvain
Bellavance and Dr Serge Legault.
THANKS TO OUR SPONSORS
PLATINUM CATEGORY
NEW RELEASE
LA RÉTINOPATHIE
DIABÉTIQUE
(DIABETIC RETINOPATHY)
Dr Jean Daniel Arbour,
a n ophtha lmo lo gist at
the CHUM-Notre-Dame
and Dr Pierre Labelle,
a n ophtha lmo lo gist at
Maisonneuve-Rosemont
Hospital have published
La rétinopathie diabétique with Annika
Parance Éditeur. This book is aimed at the
general public and deals with all aspects of
the disease, from symptoms to treatment by
way of diagnosis, prevention and research.
GOLD CATEGORY
SILVER CATEGORY
BRONZE CATEGORY
• Canadian Medical
Protective Association
• Desjardins Insurance (Life,
Health, Retirement)
• Association des
optométristes du Québec
• Desjardins
• BCP
• Desjardins Financial
Security
• Fiera Capital
• CIBC Global Asset
Management Inc.
• SEI Investments
• La Capitale Insurance and
Financial Services Inc.
• The Personal, Home and
Auto Group Insurance
13
• SSQ Financial Group
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• Le plus gros congrès annuel de
médecins spécialistes au Québec
• Créée par la FMSQ en 2008
• Ouvert à tous
• Une occasion unique d’échanger
dans un cadre de DPC
• Plus de 27 ateliers et sessions
associatives au programme
• Récipiendaire du prix 2013
d’innovation des prestataires
de DPC (CRMCC)
EN PLUS :
• Allocution de Dr Gaétan Barrette
pendant le lunch
• Cocktail de réseautage en
présence du président
• Remises de prix
INSCRIVEZ-VOUS DÈS
MAINTENANT EN LIGNE
fmsq.org/jfi
TARIF SPÉCIAL POUR INSCRIPTION
AVANT LE 15 OCTOBRE
Cette journée a été rendue possible grâce
à une subvention à visée éducative de :
ACTIVITÉS CONJOINTES
PALAIS DES CONGRÈS
DE MONTRÉAL
AU PROGRAMME CETTE ANNÉE
• Chirurgiens et anesthésiologistes :
plus que des partenaires obligés
Session associative : chirurgie générale et
anesthésiologie
• Altérations de la flore intestinale et
de l’immunité : C. difficile, mais pas
impossible !
Session associative : gastro-entérologie,
microbiologie et infectiologie
• Tumeurs de la base du crâne : controverses
et nouveautés
Session associative : endocrinologie,
neurochirurgie, ORL, pathologie,
radio-oncologie et radiologie
• Comment gérer les complications chez
les enfants munis de sondes alimentaires
entérales, de trachéostomies et de cathéters
veineux centraux
Session associative : chirurgie générale,
pédiatrie et pneumologie
• Les troubles du sommeil : quand Morphée
relâche son étreinte
Session associative : cardiologie, neurologie, • La maladie d’Alzheimer : mieux la comprendre
ORL, pneumologie et psychiatrie
Session associative : gériatrie et neurologie
• Thérapies endovasculaires
Session associative : chirurgie vasculaire et
radiologie
• Les complications ophtalmologiques de
pathologies endocriniennes
Session associative : endocrinologie et
ophtalmologie
SESSIONS GÉNÉRALES
Vendredi
15 novembre 2013
• Cessation tabagique : comment passer
à l’action
Session associative : pneumologie, psychiatrie,
santé communautaire
• Anaphylaxis and drug allergies : diagnosis,
treatment algorithms, post-interventions
studies and referral for work-up
after screening
Session associative : allergologie et
immunologie clinique et anesthésiologie
(Présentation en anglais, diapositives bilingues)
• L’expertise et le médecin spécialiste :
une longue carrière fait-elle de vous
un expert ?
• Les dix situations médico-légales les plus
fréquentes de la pratique du médecin
spécialiste au Québec
• Pour éviter de faire la une du journal :
gestes de base en réanimation
• La planification de la retraite, à court
et à long terme - les aspects financiers
(tarification spéciale pour les conjoints)
• La polymédication ou l’optimisation de
la pharmacothérapie chez le patient
gériatrique
• La lecture critique d’une étude
randomisée contrôlée
• Enhancing learning, advancing care :
the Royal College’s MOC Program
and Mainport Web Application
(English Workshop)
• Maximiser la section 3 du programme
Maincert (3 crédits/heure) : comment
autogérer et autoévaluer mon DPC
• La gestion du temps
• iPad, iPhone et autres gadgets au service
de notre pratique quotidienne
• La gestion du stress : pour le médecin, le
stress est à la fois le mal et la potion
• La planification de la retraite, à court et à
long terme - les assurances, les aspects
juridiques et les aspects psychosociaux
(tarification spéciale pour les conjoints)
• L’AVC et la fibrillation en 2013 : gestion
pratique des nouveaux anticoagulants,
accent sur les situations urgentes
• Suivre un médecin et rester zen…
suivi de : un avant-goût du mieux-être
• Les habiletés de gestion d’un chef de
département, suivi de : Leadership
médical : par son implication, le médecin
hospitalier peut améliorer sa situation et
celle de ses patients
• Comment débuter sa pratique (Session
conçue pour les médecins spécialistes en
début de carrière)
LEGAL ISSUES
BY MAÎTRE SYLVAIN BELLAVANCE
Director, Legal Affairs and
Negotiations – FMSQ
A major investment
A survey was sent out to all medical specialists in 2012 in order to
collect more information on the extent of physician participation
in the organization of hospitals. This information was used to
negotiate three new agreements on remuneration representing
a total investment of $140 million annually.
We wish to provide you with certain details on these agreements
which will take effect starting on January 1, 2014. The full text
of these agreements will be sent to you during the fall, along
with additional information on the conditions of their application.
1. MEDICAL ADMINISTRATIVE ACTIVITIES
A first Memorandum of Agreement deals with the remuneration
of medical specialists who take part in the following meetings
in their institution:
• Unit, department or client-program meetings;
• Meetings of various committees set up in the institution.
A complete list of more than 70 committees has been
identified (such as morbidity, pharmacology, discipline,
operating suite, etc.).
In order to qualify for remuneration, the following conditions must
be met:
1- Only participation in the meeting is remunerated, not
preparing for it;
2- Presence must be in person, not via telephone conferencing;
3- Only specific unit, department, or committee members
can be remunerated along with physicians who have been
invited to attend;
4- The meeting must take place within an institution, be
announced via a formal invitation and be the subject of a
written agenda;
5- Attendances must be recorded and minutes must
be consigned.
This Memorandum does not, however, apply to physicians who
are acting as heads of units, departments or client-programs
as they will be remunerated by way of another Memorandum of
Agreement which is presently being negotiated and which we
expect to finalize during the fall.
2. TEACHING ACTIVITIES
The current Memorandum of Agreement remunerating clinical
supervision activities will be modified to include the following
academic activities:
• Dispensing courses or presentations, other than courses on
the university curriculum;
• Teaching students by way of apprenticeships in
clinical reasoning;
• Teaching via simulation;
• Evaluations based on the OSCE method.
With the exception of teaching via simulation and OSCE, these
activities must take place within a healthcare institution.
The next two activities are also covered for all medical
specialists participating:
• Academic meetings during which a medical subject is
discussed within the framework of a formal presentation;
• Reading clubs during which an article published on a
medical subject of interest is discussed.
These activities must be announced via a formal invitation and be
the subject of an agenda. A record of attendance is also required.
3. MULTIDISCIPLINARY CLINICAL MEETINGS
Meetings called to discuss clinical cases and in which at least
two other healthcare professionals from another specialty take
part are included.
Participation in these meetings must be in person and in the
institution. Again, a certain level of formality is required since an
invitation and an agenda for the meeting must be sent out and
discussion notes must be compiled and included in the patient’s file.
This measure is not available for psychiatrists nor for anatomical
pathologists who already benefit from similar measures. It is also
not possible to benefit from it for tumour clinics nor for certain other
types of meetings listed in the Memorandum.
REMUNERATION FOR THESE ACTIVITIES
All of these activities will be remunerated at an hourly rate or
according to an equivalent act code. The rate is $150 per hour
starting on January 1st, increasing to $175 per hour on April 1,
2014 and to $200 per hour on April 1, 2015. Any activity must
last for at least sixty continuous minutes, otherwise it is
not remunerated.
Specific conditions apply to physicians who benefit from lump-sum
remuneration, including physicians receiving mixed remuneration
as well as physicians working in medical biochemistry or in
microbiology and infectious diseases. These receive – in addition
to the payment, if applicable, of their per diem or share –, a
remuneration that is equivalent to 50% of the hourly rate applicable
for activities taking place between 7 a.m. and 5 p.m., from Monday
to Friday. Outside of this period, the full hourly rate applies.
In order to take into account the overall budget allocated to the
remuneration of these new measures, the following maximum
annual number of hours, per medical specialist, is payable
according to the activity involved:
• Unit (20), department (20) or client-program (25) meetings;
• Meetings of a pharmacology committee (20), a CMDP board
meeting (45) or any other type of committee involved (10);
• Academic meetings (25);
• Reading clubs (15);
• Multidisciplinary clinical meetings (40).
These measures seek to recognize the role of medical specialists
in hospital organization and in teaching and to remunerate them
appropriately. It’s up to you to take advantage of them.
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DOSSIER
ACTIVITY-BASEDFUNDING:
A PANACEA?
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ACTIVITY-BASED
FUNDING:
A PANACEA?
In its 2012-2013 budget speech, the Charest government
announced its intention of improving the organization of
health services and to distribute resources more equitably
by implementing activity-based funding (ABF) in the
Quebec health and social services network, a model
already in use in various countries, including France.
An Expert Panel on Activity-Based Funding was set up in
order to provide some thoughts on the matter. The group
began working at the end of the month of April 2012. The
Marois government reviewed the name and mandate of the
panel, which became the Expert Panel for Patient-Based
Funding, during the budget speech in April 2013. The panel
of experts’ report is expected at the end of 2013.
The possible adoption of such a mode of funding would
in essence affect activities that take place in a hospital
centre. Physicians - mainly medical specialists – would
be directly involved, at several levels. The implementation
would require that physicians, who are at the heart of the
delivery of care and services, be a party to a possible
implementation process, both before and after.
In this dossier, we are presenting an overview of the various
forms of activity-based funding repertoried around the
world. We are also providing extracts of the white paper
submitted by the FMSQ to the group of experts who are
mandated by the government.
SEVERAL NAMES, SAME PRINCIPLE
Whether it’s called Tarification à l’activité (T2A) in France,
Prospective Payment System (PPS) in the United States,
Payment by Results (PbR) in Great Britain, Activity-Based
Funding (ABF) in Canada, the principle behind the funding
of activities consists essentially of granting health care
institutions the same lump-sum payment for a given
type of stay. Each patient is classified according to his
or her pathology and type of stay which are inventoried
in an overall classification. To each category of stay
corresponds a pre-determined fee.
Editor’s Note: This dossier includes extracts of a report on research and of a
white paper prepared by the FMSQ. The latter were prepared on the basis of a
large volume of documentation. Because of their pertinence and the quality of
the information they contain, complete passages of certain works are reproduced
or adapted for editorial reasons. We thus wish to ensure that the comments and
observations made by these authors are as true as possible to the originals. We
offer our thanks to them.
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BY RICHARD-PIERRE CARON
Senior Consultant
Public Affairs and Communications – FMSQ
T2A: the French Model
Of all the activity-based funding models implemented in various countries, that of France is of
particular interest, as it has relatively recently come into effect and its implementation is not
yet complete. The transition between the old and the new model of budgetary allocation was
put into effect some four years ago and this was not done without a few stumbles, since it
generated its load of problems and pernicious effects, and is still doing so.
In December 2011, close to eight years after the introduction
of activity-based funding for a few sectors, the Assessment
and Monitoring Mission for the Laws Governing Social Security
(Mission d’évaluation et de contrôle de la sécurité sociale
or MECSS), an emanation of the French Senate’s Social Affairs
Committee, decided to launch a reflection on the subject
because of the numerous irritants generated by this funding
model. On July 25, 2012, the MECSS published its report.1
AT THE BEGINNING
Up to 1984, public and private non-profit healthcare institutions
were funded by daily rates. Starting in 1984, these amounts
were replaced by a global allocation that almost automatically
renewed budgets year after year. If such a system allowed
a control of expenses, it still presented some major inconveniences: failure to act and hospital activities not adapted to the
needs of healthcare.
Credit: rubensoft.com
Starting in 1991, a first reform (in search of transparency,
equity and efficiency) implemented an analysis tool to study
medical activity and medical processes within institutions:
the Program for the Medicalization of Information Systems
(Programme de médicalisation des systèmes d’information or PMSI). Institutions had to deploy information systems
taking into account pathologies and case management methods
to improve knowledge, evaluate activities and their costs to
improve the optimization of their offer of care.
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The T2A architecture was developed
based on the PMSI, the information infrastructure.
Although it was announced in 2002, T2A
was introduced in public institutions and
in non-profit private institutions in 2004,
then in institutions for profit in 2005.
France has joined the majority of Western countries who
have adopted the principle of fees, each corresponding to a
lump-sum payment per type of stay.
THE MECHANICS
T2A only applies to and covers 3 types of activities: medicine
(M), surgery (C for chirurgie) and obstetrics-gynecology
(O) (giving rise to the acronym MCO).
Hospital stays considered sufficiently similar from a medical
and economic point of view are grouped together into homogenous groups of patients (groupes homogènes de malades
or GHMs).
Based on analytic accounting data collected in volunteer
institutions – a sampling involving only 9% of MCO stays in
hospital centres and 5% in clinics – the Technical agency for
hospital information (Agence technique de l’information
sur l’hospitalisation or ATIH) calculates the average cost
per stay for each of these GHMs. On the basis of this costing
scale, taking into account public health
objectives and the orientation of case
management methods, the Department
of Health developed a fee grid for the
homogenous groups of stays (groupes
homogènes de séjour or GHSs) as
the financial counterpart of the GHMs.
Normally, each GHS corresponds to
a GHM.
The number of patient groups varies a
great deal from one country to another.
There are 355 in Belgium, 698 in Ireland,
983 in Sweden, 1020 in Finland, 1182 in
Germany, 1389 in England and 2318 in
France. Almost all the GHMs in France
have four levels of severity. Taken apart,
the French GHMs could be regrouped
into 600 roots, each divided into various
degrees of severity.
A BIT OF USEFUL INFORMATION
In 2010, France had 2,751 hospital facilities offering 427,000 beds for
complete hospitalization and 60,500 places for one-day hospitalization.
To be more specific, the public sector included 966 institutions; the private
non-profit sector had 1051 and the private for-profit sector, 734.
1
Le Menn J and Milon A, Senators. Rapport d’information au nom de la mission
d’évaluation et de contrôle de la sécurité sociale de la Commission des affaires
sociales sur le financement des établissements de santé. Paris: Senate,
July 25, 2012.
Source: Le panorama des établissements de santé - édition 2011. Direction de la
recherche, des études, de l’évaluation et des statistiques (DREES)
ACTIVITY-BASED
FUNDING:
A PANACEA?
TRANSITION AND FEE STRUCTURE
Transitional measures were in place up to 2011 in order to soften
the impact of converting from global allocation to T2A. National
fees were gradually applied starting in 2008. Fee adjustments
were also implemented to take into account the overhead costs
for real estate, salaries and taxes as well as specific charges to
insular and overseas departments associated with remoteness
and isolation.
T2A ONLY APPLIES TO MCO ACTIVITIES.
THEREFORE, FOLLOW-UP AND REHABILITATION
CARE (SOINS DE SUITE ET DE RÉADAPTATION OR
SSR) ARE EXCLUDED, AS ARE PSYCHIATRY, LONGTERM CARE AND FORMER LOCAL HOSPITALS.
FRANCE IS KNOWN FOR THE SIZE OF ITS
ADMINISTRATIVE STRUCTURE, FOR CURRENT
MANAGEMENT, VERIFICATION AND OTHER
ASPECTS. THE IMPLEMENTATION OF T2A WAS
NO EXCEPTION TO THE RULE. TO START WITH,
PRECISE ALLOCATIONS SET BOUNDARIES TO THE
AREA OF ACTIVITY AND PLACED A FEW MARKERS.
THESE ALLOCATIONS WERE THEN ANALYZED
BY VARIOUS COST CONTROL MEASURES.
Fees established at the national level for each GHS represent
only one part of institution resources. Certain activities with high
fixed costs, such as emergencies or transplants, are often only
partially funded by fees. They benefit from lump-sum funding.
In England and in Germany, the fee for a period in hospital
is increased if the patient’s admission follows a visit to the
emergency room.
Funding based on fees (GHS plus supplements for certain
services) represents 75% of MCO activities, i.e. 41.5 billion Euros
from a total of 55.3 in 2012. Certain services are not covered
by fees (expensive medication, implantable medical devices,
emergencies, coordinating transplants and organ retrieval),
representing a total of 5.3 billion Euros in 2012. Finally, Missions
of General Interest and Assistance with Contracting (missions
d’intérêt général et les aides à la contractualisation or
MIGACs) are financed according to specific conditions. This
allocation represented 8.5 billion Euros in 2012, or 11.5% of the
National Objective for Health Insurance Spending (Objectif
national des dépenses d’assurance maladie or ONDAM).
A COMPLEX STRUCTURE
To start with, the ONDAM was a forecast amount established
annually for health insurance expenses. It was split up into six
sub-categories: healthcare costs in urban centres, expenses
related to institutions funded by activity-based fees, other health
institution expenses, expenses related to other modes of case
management, contributions to institution and service expenses
for the elderly and contributions to institution and service
expenses for the handicapped. ONDAM does not include fees
not covered by health insurance, such as the deterrent fee,
medical honoraria in excess of limits and services excluded
from reimbursement because of their nature.
In addition to the ONDAM, the MIGAC is an ad hoc allocation
that is used to finance certain specific activities. It is subdivided
into three sub-allocations: the Teaching, Research, Reference
and Innovation Missions (missions d’enseignement, de
recherche, de référence et d’innovation or MERRIs), the
Missions of General Interest (MIG) and the Assistance with
Contracting (AC). The MIGs aim to sustain the permanence
of care in healthcare facilities, a participation in certain public
health missions (urgent medical aid, prevention, education) and
the management of specific populations (patients in a precarious situation). ACs seek to support facilities on a temporary
basis for the implementation and adaptation of the care that is
offered. Even if all institutions subject to T2A are eligible, it is the
public hospitals that benefit from almost all the allocation (private
institutions only received 1.1% in 2010). The three components
of the MIGAC have been, and still are, subjected to reforms at
the level of the mechanics of attribution.
It should be noted that a part of the MIGAC allocation is now
frozen at the start of the fiscal year. Should there be a risk of
overshooting the overall ONDAM allocation – which is frozen –
the regulatory instrument is applied during the year, thus
cancelling in whole or in part projected allocations.
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ESTABLISHING FEES AND CODING
MEDICAL ACTIVITIES
The National Cost Study (Étude nationale des coûts or ENC)
for MCOs is performed each year by the ATIH. Institution participation is voluntary, although there is modest remuneration.
Participating in the study involves a significant technical and
human investment on the part of institutions, in particular to
ensure quality in analytic accounting since the ATIH’s requirements are very detailed. Approximately 70 public and private
health institutions take part in the ENC each year.
The T2A imposes a requirement to transcribe medical activity
into a new language: that of a complex fee structure that is
supposed to allow all patient stays, with their uniqueness and
their diversity, to be entered into a re-established classification.
This coding job of medical acts and patient management falls
to practitioners to start with, those who had to take on this new
responsibility, more administrative than medical. Medical information departments (départements d’information médicale
or DIMs) have now taken on a central role, without having
been prepared in reality nor supported in terms of training and
human resources.
THE GROWING WEIGHT OF THE ADMINISTRATIVE
CODING HAS OFTEN BEEN MENTIONED BY
PRACTITIONERS WHO HAVE NOT BEEN
TRAINED OR PREPARED FOR THIS NEW TASK
THAT IS BOTH TECHNICAL AND PERIPHERAL
TO THEIR ESSENTIAL FUNCTIONS.
One department head estimated that this work responsibility
represented six weeks of work per year, based on ten to fifteen
minutes per file, thus more and more limiting the time dedicated
to the patient. Practitioners recall, justifiably, that they are there
to treat, not to feed databases.
20
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Practitioners have also highlighted the heavy responsibility
that rests on their shoulders in an area outside their competence: inadequate coding results in a loss of revenues for the
institution. On the other hand, the latter risks heavy financial
sanctions in case of errors picked up during the external
audits performed by the medical insurance authorities.
Finally, even with comparable files, coding results can be very
different, if one considers the complexity of the fee structure.
An institution’s resources being directly affected by the efficiency and quality of collected medical data, the Medical
Information Department – placed under the responsibility of
physicians in order to ensure the pertinence of the treatment,
control of the data as well as its protection by medical
secrecy – from this point on becomes an essential linchpin
with regards to the financial operation of each institution. In
a rather astonishing way, reinforcing the capacity of health
care institutions, in the area of medical information, is not the
object of any plan or program under a national impetus. This
unique situation comes from the fact that medical information
was set up on empirical bases and left to the initiative of institutions. The organization and operation of institutions being
variable, some have had recourse to a centralized coding
within DIMs, while others perform these tasks within departments themselves (with the DIMs ensuring control of the files).
CONTROL MEASURES
The funding of institutions rests indirectly on the billing information they send to the Health Insurance. This system involves
ensuring the rules of coding and billing are respected, medicoadministrative information produced during a stay is exact and
the whole complies with social security legislation. Control falls
under the authority of the directors general of the regional health
agencies (agences régionales de la santé or ARSs), within
the framework of nationally-established priorities.
In each region, a control commission, composed equally of
representatives from the State and from the Health Insurance,
is on a level with the director general of the ARS. The control
commission is supported by a technical entity, the Regional
Coordination Unit (Unité de coordination régionale or UCR).
This entity, made up of approximately one-third of the staff of the
ARS, is in charge of ensuring effective external control. Control
based on documents and on site are performed by physician
consultants of the Health Insurance and by physicians from the
ARS. This is usually done on the basis of a random sampling
of the files (at least one hundred). The Health Insurance has
the right to claim a refund of sums overpaid on the basis of the
files verified on site. In addition to these refunds, a sanction can
be added as decided upon by the director general of the ARS,
which amount is calculated not on the files effectively controlled
but on the overall area of activity subjected to control.
POUR TOUS VOS
BESOINS D’ASSURANCES
FINANCEMENT
À L’ACTIVITÉ :
LA PANACÉE ?
THE FAULTS AND IRRITANTS
ASSOCIATED WITH THE MODEL
Grâce au
The inflation effect is one of the main risks generally associated
with activity-based fees, since T2A encourages the development
of activity
in order
to stockpile
receipts. It is
LAISSEZ
LIBRE
COURS
À VOSadditional
PASSIONS
therefore possible that certain institutions are tempted to involve
themselves in a race to activities, by taking charge of patients
or by performing useless acts. Several spokespersons for the
MECSS believe that this temptation exists, whether it involves
sequencing stays or proceeding to certain acts in order to
significantly increase revenues from fees. Sequencing stays is
encouraged by the fact that it is much more interesting financially for the institution to proceed with two stays separated by
Qu’il
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d’assurance
professionnelle
a few
days
and thus
be remunerated
for two GHS. The director
ou personnelle
invalidité,
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general
in charge of (vie,
the offer
of care estimates
that T2A tends
service
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personnalisé
to notre
“develop
activity
beyond what
is medicallyvous
necessary on a
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SERVICE PRÉFÉRENCE
SOGEMEC ASSURANCES
ÉVOLUE AVEC VOUS
à vos questions.
Data transmitted by institutions allows for the follow up of all
of a given patient’s data (not personally identified), whatever
institution is involved and whether for a short or a medium
stay. It is thus possible to identify an institution that has a rate
of re-hospitalized patients that is higher than average for a
given discipline, to undertake an audit of medical files and, if
appropriate, to have sanctions imposed by the Director General
of the ARS.
T2A PROMOTES OPTIMIZING THE
ORGANIZATION OF CARE AND, AS SUCH,
PRESENTS THE RISK THAT SEEKING A BETTER
COST-TO-FEE RATIO WILL BE DONE TO THE
DETRIMENT OF THE QUALITY OF CARE.
INSTITUTIONS COULD BE DISSUADED FROM
PERFORMING CERTAIN ACTS OR EXAMINATIONS
OR FROM UNDERTAKING CERTAIN TREATMENTS
THAT WOULD INCREASE THE COST OF A STAY
BEYOND THE LEVEL OF THE ESTABLISHED FEE.
THEY COULD ALSO REDUCE THE LENGTH OF
STAYS EXCESSIVELY AND DISCHARGE PATIENTS
PREMATURELY. T2A COULD ENCOURAGE
STRATEGIES OF SPECIALIZATION THAT WOULD
ENCOURAGE REPETITIVE ACTS OR AMBULATORY
SURGERY TO THE DETRIMENT OF ACTIVITIES
THAT ARE HEAVIER OR MORE COMPLEX OR,
ON THE CONTRARY, THOSE THAT INVOLVE
FEW TECHNICAL ACTS AND THUS ARE OF
SOGEMEC
ASSURANCES
LITTLE
VALUE.
filiale de la
T2A has resulted in the redistribution of resources between
institutions. Some have gained from it, others have lost. Those
that are located in areas with a small population are less likely
to develop their activities in terms of volume. By applying fees
established on the basis of a “forecast” increase in activity for
them, we inevitably provoke an erosion of their resources, thus
dragging them down a deficit slope. If corrective measures are
absent, an institution whose population base does not allow
it to have a rate of activity that corresponds to its costs will
remain in a difficult situation.
Medical demographics is another external factor that, within the
context of T2A, has a direct influence on the financial situation
of institutions. Confronted with a shortage of practitioners,
these institutions must call upon temporary medical staff,
with very significant additional costs. Interim physicians may
benefit from a remuneration that is up to three times greater
than that of tenured practitioners. Since the remuneration
of practitioners is the responsibility of institutions, we can
thus truly speak of a deficit spiral that the institution will have
difficulty stopping on its own. The current mode of financing
tends rather to aggravate this problem.
A lot of criticism has been made by people in charge of
institutions and by physicians insofar as external controls
and their associated set of sanctions are concerned.
Control is often criticized for being too often systematically
accusatory, and performed in a spirit of suspicion towards
institutions. Even if one admits the legitimacy of a control,
it must be emphasized that errors are rarely intentional.
Physician controllers are also criticized for too often ignoring
real situations of case management, for example when the
urgent nature or the uncertainty of a diagnosis explain rapid
decision-making and examinations (or acts) that are not really
necessary. Health Insurance is criticized for being both judge
and party, even when it responds that it is only acting by virtue
of legal and regulatory measures that give it this mission,
within a framework established by, and in association with,
the ARSs.
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RECOMMENDATIONS
The MECSS does not question the principle of T2A, but it does
promote a better accounting of certain medical activities, of
general interest missions as well as of territorial disparities. It
estimates that T2A, focused more on the illness than on the
patient, can be a handicap for the implementation of a health
pathway; it suggests instituting global funding for certain pathologies including case management in the city and in institutions.
The MECSS recommends the development of an analytic
accounting system in institutions, enlarging the sample and
trying, for certain acts, to establish the cost of a targeted
reference and no longer just an average.
SOME OBSERVATIONS
T2A was supposed to theoretically procure revenues
for institutions that would be proportional to the volume
of stays effected. Instead, from management’s point of
view it is considered a closed envelope, which does
not bring about any fundamental changes in relation to
global funding. T2A is a new way of allocating resources
but it never covers all the financial resources needed by
hospitals. Activities not directly associated with care,
such as teaching and research, call upon complementary envelopes.
While needs increase, in particular because of population
aging and the development of chronic pathologies, the
volume of activities is increasing rapidly, so that fees
have to be stabilized, and sometimes reduced. France
has chosen to regulate expenses by fees rather than
by volumes and this at a macroeconomic level, without
taking into account the activity at each of the institutions
taken individually. Such methods of fixing fees can only
increase the margin between fees and real costs.
Global funding has been replaced by a complex architecture in which there is a juxtaposition of general fees and
a very large number of targeted provisions destined to
finance activities, services or charges that are not taken
into account in the GHS classification.
T2A IS NOT WELL ADAPTED TO CERTAIN
ACTIVITIES: THOSE WITH REGULATORY
STANDARDS THAT ESTABLISH MINIMUM
CONDITIONS FOR THE MANAGEMENT OF
PATIENTS; THOSE THAT ARE DIFFICULT
TO STANDARDIZE (FOR EXAMPLE,
RESUSCITATION); THOSE PERFORMED IN
ISOLATED AREAS, OR IN THOSE WITH A LOW
DENSITY, BUT THAT ARE INDISPENSABLE
TO ENSURE HEALTH NEEDS ARE COVERED.
REVIEWING THE BOUNDARIES
AND THE FUNCTIONING OF T2A IN MCOs
The MECSS proposes holding multi-disciplinary consensus
conferences in order to produce a definition, based on medical
criteria, of those activities that could be part of a funding per
stay. Those that are not could be financed either by excluding
them from the logic of fees to apply a system based more on
lump sums, or by using a system of minimal financing based
on a fraction of fixed costs.
T2A is better at establishing values for technical acts and is
better adapted to surgery and obstetrics than to medicine.
As much as it is possible to create a structure of fees for a
normal delivery, an appendectomy, cataract or carpal tunnel
surgery, that linked to the failure of one or more organs cannot
be homogenized nor standardized. The MECSS believes it is
necessary to adopt a new common classification of medical
acts that would allow more accurate funding of the medical
time used.
Historically subject to different modes of financing, the public
and private non-profit sectors on the one hand and the private
for profit one on the other have seen the application of distinct
fee schedules at the moment T2A was implemented.
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ACTIVITY-BASED
FUNDING:
A PANACEA?
These grids do not cover the same charges: for example,
physician fees, billed separately to patients in clinics, are not
integrated in the fees. Because of this, comparing fees requires
complex reprocessing and statistical aggregation that render
the process artificial. In addition, such a comparison could only
be performed legitimately if “all things were otherwise equal.”
And it appears impossible to model certain constraints, like
the portion of planned activities and that of acts performed
serially on a technical platform. Seeing that these divisions have
become, without reason, almost ideological, the MECSS has
recommended that fee convergence be suspended.
The MECSS considers it illegitimate for fees to finance investments in real estate for hospitals and believes it necessary to
orient oneself towards a funding that is not directly linked to an
activity, favouring instead the concept of a multi-annual project
contract and by calling upon resources of the “large loan” type.
MIGACs, distributed among 93 missions in 2010, make up a
discordant whole whose contours have fluctuated during the
first years of T2A. If the 10 most expensive missions made up
73% of the whole, 8 of them have amounts under one million
Euros. Despite the efforts expended to improve methods of
allocation and avoid the automatic renewal of historical budgets,
the lack of coherence of the envelope and the underfinancing
of certain missions remain obvious.
The MECSS recommends a complete review of all the MIGACs
with a view to simplifying and clarifying the allocation. Based on
forecasts of activities for the coming year, the Department of
Health annually adjusts the fees in order to respect the ONDAM;
in practice, they have continuously reduced them, because the
increase in volumes were superior to the ONDAM. This method
of macro economically regulating expenses ends up making it
increasingly difficult to cover costs by way of fees. An institution whose activity increases, but not as quickly as the annual
forecast, will see its revenues stagnate or go down, which has
a very negative effect on team motivation.
The MECSS is demanding a global review of expenses so as
to be closer to each institution’s own evolution. Fees that are
set for multiple years could be applied up to a certain volume
of activities, with decreasing fees being used afterwards.
The MECSS believes it is necessary to counteract this
phenomenon by giving regional health agencies the means
to allocate temporary financing to encourage cooperation
between hospitals.
Information systems that are essential both for the coding of
stays and to better respond to more extensive health stakes, are
very heterogeneous. To this is added the absence of a legal and
organizational framework for medical information departments.
The MECSS recommends implementing a plan to update and
coordinate hospital information systems and to involve itself in
the professionalization of DIMs.
ENSURING QUALITY IN THE CASE
MANAGEMENT OF PATIENTS
T2A presents inherent risks that the model must take into
account, in particular inflation and the sequencing of stays
(the benefit of having the patient come back for a second stay,
when the examination or act could have been performed along
with the first one).
Other external factors have the same tendency: according to
data collected by the MECSS, a not insignificant number of
acts is performed solely because of an inadequate appreciation
of the safety-first principle and to take measures against
possible litigation.
Chronic pathologies make it necessar y for the case
management of patients to evolve, especially since the number
of hospitalizations, in particular of the elderly, are avoidable.
TWO GOALS MUST BE PURSUED: IMPROVING
QUALITY AND CONTROLLING EXPENSES. A
STRUCTURAL RESPONSE IS ESSENTIAL AND
RESIDES IN A PROFOUND REORGANIZATION
OF THE HEALTHCARE SYSTEM IN ORDER
TO BEGIN THE JOURNEY TOWARDS A
GLOBAL PATHWAY TO HEALTH.
In terms of financing, T2A, which is focused on the illness rather
than on the patient, can be an obstacle to the development of
a pathway logic.
T2A CAN BE AN OBSTACLE TO COOPERATION
BETWEEN INSTITUTIONS, SINCE THESE WILL
NOT BENEFIT FROM SHARING THE ACTIVITY.
In addition, T2A is supposed to be extended to institutions
providing follow-up and rehabilitation care as early as 2013.
The MECSS suggests seizing the opportunity to reform the
financing of the SSRs in order to try out the fee structure based
on “the pathway”.
23
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ACTIVITY-BASED
FUNDING:
A PANACEA?
Other experiences around the globe
Activity-based funding was first put into practice in the United States starting in 1983. The formula was then
adopted, in different forms, by most European countries starting in the 1990’s. Sweden adopted it in 1992;
Hungary, Ireland and Australia in 1993; Italy in 1995; Catalonia in 1996; Finland and Norway in 1997; Portugal
and Austria in 1998; Denmark and Poland in 2000; Belgium in 2002, England in 2003; France in 2004 and the
Netherlands in 2005.
In 2007, the Centre for Health Economics at York University (CHE) published a comparative study1 on the various
models of activity-based funding that were adopted in different countries. The study presented the formulas
implemented for the classification of patients, as well as the mechanics of establishing prices and of financing
services. Here are a few observations compiled by the authors.
A FEW QUOTES FROM THE CHE STUDY
FEES AND BUDGETS
“In almost all countries that have introduced activity-based funding, hospital
revenue is not solely determined by the number of patients treated. Hospitals
also receive revenue in other forms – for instance, for teaching and research,
to compensate for different locational costs, or to cover some element of the
fixed costs of providing services. It has been demonstrated that this ‘mixed’
funding system creates better incentives than a system of ‘pure’ activity-based
funding. The composition of these other revenue forms varies across countries
and over time...”
The ratio between fees and the complementary
methods would be in the range of 80-20% in
France, Germany, the Netherlands, Ireland and
in Portugal. It would be in the range of 60-40%
in England and in Poland. Only in Austria is an
almost exclusive role (96%) granted to fees.
“First, a ‘target’ level of activity needs to be defined for each hospital. In some
countries, this is based on historical activity. Second, a decision must be made
about what price should be paid for additional activity beyond the target level.”
“Quite often, policy-makers have introduced activity-based funding in order to
stimulate activity beyond existing levels. But there are reasons why they may not
wish for ‘unconstrained’ growth in activity. First, they need to maintain control
over global expenditure. Second, policy-makers may believe that hospitals are
able to expand activity at low ‘marginal’ cost – perhaps because they have
under-utilised resources available. If so, there is an argument for reducing the
unit price for additional activity.”
“Another feature of international policy is a deliberate separation between
prices and the underlying cost information on which they are based. Instead of
reporting price in monetary units, cost information is converted into a system of
cost weights like a points system, whereby a benchmark treatment is assigned
a score of (say) 100 points, with more points for more costly procedures.
National and, in some countries, local policy-makers then decide how much
to pay per point and, if necessary, can adjust this monetary value periodically
to control global expenditure.”
“In England, France and the United States, the cost information is converted
(more or less) directly into prices. This means that any general cost inflation
will automatically feed into future prices. In England and France prices reflect
average cost.” (this approach is being called into question in France). “In the US
a more challenging benchmark is established, so all hospitals have an incentive
to improve their performance. For example, rather than basing prices on the
average cost in the sample, the benchmark price might be set on the basis of
the costs achieved by the 10% lowest cost providers.”
1
In Belgium, since 2002, institutions retain their
funding via a global allocation, but data on
activities are a key element to determine its
amount. Each hospital is provided with a draft
budget established according to data on the
activities. A period of discussion during which
the institution makes its point of view known
precedes the budgetary notification.
IN AUSTRALIA
At the beginning of the 1990’s,
25% of Australia’s inhabitants
(4.2 million people) lived in the
State of Victoria. The budget for the Department
of Health Community Services (DHCS) amounted
to AU$4 billion: 56% of the budget was dedicated
to acute care dispensed in hospital centres (HC).
Victoria had a total of 16 teaching and specialized
care HCs each serving 27,000 people, 51 front
line HCs each offering services to 8,000 people,
and 75 rural or isolated HCs each serving some
1,000 people.
Activity-based funding was introduced in July
1993. It represented 25% of HC revenues. In 2001,
this percentage had gone up to 70%. The model
was also extended to rehabilitation activities and
external services.
Street A, Vitikainen K, Bjorvatn A, Hvenegaard A. Introducing Activity-Based Financing : A Review of Experience in Australia, Denmark, Norway and Sweden. CHE
Research Paper 30. York, UK : University of York. Centre For Health Economics, 2007. Available at york.ac.uk/media/che/documents/papers/researchpapers/rp30_
introducing_activity-based_financing.pdf.
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IN DENMARK
In early 2000, the population of Denmark
counted 5.3 million inhabitants. Three levels
shared the management of the healthcare
system: the Ministry of Interior and Health for the budget, directions and control; 14 counties and the Copenhagen Hospital
Cooperation for the management of services, hospitals,
health insurance, professionals (physicians, dentists and
pharmacists) as well as post and perinatal health prevention;
271 municipalities for proximity care (dispensaries, dental care
and prevention). Each level had taxation power to finance the
services placed under its responsibility. In 2007, a reform of
the territory reduced the number of municipalities to 98 and
replaced the counties with 5 regions. The regions maintained
their responsibilities, but their taxation powers were abolished.
Activity-based funding was introduced in 2000 and covered
only the costs for patients who chose to undergo a treatment
in a hospital outside of their own region. During the same year,
the 90/10 model was introduced, made up of a global budget
covering 90%, with 10% being provided by activity-based
funding. For each year from 2002-2006, an extra 1.5 billion
DKK fund was made available by the state in order to increase
hospital productivity.
Regions had access to it if they could demonstrate, with the
help of agreed upon and pre-established indicators, that there
had been a real increase in productivity. Indices were based
on the results of the previous year: the targeted increase was
fixed at 1.5%. In 2004, an additional stage was crossed: 20%
of funds allocated to hospitals by the regions should come
from activity-based funding. In 2005, an evaluation showed that
between 39% and 52% of hospital budgets came from activity-based funding. The same evaluation showed an increase
in activities and a decrease in waiting times. Highlighted is
the fact that adopting the model created great uncertainties
within the budgetary processes. The prices associated with the
Diagnosis Related Groups (DRG) are reviewed each year taking
into account the previous year’s activities and those from the
annual financial report. Activities increased rapidly after having
injected the envelope of DKK 1.5 billion destined to finance
activities. They increased in terms of value associated with the
DRGs, the number of operations and the number of contracts.
Since 2004, the progression has continued to increase rapidly.
In Denmark, special fees are set aside for patients located in
the “grey Zone”, i.e. those who could be treated as outpatients
rather than being hospitalized. With a view to creating the right
incentive, reimbursed fees are higher than the fees normally
reimbursed for ambulatory care, but a bit lower than the established DRG rate if the patient is admitted.
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IN NORWAY
In 1997, the population of Norway was
4.4 million. Activity-based funding was introduced the same year. Envelopes, based on
prices associated with the DRG, were combined with existing
blocks of grants. Since 1997, the portion of revenues issuing from
these two modes of funding have varied. In 1997, the ABF represented approximately 35% of hospital revenues. This portion,
which reached 60% in 2005, was brought back to 40% and has
remained there since 2006.
The Norwegian system of healthcare is mainly financed by taxes
and government transfers. Four levels share the management of
the healthcare system. The Ministry of Health and Care Services
assumes its responsibilities at the national level (budget, regulations, guidelines, etc.). Five Regional Health Authorities (RHA),
each responsible for a population basin varying between 462,000
and 1.7 million inhabitants, are also charged with managing
tertiary, acute healthcare and mental health. The 19 counties, that
cover approximately 240,000 individuals each, are responsible
for dental care and public health. The 434 municipalities, with
local taxation power, are responsible for the delivery of primary
care and social services. One element that is unique to Norway,
26 Health Enterprises are owned by the RHA. Comparable to
Hospital Trusts, they are the result of a regrouping 50 hospitals.
Each region now has at least one university hospital. Norway
has 10 overall.
In Norway, the weight associated with the DRGs is equivalent
for all hospitals, without taking into account the structure of
costs, the size and the type of hospital. The weights associated
with the DRG are determined at the national level by proceeding with a sampling of costs observed in selected hospitals.
Prices that correspond with DRGs are similar everywhere and
reimbursements issued by the national authority to regional
authorities are as well. Regional authorities are nevertheless
authorized to modulate the level of reimbursement they will issue
to regional enterprises.
Reimbursements issued on the basis of the DRGs are only done if
the patient remains more than 24 hours at the hospital. For a stay
of less than 5 hours. there is no DRG reimbursement allocated.
Instead, the hospital receives an amount that corresponds to
the rate for a consultation in a polyclinic. For treatments that are
elective and acute for more than 5 hours but less than one day, a
reduced DRG rate, adjusted for each type of treatment, is granted.
In 1999, day surgeries were also included in the reimbursement
system based on DRG prices.
A study was undertaken on the impact of the reform on the
productivity of hospitals for the period from 1999 to 2001. The
study was based on different indicators. It was established that
the level of overall productivity, which was 9.4% before the reform,
was at 18.3% after the reform. However, the level of activity varies
according to the DRG. Some DRGs have posted positive growth
while others decreased after the reform.
ACTIVITY-BASED
FUNDING:
A PANACEA?
IN SWEDEN
At the start of the 1990s,
S we d e n h a d 8.6 m i l l i o n
inhabitants. Three decisionmaking levels shared responsibilities in matters of
health. At the national level, the Ministry of Health
and Social Affairs is responsible for the overall
sector. At the regional level, two sub-structures
work together. Six medical care regions (MCRs)
regroup 21 county councils (CCs or regional
councils). The MCRs are responsible for tertiary
care and cover a little more than one million individuals. The CCs, whose members are elected
by the population, are responsible for the delivery
of care and the guidelines within which private
suppliers operate as well as owning most facilities.
Finally, at the local level, the 290 municipalities,
whose population varies between 3,000 and
760,000 inhabitants, are responsible for long-term
care, care of the elderly and mental health. CCs
and municipalities both have taxation power.
The case of Sweden is unique because each CC
has its own particularities when it comes to the
funding of health care services. At the beginning of
the 90’s, most CCs implemented a system based
on the purchaser-provider model. The model of
annual allocation was abandoned and replaced by
a payment system based on the volume of activities. Starting in 1994, 14 of the 21 CCs financed
hospitals according to this model, the others with
a global budget. Buyer organizations negotiate
with the various suppliers of the hospital centres,
establish financing and activity contracts. The use
of DRG or other methods of classification vary
according to the region or council.
It was predicted that productivity in Stockholm’s
hospitals should increase by 20% in the first two
years after the reform. From year to year, costs
have gone down because of the reduction in
prices associated with the DRGs. Productivity
increased, but this increase was the result of a
shortening of the length of stays, an increase in the
number of interventions and of discharges given
earlier to patients. This increase in productivity
lasted only a short time. Starting in 1997, the level
of productivity in Stockholm’s hospitals was back
down to what it was in 1991. This resulted in a
reappearance of wait times and a devaluation of
the DRGs was noted.
AND IN CANADA
One study1 made for the Canadian Health Services Research
Foundation (CHSRF) dealt with the hospital funding mechanisms. It was published in 2011 providing observations and
conclusions on activity-based funding (ABF) and issued
certain recommendations. Here are a few of the highlights:
• Most countries using activity-based financing (or funding) have
developed their own systems of diagnosis-related-groups (DRGs)
taking into account treatment patterns and costs. The success of any
ABF system is based on the capacity of closely aligning the amount
of the payment associated with each DRG with the projected cost
of hospitalization.
• In Canada, the CIHI has developed and maintains a system of groups
of similar illnesses known as CMG+ (case mix groups) that can be
used as a starting point for the development of an ABF system. Three
provinces (Ontario, Alberta and British Colombia) currently feed into
the CIHI Discharge Abstract Database (DAD) (clinical, administrative
and demographic data).
• Examination of DRG systems worldwide reveals that most systems
have settled on anywhere from 500 to 1,400 patient complexity
groupings. The CIHI’s 588 CMG+ groups include additional substrata
for high-cost procedures, return trips to the operating room, age
groups plus prevalent comorbidities, leading to thousands of possible
combinations and thus approximating a highly complex cost-based
reimbursement structure.
• The CHSRF clearly indicates that the CIHI’s CMG+ approach should
not be adopted as it is too complex and opaque for hospital managers
and clinicians. It adds that the numerous adjustments too closely
mirror the disincentives of cost-based reimbursement.
• ABF increases the responsibility of hospital managers from only cost
control to cost and revenue.
• There are costs associated with implementing and regulating ABF.
In the United Kingdom, the transition from global budgets to ABF
incurred costs for monitoring changes in hospital activity, collecting
patient level cost data, surveillance of data quality, and development
and management of service contracts for hospitals.
• Fee-for-service indirectly encourages hospitals to provide more
services to their patients (yielding additional revenue for the hospital)
though not necessarily increasing the volume of patients. While
lengths of stay tend to decrease, volume of hospitalizations tends
to increase and total hospital costs increase.
• Combining properties of ABF and global budgets may optimize the
strengths of both approaches, including global budgets to control
spending, while instituting an ABF mechanism to create incentives
for hospitals to provide timely and equitable access, appropriate
volume of care, and efficient care.
1
Sutherland, J. M. Hospital payment mechanisms: An overview and options for Canada
© 2011 Canadian Health Services Research Foundation. CHSRF series on healthcare
cost drivers and health system efficiency: Paper 4. Ottawa, Canada: CHSRF.
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Activity-Based Funding in Quebec:
At What Cost?
Within the framework of the mandate given to the Expert Panel for Patient-Based Funding,
the Fédération des médecins spécialistes du Québec prepared a white paper which was then
distributed to the members of the Panel. In this document, the FMSQ dealt with the central
question of activity-based funding. Here are a few extracts:
CLASSIFICATION AND CODING:
CORNERSTONE OF ALL SYSTEMS
Implementing an activity-based funding mechanism first
requires taking a basic step which consists of defining,
classifying and coding care episodes according to the patient›s
diagnosis. This step is crucial, since it is on the accuracy and
precision of the coding that the establishment of rates rests
as well as, de facto, reimbursement mechanisms. Hospital
stays considered sufficiently homogeneous from the medical
and economic standpoint are classified into groups. The
classification system used in all countries, but with local
variations, is inspired by or is widely based on the DRG model
(Diagnosis Related Group) which
was developed in the United States.
In certain cases, an episode of
c a re a s s o c i a te d w i th a g i ve n
group can be divided into several
subcategories to take into account
the severity or the complexity of
cases, procedures, etc.
DETERMINING THE COST OF A CARE EPISODE
The second step, just as fundamental and complex, consists
of establishing a price for each group identified. In France, as
we have seen previously, the process starts with analytical
accounting data collected from volunteer institutions.
The method known as “top-down costing method” is generally
used to establish a price associated with a typical episode
of care. First, all fixed cost items for the hospital centre are
detailed (electricity, building maintenance, accommodations,
salaries, etc.). A portion of these fixed costs is added to the
direct costs of the patient’s care episode (bed, examinations, laboratory, operating room,
housekeeping, pharmacy, medication, nursing staff, medical supplies,
IT SHOULD BE NOTED THAT IN FRANCE, etc.). Once added up, these costs
IN PARTICULAR, ESTABLISHING
are associated with one of the
medical specialties. In all cases,
RATES FOR PROCEDURES OR FOR
these can involve direct or indirect
CASE MANAGEMENT CANNOT BE
costs, such as the operating costs of
DONE BY ANYONE OTHER THAN THE
a surgical suite that varies according
PRACTITIONER WHO PROVIDED THEM to the specialty or the type of case.
According to the literature, the use
OR ON HIS OR HER INSTRUCTIONS.
of HRGs ( Healthcare Resource
In Australia, calculating costs
COULD
IT BE OTHERWISE IN QUEBEC?
Groups) in the United Kingdom
is per formed according to the
and of DRGs in the United States,
“bottom-up costing method”. This
in Scandinavia and in Australia,
three-step method consists essengenerate two problems. To start with, these classification
tially of compiling information by specialty centre based on
systems were only designed to describe the care required by
data issue from the clinical pathway taken by the patient
patients either admitted to hospital or on an ambulatory basis
during his or her hospitalization: diagnostic tests, blood tests,
(Day Case Basis). Secondly, there is no classification system
radiology, nursing care, time and procedures in an operating
that can perfectly group patients on the basis of the resources
room, etc. Are taken into account indirect costs (expenses
required by a typical group. Since each case is different, it is
associated with infection-control measures, sterile materials
difficult to establish uniform categories. For example, HRG
and domestic services) and the direct costs of the stay where
B13 is used to classify all patients who undergo a procedure
each product or service used has been weighted or has a
to extract a cataract and insert an intraocular lens. All cases
relative price established for it. For example, all nursing care
are classified under code OPCS C712. On the other hand, the
required and performed for each type of patient is detailed
HRG E03 (cardiac valve procedure) covers up to 48 different
and sequenced for each work shift. In summary, in this model,
procedures, while the HRG E04 (coronary bypass) covers 52
material resources and services used are directly linked to
of them.
the patient.
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ACTIVITY-BASED
FUNDING:
A PANACEA?
The length of a patient stay makes up another important
component for the evaluation of costs associated with a care
episode. Certain patients will be hospitalized for a longer or
shorter period than others for the same pathology. Thus, all
information relative to the length of a stay must be compiled
to establish an average per group and associate a price to it.
Patients who generate very high costs or whose stay is longer
than the average are considered “phenomena” that are outside
the hospital’s control. Several countries keep track of these non
standard cases, called “outliers”, and compensate hospitals
for the additional expenses incurred.
NOTHING CAN GUARANTEE THAT ACTIVITY-BASED
FUNDING CONTRIBUTES TO IMPROVING THE
QUALITY OF CARE. THE SAME APPLIES WHETHER
THE PAYMENT SYSTEM IS GLOBAL OR HISTORICAL.
POSSIBLE DIGRESSIONS?
Activity-based funding can, however, encourage hospitals to
reduce the cost of care per patient by cutting back on quality.
In the United States, certain hospitals practice patient selection
according to risk, by attempting to determine before admission
if the estimated cost for the episode of care will be lower than
the price associated with it (anticipation of profit), a practice
aimed at avoiding taking charge of patients whose cost risks
being greater than the normal fees granted (anticipation of loss).
Certain hospitals will attempt to release patients more rapidly
than is clinically appropriate in order to pass on a part of the
costs to first-line services. This phenomenon was observed
in the United States immediately after the implementation of
activity-based funding. Hospitals can be encouraged to use
codes that are better remunerated.
In Norway, a study of over-coding was performed on the basis
of data on 2 million patients. The study showed that, based on
the codes used, the percentage of complex cases had gone
up from 17.4% in 1997 to 30.4% in 2000.
Dr Diane Francoeur, Vice-President of the FMSQ and Dr Gaétan Barrette, its
President; Madam Wendy Thompson and Mister Pierre Shedleur of the Expert
Panel for Patient-Based Funding, at the time the Federation tabled its white paper,
on February 11, 2013. Mr Roger Paquette, also a member of group, took part in
the meeting by telephone.
In most countries having introduced activity-based funding,
hospital revenues are not only established on the basis of the
number of patients treated. Hospitals also receive revenues
in other forms, for example, for teaching and research, for
localization (remote regions), or to compensate certain fixed
costs for the delivery of services. It has moreover been shown
that a mixed system of funding created better incentives to
performance than a system based only on payment per activity.
The make-up of these forms of revenue vary according to the
country involved and over time.
In the United Kingdom, the transition from global budgets to
activity-based funding resulted in costs associated with supervision of changes in hospital activity, data collection on costs
at the patient level, supervision of the data quality as well as
the service contracts for the development and management
of hospitals.
DEFINITE QUESTIONS!
In 2007, within the framework of the mandate of the Task
Force on the Funding of the Health System, presided by
Claude Castonguay, a report was deposited by Pierre
Ouellette, tenured professor in the department of Economic
Sciences at the UQAM, aimed at evaluating the status of the
various methods of financing that were possible. He notes in
passing the results of an analysis on the efficiency of hospitals
performed on the basis of data covering the period from
1981 to 1993. The results are clear: there is inefficiency in the
network and the cost of this inefficiency amounts to more than
10% of the budget for hospitals and CLSCs.1
1
Ouellette P. Efficience et budgétisation des hôpitaux et autres institutions de
santé au Québec. Report delivered to the Task Force on the Funding of the
Health System, November 2007.
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In his report, Pierre Ouellette asks certain fundamental
questions: “How is the cost of an episode of care established?
And more specifically, how is the efficient cost established if
nothing leads us to believe that the episode observed among
existing institutions is efficient? How can we defend ourselves
from the account manipulations of patients by hospitals who
would benefit from accounting for patients in ‘better-paying’
categories in the form of a larger budget? This would involve
the cost of supervision to ensure homogeneity in the accounting
of hospital patients. According to him, the greatest difficulty we
would encounter in changing from a historical funding mode
to activity-based funding would come from the organizational
changes that this type of funding would require, and this would
involve in-depth modifications of the entire system. By granting
more autonomy to health institutions and encouraging them to
better manage their resources, it is possible that this autonomy
would work against certain acquired rights and privileges. A
better management of resources could result in lay-offs. While
it is important to respect the rights of workers, it must be understood that the healthcare system’s aim is not to create jobs, but
to render healthcare services to the population.”
Professor Ouellette mentions that “establishing reference costs
is not an easy job and evaluating the needs of the population
is even harder. In addition, the idiosyncrasies of the institutions
must be taken into account: size, diversity of services offered,
presence of teaching and/or research activities, differences
in salary rates, services rendered to patients from outside the
territory, etc. […]. The econometric methods that some of these
adjustments require are not as robust as desired (sic). The
information needed to correctly undertake this work goes way
beyond the possibilities of today’s information systems. In fact,
and this is one of its greatest failings, to make this method
operational, we have to consider hospital activities as if they are
performed in isolation. By proceeding this way, we do not take
into account interactions between the different activity centres
(within one and the same institution). We would also need to
have an idea of the nature of the equipment per activity centre,
of their condition, age, etc. This information is not part of current
hospital databases. Performing an inventory by activity centre
would be a costly obligation.”
A POSSIBLE MEASURE?
Implementing an activity-based funding system is a complex
operation that would require a significant transition period
stretching over several years. In the case of France, it took eight
years, even though it wasn’t starting at zero since the Program
for the Medicalization of Information Systems (PMSI), the pillar
on which T2A rests, had already been implemented in 1991. In
Quebec, no such system exists. Are we ready?
ADEQUATE INFORMATION SUPPORT
Any activity-based funding system requires the deployment
of a sophisticated, ultra-complex and “universal” information
system that allows for the input of codes corresponding to
preidentified groups, the matching of codes to patients and
attending physicians (acts performed), the compilation of non
identifiable information for budgetary and public health reasons,
the transmission of information to the paying agent as well as
the internal and external verification by case sampling. Contrary
to the Quebec Health Record (QHR) and for evident reasons,
the information solution must be obligatory for institutions. The
information support must be reliable, with a high level of security,
interoperable, designed and developed specifically to perform all
the functions of recording, extracting and archiving data under
all its formats and all its variants.
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In Quebec, in the area of information technologies (IT), failures
are common and the costs are more than prohibitive (QHR,
GIRES, SAGIR, RITM, Agri-Québec, etc.). According to recent
data published by the Conseil du trésor, the overall bill reaches
$2.6B and it excludes projects from the departments of
Education and Health, QHR included.
Within the context of public finances that we are familiar with,
the development of a new dedicated system would represent a
wager as risky as it is dangerous in matters of costs.
Before thinking of launching a project of such magnitude, the
government should first of all ensure that QHR is fully operational.
THE STRUCTURE
Activity-based funding requires that the institution bill its services
to a paying agent who needs to perform the appropriate verifications before reimbursing the institution. The formula implies
the implementation of efficient control and verification measures
that, in case of defaults, should generate financial penalties for
the delinquent institutions.
Those who are promoting the adoption of this model of
endowment could be tempted to see only the possibility of
additional revenues for the institutions while the financing is
conditional upon effective control. In this respect, the provisions
and current obligations of institutions regarding the rendering of
accounts seem very minimalist when compared to those that
would need to be implemented.
In Quebec, adopting this model would require the creation of a
new administrative structure dedicated exclusively to the control
and verification of data issuing from the institutions. Does the
network have the administrative staff or the needed expertise to
perform the tasks of coding, verifying and controlling? We can
assume that adopting this model would result in a significant
increase of administrative manpower.
ACTIVITY-BASED
FUNDING:
A PANACEA?
THE MIRACLE CURE?
Activity-based funding is certainly not a miracle cure when one
considers all the countries that adopted it must curb the increase
in their expenses by using macroeconomic measures. In almost all
cases, we see the presence of hybrid formulas, associating activity-based financing and complementary endowment measures within
the framework of a global envelope that is closed and regulated.
In all cases, the institutions do not benefit from unlimited financing
linked to performance since the final aim of the model is to measure,
standardize and control production costs, in other words expenses.
AIM FOR EFFICIENCY OTHERWISE
Before thinking of implementing the activity-based funding model,
perhaps we should think of reviewing the network’s organization and
the mechanisms that regulate the management of institutions with,
at the head of the line, the accountability of managers: a notion that,
even if it is inscribed in the law, still remains theoretical in the network.
In line with this, let us add that the existence of preauthorized deficits
does not promote a better management of institutions. This systematic
recourse should be banished.
PROCEEDING BY STAGES
Adopting a model of activity-based funding in
Quebec would first require various modifications
or implementations of structures, such as:
1- CHANGING THE LAW
Major legislative changes would need to be
made, in particular to the Act respecting health
services and social services (LSSSS), to take
into account, among others, the new parameters
of management, endowment and accountability
of institutions and the various instances that
would be affected by these changes. Such a
process could be laborious, as we were able
to see with the QHR. Three legislative versions
were needed before Bill 59 was adopted in the
spring of 2013.
2- CHOOSING THE AREAS OF ACTIVITY
Several experts have looked at the financing of the network and
have recommended a major cleanup of the structures. In 2009, the
Advisory Committee on the Economy and Public Finances estimated
at $600 million per year the recurrent cost of duplications between
the department and agencies. As for the Auditor General of Quebec,
for many years, several reports have been produced regarding the
optimization of resources within the network: common procurement,
food services, accommodations, etc. According to the AG, potential
gains or savings which could result from better management practices
of these activities amount to more than two billion recurrent dollars
per year (combined estimate).
Before associating a fee to an episode of care,
it would be necessary to choose the areas
of activity that would be subjected to this
financing formula.
If the government wishes to go ahead with the implementation of an
activity-based funding model, the FMSQ considers that it should be
done within the framework of a pilot project, regrouping a sampling
of representative institutions in terms of size, mission or location.
A team of experts should be trained and made up in particular of
medical specialists from the appropriate disciplines in order to begin
constituting a list of homogeneous case groups specific to Quebec.
The work should then move into the area of sequencing costs specific
to each group based on data supplied by the institutions in close
cooperation with experts in econometrics.
4- ANALYSING COSTS
3- CHOOSING THE GROUPS
Once the areas of activity chosen, it would
be necessar y to choose the groups, the
fundamental bases on which the model of
coding and the rates would rest.
The next step would require the assembling of a
sufficiently representative sampling of institutions
that would cover all the types of care episodes
in order to establish fee schedules that could
be associated to groups of patients. Such an
exercise could only be undertaken with the
close collaboration of professionals, staff and
institution management.
BEFORE WE START, LET’S START BY…
Before considering undertaking an information project as important as that of activity-based funding,
the government must without fail finish the QHR and render it completely operational. Just like the T2A,
which rests upon the Program for the Medicalization of Information Systems, an activity-based funding
system must be capable of basing itself on a 100%-functioning QHR. This is a sine qua non condition.
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GREAT NAMES IN QUÉBEC MEDICINE
BY PATRICIA KÉROACK
A True Gentleman
While Albert Schweitzer was pursuing his work in Africa, a young man, the son of two
psychologists, dreamt of freedom, immortality and following in the footsteps of his idol. This
youngster had already, at the age of 4, drawn the path he wanted to follow, both personally and
professionally. He wanted to work in Africa, to be a soldier, a musician and, finally, a physician.
However, his parents quickly derailed his military dreams. No matter, he had other choices.
And so, at the age of 5, a young Brian (Bexton) began taking
piano lessons and successfully passed all of the exams of the
Royal Conservatory of Music. He would continue his musical
training up until he started at the university. During his youth, he
often accompanied his parents to the university where both were
researchers and teachers. The neurosciences fascinated and
attracted him. In particular, he liked the cubicle section where
the various experimental subjects were placed. His father was,
in fact, the first to do research on the effects of sensory deprivation. His work, criticized by some, greatly advanced knowledge
involving patients admitted to intensive care or to the burn unit,
as they were generally intubated or unconscious. The research
done by his father showed that the absence of sensory stimulation could result in problems, such as psychoses. Since then,
various forms of stimulation are offered in these units.
The constant presence of science was a determining factor in the
Bexton family. His two brothers also chose scientific disciplines
at university, with one of them today being a physician and the
other an architect. When his family decided to move to the United
States, he refused. He was 17, knew he was a go-getter and, no
matter what happened, it would be for the best! He registered
at McGill in biochemistry.
During the summer of 1967, he participated actively in research
on sugar cane in Saint Kitts. His employer wanted to improve
his rum! What a slew of practical tests to be done... and redone!
During his stay, war broke out between Saint Kitts and Anguilla.
So, he returned to Montreal to finish his bachelor’s degree. He
then became a CUSO volunteer for Nigeria with a two-year
mandate. However, he arrived in the middle of the Biafran
war, a situation that he is unable to forget (curfews, the noises
and troubles of war, decapitated heads placed on trucks and
tanks as trophies, etc.). However, in Nigeria he discovered the
opposite of war: real friendship. During his stay, his best friend
Olu, who is a tribal chief in Ife, made him a child of the country,
which means that he was officially adopted by the Yoruba (this
involved all the ceremonies, rituals and festivities that followed!).
He was baptized Omowalé, which means “child comes home”.
Brian Bexton became an adopted African. From then on, he
lived completely like Nigerians, sharing their way of life and their
customs, speaking their language and living from day to day. He
took advantage of his stay to tour Africa, mostly on a motorcycle.
“Two years of pure happiness and freedom,” he said to us.
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DR BRIAN BEXTON
Psychiatrist
Back in Quebec, he decided to pass the entrance examinations
to register in medicine. He succeeded his exam with excellent
results. He registered at McGill in neurosciences. But Montreal
at that time was in the grip of the October Crisis (1970). His
subversive tendencies, his stance as a free thinker and libertarian
took over. He organized seminars and discussion groups to
actively participate in the great movements of the period, the
one that would be known as the Quiet Revolution.
DURING HIS YOUTH, HE OFTEN ACCOMPANIED HIS
PARENTS TO THE UNIVERSITY WHERE BOTH WERE
RESEARCHERS AND TEACHERS. THE NEUROSCIENCES
FASCINATED AND ATTRACTED HIM. IN PARTICULAR,
HE LIKED THE CUBICLE SECTION WHERE THE
VARIOUS EXPERIMENTAL SUBJECTS WERE PLACED.
As neurosciences were not as palpitating as he would have
wished, he had an idea to carry on his medical studies at the
Université de Montréal. Any American university would have
accepted him based on his academic results. However, what
was happening in Quebec was too important for him not to be
a participant, to watch the parade did not fit him. Despite his
social implication, he had a major handicap: he didn’t speak a
word of French. The Université refused him due to an insufficient
knowledge of the language. Obstinately, he refused their refusal!
He wrote to all the directors and persons in charge of admissions
and signed up for intensive classes in conversation. Faced with
his insistence, the Université convened him again, just one month
after their initial refusal. During the interview, disaster struck:
he could no longer distinguish nor correctly use the verbs avoir
(to have) and être (to be). The examiner told him he could not
recommend him for the quality of his French, but that he would
do it for his courage and determination.
GREAT NAMES IN QUÉBEC MEDICINE
Having completed his medical studies, he turned to psychiatry.
During his specialization, he took up one of his father’s experiences, but in his own way: instead of dealing with privation, he
interested himself in sensory (over)stimulation. The process was,
according to him, both scientific and philosophical: he wanted to
understand the meaning of the universe and our dealings with
our environment. An experiment that he said came directly from
the 1970s. Today, those years or work and experimentation made
him realize how much this allowed him to understand certain
phenomena, to explain concepts that, up to now, were not understood by a number of clinicians.
WITHIN THE FRAMEWORK OF HIS HOSPITAL
DUTIES, DR BEXTON WAS CALLED UPON TO
INTERVENE WHEN PEOPLE WITH DEPRESSION
OR BIPOLAR DISORDER WERE IN CRISIS.
HE DISCOVERED THE RICHNESS AND THE
POSSIBILITIES THAT WERE AVAILABLE TO THEM.
A CAREER ABOUT-FACE
As a young psychiatrist, Dr Bexton was especially interested in
psychosis and in schizophrenia and he organized poetry, art
and theatre groups for people suffering from these disorders.
But he realized that, while the universe these people live in is
phenomenal and research subjects are innumerable, they have
no chance of resuming a normal life. Within the framework of his
hospital duties, Dr Bexton was called upon to intervene when
people with depression or bipolar disorder were in crisis. He
discovered the richness and the possibilities that were available
to them. And he fell in love. For someone who wanted to see and
take part in scientific advances, he discovered a universe that
was perfectly suited to his professional aspirations. Dr Bexton
would not remain there: by 1992, he joined Revivre, a young
non-profit organization that came to the aid of people suffering
from anxiety, depressive and bipolar disorders as well as their
families and friends. He acted in a volunteer capacity as scientific consultant and took part in tours of conferences, courses,
workshops and more, all to explain these personality disorders.
His general public conferences were often accompanied by a
show featuring the humorist Pierre Légaré, no less!
Dr Bexton did not hesitate to present his patients to filled houses
or even to the media, but he was stopped by people’s misunderstanding of the illness: depression is not an illness, it’s a
weakness and psychiatrists are not real physicians, they are
half-physicians! Faced with so much misunderstanding, he
decided to beat down the taboos, one at a time, by answering
all questions, by demolishing all arguments.
In so doing, he realized that his sphere of activity was full of
internal taboos. Dr Bexton scaled the barricades… from the
inside! He wanted to provoke discussions that would result in
changing the vision of psychiatry held by psychiatrists, those who
felt they had a mission, while what was expected of them was to
participate in a patient’s care. And the association of psychiatrists did not help the situation, preferring overall global fees to
an activity-based fee. As a delegate, he became interested in
how the association worked and in the decisions taken there.
Dr Bexton presented himself at the elections and was elected
to the board.
He became one of the actors in the reorganization of the association and its President in 1998. He was especially passionate
about the issues of negotiations and professional development.
When this text was written, he had just ceded his seat after
15 years as President. This departure, which he affectionately
called his pre-pre-retirement, would give him a flexible schedule
of some forty hours a week, when he was used to 60 to 65 hours
during his time as President. He has so many projects he will
surely have to cut back elsewhere to accomplish them! But,
he will never give up his daily meditation at sunrise, sitting
comfortably, when the temperature allows it, on his terrace
overlooking the city’s downtown core. This daily session is a
veritable therapy, a spiritual voyage, allowing him to start his
day calmly. Each session represents for him a true satori, a
chautauqua, enabling him him to find answers to his questions,
to appreciate the beauty that surrounds him or the moment that
passes. “These moments with their own particular richness are
not known by many people - and yet, they could benefit so much
from knowing them...,” he told us.
A WELL-EARNED TRIBUTE
Some 175 persons got together to mark the departure of
Dr Bexton during the dinner closing the Annual Congress
of the AMPQ last June.
From left to right (back row), Philippe, Dr Bexton’s son, Dr Christiane
Bertelli, Dr Pierre-Paul Yale and his wife. Seated, we see Christine,
Philippe’s wife, Dr Bexton and his wife Marcella as well as Mr Jean-Rémy
Provost, Executive Director of Revivre, a Quebec association supporting
people suffering from anxiety, depressive and bipolar disorders –
Dr Bexton has been active there for several years and is
its Vice-President.
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CONTINUING PROFESSIONAL EDUCATION
BY SAM J. DANIEL, MD
Director
Office of Professional
Development - FMSQ
Evolution in CPD
Continuing professional development (CPD) is a priority and
a professional obligation for all physicians in Quebec. The
FMSQ’s Professional Development Office (PDO) works closely
with all affiliated medical associations to offer medical specialists a creative CPD path with up-to-date practices that meet
the needs of members. We are making use of this article to
announce a few innovations that will touch several among you.
NEWS FROM THE PDO
The PDO family has grown with the arrival of
Mrs Patricia Wade. Within the mandate of this
specialist in continuing medical education is the
responsibility of providing practical tools that will
help our members develop their own self-training
and practice evaluation projects. One of our projects
this year is to renew the CPD section of the FMSQ
Patricia Wade
portal. To this end, we are soliciting your help to
supply us with suggestions of tools, themes or presentations
that could enrich the CPD section and be useful for your own
development. Send your suggestions to [email protected].
In addition, we are currently fully involved in preparing the next
Interdisciplinary Education Day (IED). I am extremely happy to
announce that this event received the 2013 Innovation Award for
providers of CPD certified by the Royal College of Physician and
Surgeons of Canada (RCPSC). This prize recognizes the innovative work of certified suppliers of CPD to develop and implement
educational processes, resources and tools. The FMSQ will
be accepting this prize during the 5th National Conference on
Certifying CPD which is to be held on October 7, 2013. The
FMSQ has been invited to present its innovations before all the
other national organizations supplying CPD.
On November 15, 2013, I will be happy to welcome you personally to the largest annual conference of medical specialists in
Quebec. Register online at www.fmsq.org/jfi. The members
of the board of directors of your Federation will be present.
In addition, we will be honouring CPD personalities via the
awarding of prizes during the luncheon.
CHANGES IN THE CQDPCM CODE OF ETHICS
The Quebec Council on Physicians’ Continuing Professional
Development (CQDPCM), whose mandate is to promote
exchanges, consultations and the development of consensus
in order to harmonize CPD for physicians in Quebec, is finalizing the review of its code of ethics. This code, the previous
version of which dates back to 2003, must be complied with
by all stakeholders in continuing medical education and professional development.
34
vol. 15
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By 2015, the FMSQ, one of the 11 organizations members
of the CQDPCM, will be organizing information sessions and
educational modules to help its members familiarize themselves
with these changes and promote a fluid transition.
MOC: IMPORTANT CHANGES
The Royal College of Physicians and Surgeons of Canada
has just made two important changes in its Maintenance of
Certification Program (MOC).
• Cancelling the policy that limits the number of credits
that can be obtained in a given section. From now on,
it is no longer necessary to limit the number of credits
to 300, or 75% of the credits in a given section of the
program, during one five-year cycle. The cancellation of
the maximum number of credits allocated to each section
of the MOC program aims to correct the situation wherein
approved training activities beyond the maximum number
of credits “no longer counted” even if they respected the
program’s standards.
• Participants in the MOC program, whose new cycles start
on or after January 1, 2014, will need to obtain at least
25 credits in each section of the MOC program. This means
a minimum of 25 credits in section 1, 25 in section 2, and
25 in section 3. Since the activities in section 3 entitle
participants to three credits per hour, a total of eight hours
will need to be taken over a period of five years to satisfy
this new requirement of section 3. These requirements
apply to five-year cycles in the MOC program and do not
constitute an annual requirement.
The Professional Development Office will be working in cooperation with affiliated medical associations in order to develop
activities and tools for sections 2 and 3. In fact, the Office has
been successful in its request and is authorized to certify association CPD activities in section 3. Requests for certification can
be sent to us directly by your association. These section 3 activities are becoming increasingly important, as their evaluation
is an important educational strategy to modify behaviour and
improve effects in patients. In addition, evaluating competence
and performance in areas of practice is an expectation of the
public that is growing in demand.
CPD is clearly subject to evolution, or even revolution, and the
PDO is here for you. We invite you to send us your suggestions
so that we can better serve you and thus meet your needs.
S
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OUR SUBSIDIARIES
PROFESSIONALS’ FINANCIAL
Disciplined savings
THE solution to reaching
your financial goals for retirement
BY BENOÎT CHAURETTE,
B. SC., PL. FIN.
Analyst, Financial Planning
As investors, we are constantly looking for investments that
would make our savings grow rapidly. Several hope to find the
miracle investment that would immediately provide financial
security. Unfortunately, very few investors will be able to
depend upon exceptional returns to finance their retirement
plans, for the secret of sound financial health rests primarily
upon strictly disciplined savings.
Although savings is subject to variations as years go by, lifestyle
as far as it goes should remain generally the same during the
active period. One very frequent error is to greatly increase
household expenses when revenues go up. By acting this
way, retirement savings remains weak and insufficient to attain
financial independence. Here are two suggestions to improve
the discipline of savings:
Well-planned savings for retirement have to take into account
savings that fluctuate according to life events. It’s normal for it
to be harder to set aside significant amounts at the beginning
of one’s career. Whether the underlying cause is the payment
of a mortgage, expenses for one’s children or investments in
one’s professional practice, many reasons exist that can apply
the brake to personal savings. On the other hand, towards
the end of a career, retirement savings should be easier.
Several households increase their retirement savings once
the mortgage has been repaid or when children have attained
their own financial autonomy.
1- Take advantage of increases in revenue that exceed
inflation to increase your savings.
Here is a projection of the rate of savings required, as a
percentage of gross revenues, to reach retirement goals. This
projection is based on a typical family, made up of a couple in
their thirties, with a mortgage and two children. The two adults
are professionals without access to a pension fund.
2- Once one of your loans is completely repaid, invest an
amount equal to its previous payments.
30%
Maybe
your career is well underway at present and you wish
25%
to know if your current savings are sufficient, taking your age
20%
into account.
The best way to ensure your financial situation
is on target to reach your financial goals for retirement is to
15%
consult a financial planner, who will provide you with a detailed
projection
10% of your retirement income. To provide you with an
approximate idea, the following graph illustrates an estimate
5%
of gross
savings needed according to age, as a percentage
of your0%revenues.
30 35 40 Percentage of annual revenues
Percentage of annual revenues
25%
20%
15%
10%
5%
0%
50 55 60 years
Times 5.5
800%
30%
45 700%
600%
60 65 Approximately 7 times
revenues for a
peaceful retirement
50 years
Times 2.5
500%
400%
40 years
Times 1
300%
200%
100%
0%
30
40
50
60
70
80
90
Age (in years)
30 35 40 45 50 55 60 65 Age (in years)
800%
700%
As you can see, the projection predicts a constant increase in
600% savings. Once the mortgage is paid and the children
retirement
financially
500% autonomous, household savings should reach close
to 25%
of gross revenue. Although savings at the beginning
400%
of one’s career are less important, it is still important to start
300% early in order to benefit from capital growth over the
investing
long200%
term.
100%
0%
30
40
50
60
70
80
90
As illustrated in this graph, in order to have a comfortable
retirement, a professional without access to a pension fund
should have accumulated savings representing approximately
7 times his revenues from work at the time of retirement.
For example, a 30-year old professional with a revenue of
$100,000 today, but estimating a revenue of $250,000 at date
of retirement (taking inflation into account), should have saved
approximately $1,750,000 by the time he or she retires.
Beyond disciplined savings, several components can be
maximized to improve your financial situation. From the choice
of investments to fiscal optimization, we can help you make
your assets grow. Get in touch with your advisor to talk it over.
35
vol. 15
no. 3
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OUR SUBSIDIARIES
SOGEMEC ASSURANCES
True or False?
BY CATHERINE FELBER
Financial Planner
Day-to-day Myths and Realities
The field of insurance is full of myths that have persisted over time. Here is a true-or false game
to evaluate your knowledge of certain subjects and notions specific to the field of insurance that
are an integral part of daily life. Can you give the correct answer to each of these statements
without hesitating?
MY BROTHER-IN-LAW JUST BOUGHT A CONDO AND SIGNED
UP FOR A MORTGAGE WITH HIS FINANCIAL INSTITUTION. HE
IS UNDER THE OBLIGATION OF INSURING HIS MORTGAGE.
There is no law that obliges you to insure your mortgage. If a
client dies suddenly, mortgage insurance protects the family
from a precarious situation. On the other hand, the mortgage is
not the only debt to take into consideration. It is also important
to make sure that the family income is maintained so that
the family can have the minimum revenue required to meet
other needs. This is why buying an individual insurance is
often recommended.
NO COMPANY IS TOTALLY SAFE FROM BANKRUPTCY. IT
IS SAID THAT MOST INSURANCE POLICIES ISSUED BY
CANADIAN INSURANCE COMPANIES ARE PROTECTED.
In fact, there is a not for profit organization that protects insured
Canadians in case their life-insurance company declares
bankruptcy: Assuris. Financed by the industry, it administers
the industry’s guarantee fund for the benefit of consumers.
MY FATHER HAS AN OLD LIFE-INSURANCE POLICY THAT
HAS ACCUMULATED A SIGNIFICANT BUY BACK VALUE
OVER THE YEARS. HE HAS ASKED ME IF HE CAN WITHDRAW
SOME MONEY FROM IT WITHOUT CANCELLING IT.
In certain circumstances, yes. If life insurance is an investment
appreciated by individuals, it’s in part because it can be adapted
to several situations thanks to its flexibility. It is possible, for
example, to draw from one’s contract without closing it out
which is what we call partial withdrawals. Such a situation is
very useful in case of a sudden need for cash. Nevertheless,
such a transaction can have fiscal repercussions.
ANTOINETTE SLIPPED IN HER BATH AND BROKE HER
LEG IN TWO PLACES. SHE IS WONDERING HOW SHE WILL
MANAGE WITH HER BILLS SINCE SHE’LL BE UNABLE
TO WORK BECAUSE OF THE ACCIDENT. DISABILITY
INSURANCE OR INCOME REPLACEMENT INSURANCE WILL
COVER LOST SALARY DURING HER CONVALESCENCE.
How to meet one’s financial obligations when one cannot work
due to an accident or illness? Disability insurance is essential:
it provides a source of revenue to replace a salary if there is a
disability resulting from an accident or an illness.
36
vol. 15
no. 3
LS
RECENTLY DIVORCED, CHANTAL LEAVES ON VACATION.
SHE HAS HOWEVER FORGOTTEN THAT HER EXHUSBAND IS STILL THE DESIGNATED BENEFICIARY
OF HER LIFE INSURANCE POLICY. HER DIVORCE
JUDGMENT IS ENOUGH TO CANCEL THIS PROVISION.
In Quebec, the Civil Code specifically stipulates that divorce
(but not separation) automatically cancels the interests of the
designated spouse.
SAD NEWS: A NEIGHBOUR COMMITTED SUICIDE. HE
HAD SIGNED UP FOR A LIFE INSURANCE POLICY THREE
YEARS AGO. THE FACE AMOUNT WILL BE PAID OUT BY
THE INSURANCE COMPANY AS A RESULT OF THE DEATH.
An insurer has the possibility of refusing to pay if the suicide
occurs within two years of the signing of the insurance policy.
After this delay, its obligation is to pay. Most Canadian insurers
will not exclude suicide as a covered risk unless the suicide
occurs before the insurance has been in force for an uninterrupted period of two years.
YOU HAVE AN INSURANCE CONTRACT IN CASE OF
SEVERE ILLNESS. IN 2003, AFTER A CARDIOVASCULAR
ACCIDENT, THE INSURANCE COMPANY PAID OUT
AN INDEMNITY, BUT ONLY AFTER A PERIOD OF 31
DAYS FOLLOWING THE DIAGNOSIS. THE INSURANCE
COMPANY HAS THE RIGHT TO IMPOSE THIS DELAY.
A severe illness insurance allows you, while you are still alive, to
claim the insured amount when you receive a diagnosis of an
illness covered by the contract. You receive the total amount
of the indemnity because you have a severe illness covered
by the contract, but you must live for at least 30 days after
the diagnosis.
If you indicated that all these statements are true, except for
the first one, congratulations! If certain statements made
you anxious or generated questions, know that Sogemec
Assurances is always there, and has been for 35 years, to
provide you with all the answers! Sogemec offers you, not
only a plan designed for medical specialists in Quebec, but
also access to a certified financial security advisor assigned
to you who will undertake to fully analyze your needs and
ensure you understand the different products that can apply
in your circumstances.
OUR
NOS
SUBSIDIARIES
FILIALES
SOGEMEC ASSURANCES
At Your Service for the
Last 35 Years!
BY MAURICE GIROUX
General Manager
Ever since Sogemec Assurances was created in 1978, we have
been involved as much in the field of personal insurance (life, disability and others) as in that of property insurance (automobile, home
and business) in order to meet the continuously increasing demand
from medical specialists for these types of coverage.
We are an independent financial services company that advises
professionals on all aspects of insurance. We have developed
an expertise in group insurance, in particular in the case of
associations, and we know and understand the needs of
medical specialists.
We are also proud of the fact we can count on our team of twenty
experienced employees to service the needs of our clients. These
are all excellent reasons to get in touch with us to obtain a quote.
We have the product you need!
• Life Insurance – offering temporary or permanent
protection, for your estate or to cover your mortgage.
• Disability Insurance – offering a high quality contract that
includes protections that are unique on the market.
• Drug, Medical or Dental Care Insurance – offering a choice of
3 options to meet the needs of everyone.
• Car Insurance – offering riders for replacement values and
multiple vehicle rebates
• Home Insurance – offering protection exclusive to physicians
EXCLUSIVE OFFER TO NEW MEMBERS
In order to allow you to replace your resident insurance rapidly and
thus ensure you have minimal protection, your Federation offers you
the chance to subscribe, without filling out a medical questionnaire,
to the following coverage options:
• Disability Insurance: $3,000 per month coverage1
• Life Insurance: $100,000 coverage1
• Drug, Medical or Dental Care Insurance – offering a choice among
3 options to meet the needs of everyone.
In addition, upon completing a medical questionnaire, it will be
possible for you to subscribe to higher amounts of insurance and
this at any time.
For more information on the protection we offer or to obtain an
insurance proposal, please feel free to get in touch with one of our
advisors today at 1 800 361-5303 or online at sogemec.qc.ca.
1
For subscribers less than 35 years old only, the member must sign up within
90 days after the end of his or her residency. Please get in touch with us to
know what is available if you are older than 35.
4575_SOGA_annonce_FMSQ_2012_montgolfiere_7x4.5(8)_Layout 1 4/2/12 2:25 PM Page 1
POUR TOUS VOS
BESOINS D’ASSURANCES
Grâce au
SERVICE PRÉFÉRENCE
LAISSEZ LIBRE COURS À VOS PASSIONS
PUBLICITÉ DEMI PAGE
SOGEMEC
ASSURANCES
ÉVOLUE AVEC VOUS
• Vie
• Médicaments
• Invalidité
• Maladie
• Frais généraux
• Dentaire
• Maladies graves
• Automobile
• Soins de
longue durée
• Habitation
Sogemec Assurances
• Entreprise
POUR EN SAVOIR PLUS :
1 800 361-5303
REPEAT OUI OU NON
514 350-5070 / 418 990-3946
Par courriel ou Internet :
[email protected]
www.sogemec.qc.ca
SOGEMEC ASSURANCES
filiale de la
37
vol. 15
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L’ÉDITORIAL DU PRÉSIDENT
DR GAÉTAN BARRETTE
Ô Canada, au Canada
Tiens ! Pourquoi pas une conversation sur ce grand pays ? En cette période d’émoi identitaire,
n’est-ce pas un bon moment ? D’autant plus que la FMSQ était invitée par l’Association médicale
du Québec (AMQ) à assister à la réunion annuelle de l’Association médicale canadienne (AMC)
tenue à Calgary en août dernier.
U
n petit mot d’abord sur les gens. Gentils, très hospitaliers,
très fiers de leur labeur, pas du tout prétentieux malgré
leur richesse. Entendu là-bas : « Nous avons travaillé fort
pour nous rendre là. » « Nous » comme dans « La population de
l’Alberta ». Ils ont raison. D’autant plus que nous en bénéficions !
Voilà pour les hôtes. Mais l’AMC, c’est tout le Canada ; le Québec
et le ROC. Jamais cette différence ne nous est apparue aussi
grande. Prenons deux sujets âprement débattus : le chômage
médical et les soins de fin de vie.
D’abord, le chômage médical. En anglais, on traite de medical
underemployment. Le sujet faisait l’objet d’une session de débat
stratégique. À l’AMC, un tel débat mène à un vote sur une ou des
résolutions qui forment la base des positions ensuite défendues
par l’AMC. Pour lancer le débat, l’AMC avait invité un conférencier, présenté comme un expert en la matière. Imaginez la
scène. Milieu quarantaine, il annonce s’être intéressé à ce sujet
depuis sa résidence et, pour cette conférence, s’être adjoint une
multitude d’experts pour analyser et rendre compte de la situation
pancanadienne quant à cette question. Quelle ne fut pas notre
surprise, dès le début de sa présentation, de l’entendre affirmer
avec insistance que nulle part au Canada, vous avez bien lu, nulle
part n’y avait-il eu d’évaluation ou de planification des effectifs
médicaux en fonction des besoins de la population et, pire, que
nulle part au Canada n’y avait-il de mécanisme quelconque
visant à assurer la distribution des médecins sur le territoire ! ! !
Les réunions de l’AMC étant très protocolaires, il a fallu l’aide
de l’AMQ pour que la FMSQ puisse s’adresser à l’assemblée
et informer ledit « expert national canadien » que le Québec
existait et que, dans son Canada, il y avait une province visible
sur l’écran radar où non seulement tout cela se faisait depuis
plus de 10 ans, mais qu’une telle planification était déjà produite
pour les 25 prochaines années ! ! !
38
vol. 15
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Malgré tout, ceci soulève un vrai problème politique. Il survient
quand les constats sont volontairement biaisés. Dans le ROC,
comme au Québec, les médecins résidents sont inquiets. Dans le
ROC, il n’y pas de PREM, de PEM, etc. Conséquemment, c’est le
libre marché dans lequel tous les finissants tentent de se trouver
un poste au centre-ville de Toronto, de Calgary ou de Vancouver.
On dit même que c’est le parfait bonheur pour les patrons en
exercice voulant prendre six mois de vacances : on se bat pour
faire le remplacement et la compétence est là ! Mais ça, ce n’est
ni du sous-emploi ni du chômage médical. C’est du refus, de
l’évitement. Car il faudra bien un jour couvrir tout le territoire…
Malheureusement, faire le mauvais constat peut mener à un jeu
très dangereux. En effet, un tel discours mène directement à
proposer une baisse des entrées en médecine. Or, c’est exactement le même discours qui se tenait au début des années 1990.
On connaît la suite. Nous-mêmes l’avons précédemment abordé.
Mais une planification rationnelle existe au Québec, à laquelle
nous collaborons tous. Oui, il y a quelques spécialités où pointe
le plein-emploi. Mais pas le chômage médical. Dommage que les
« experts nationaux canadiens » ne soient pas bilingues.
Ensuite, il y a eu cet autre « débat stratégique » sur les soins de
fin de vie. Alors là, ce fut du grand art côté patinage. D’abord,
le discours d’ouverture, lequel est toujours donné par le ministre
fédéral de la Santé. Cette année, ce fut par Mme Rona Ambrose,
elle-même originaire de l’Alberta. Elle savait que ce sujet allait être
abordé plus tard et avant d’être questionnée, elle a immédiatement
pris position : non au suicide assisté ! Exit la discussion sur les
soins de fin de vie, focus sur le suicide assisté ! Puis, plus tard, le
débat lui-même. Là, tout pour éviter le sujet, même le prononcer.
Donc, blitz sur les soins palliatifs. Tant qu’à faire, on est allé jusqu’à
proposer une spécialité de soins palliatifs en médecine familiale.
Un bon docteur du ROC est même venu comparer le projet de
loi no 52 du Québec (voir en page 9) en décrétant l’aide médicale
à mourir tout aussi immorale que les sites d’injection supervisée.
Vous avez bien lu.
Plus tard, dans une session plus légère était invitée Mme Chantal
Hébert, une personnalité des médias, pour échanger. Très
poliment, elle leur a expliqué que s’ils (les médecins) pensaient
pouvoir éviter le débat, c’était peine perdue tout en leur rappelant
qu’ils étaient là pour servir la population et qu’en matière de soins
de fin de vie, incluant l’euthanasie, c’est la population qui choisirait.
Je riais. J’aurais été gêné à leur place en lisant André Picard
qui rapportait ces débats dans le Globe and Mail : With doctors
ducking the issue […] That is unsatisfactory, and it’s no way to
show physician leadership. We trust doctors with our lives, and
with our deaths. Physicians make tough decisions every day at
the bedside. They should be willing and able to do so on the
convention floor as well.
En tout cas, à la FMSQ, nous n’avons jamais eu peur des débats
et quand nous y participons, nous disons les choses telles quelles
sont, n’en déplaise aux bien-pensants.
Syndicalement vôtre !
S
L
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