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"I go help mothers with their sick children while I leave mine at home," Saoud said. "I can't see how I can do more." Saoud has three young children. She devotes 60 per cent of her workweek to a Montreal hospital's emergency department - irregular hours that include evening and weekend shifts - while the rest of her schedule is split between a walk-in clinic and what's known as "dépannage," replacing doctors in Quebec's more remote regions at least once a month. What she wants is more time for her job as a mother - helping with their homework and sharing meals - and not have to meet "an impossible" quota of following 1,500 patients, as the original Bill 20 would have required of each family doctor.

I am already at my maximum," said Saoud. And so, she has applied for a licence to practise outside Quebec. Nearly 24 per cent of Quebecers are on a waiting list or desperately searching for a family doctor. The crisis is rooted in a 1990s provincial government plan to save money by encouraging doctors to retire early. Staffing shortages ensued, and family doctors were obliged to fill the gaps by working outside their clinics in hospitals and far-flung regions. Quebec has attempted, with little success, to improve primary care over the last two decades by expanding community health clinics (CLSCs) and creating pools of doctors known as Groupes de médecine de famille (GMF) but both limped along under budget constraints and heavy bureaucracy. Barrette contends that the province has more than enough physicians to meet its needs, but that a profound structural change is needed.

He presented Bill 20 last fall as his road map to ensure that every Quebecer has a regular doctor. But the bill's punitive measures sparked widespread discontent among doctors against what they called a one-size-fits all, state-controlled, conveyor-belt approach to medicine. Doctors were further incensed at Barrette's assertion that doctors are not productive enough - which they saw as being accused of laziness - and frustrated at being blamed for a broken health system.

Like Saoud, many doctors prepared exit plans - from retiring to leaving the province. Some med students, many of whom were actively recruited to shore up Quebec's supply of family doctors, began reconsidering family medicine - or simply leaving to do their residency out-of-province, according to the Fédération des médecins résidents du Québec. Saoud was heading home to her sick daughter on Monday when Barrette announced he had cut a deal with the provincial federation of family physicians to exempt them from Bill 20 - temporarily. There would be no quotas and no penalties, Barrette said, as long as family physicians were able to collectively ensure that 85 per cent of Quebecers had a family doctor by the end of 2017. But Saoud says the change will not keep her here. And she's not alone.

The buzz among disillusioned physicians is that "everyone has a Plan B." And while the bill's delay has eased tensions a notch, some doctors are saying the two-year delay simply means they now have until 2017 to prepare a better exit. Bill 20 remains a guillotine above the heads of doctors. "Most definitely, there are physicians investing in Ontario licences and poised to leave if Bill 20 passes. I myself may have to leave," family physician Maggie O'Dell, who works at the Wakefield Family Medical Centre near the Ontario border, said before the bill was modified. And after Barrette backtracked, she had this to say: "It's nice to have reprieve, so it's a relief - for now ... a reason for many to hold back on pulling up stakes in the short term."

Montreal family physician Fahimy Saoud hated leaving her sick 5-year-old in someone else's care this week, but it was her turn to staffa walk-in clinic and she didn't want to let those patients down. But as the day wore on, Saoud kept hearing her daughter's plea when she left the house: "Who will take care of me?" So on Monday, after seeing everyone in the waiting room, Saoud left the clinic early; her daughter needed her as much as her patients did.

The group's recent survey - 204 of its members responded - indicated that Bill 20's sanctions would backfire. While the survey was taken three days before Barrette modified Bill 20, Duong said the results reveal that doctors, in particular those whose mother tongue is English, are at risk of leaving the province. Among the 134 francophone doctors polled about their intentions if Bill 20 were applied, 32 per cent said they would resign from hospitals, 12 per cent said they would leave Quebec and another nine per cent would go into private care.

Among the 70 anglophone respondents, seven said they already sent letters of resignations to their hospitals (it's not clear whether they are keeping their office family practice) and among the remaining 63 doctors, 34 - more than half - said they planned to leave Quebec. Another seven said they would retire early, seven would move to the private system and three would stop working as family doctors. It's a small sample, Duong conceded, but the study is nonetheless alarming.

We are worried that doctors will leave," Duong said, noting that every year, more doctors are opting out of the provincial insurance board (RAMQ), meaning they are no longer on the public payroll, though it's not clear whether they went to private practice or left Quebec. RAMQ representative Marc Lortie confirmed this week that 246 family physicians dropped out of RAMQ between May 2014 and May 2015, up from 204 the previous year and 187 in 2012-2013.

In the wake of Monday's announcement to put offBill 20's sanctions, many doctors remain skeptical of Barrette's 85-per-cent target, Duong says, "because it's far too ambitious a goal." Whatever doctors' efforts, Duong says, the reform will fail if the government doesn't help them do their jobs - for example, by abolishing mandatory hospital work. Others suggest the crisis between the province's doctors and Quebec's health minister is over. Bill 20 was heavy-handed, they argue, but if it leads to doctors taking on more patients it will have been a successful negotiating tool. Dr. Yoanna Skrobik, a critical care researcher and adjunct professor at McGill University's department of medicine, is among those who wholeheartedly support the Barrette reform.

It's the most dramatic change in the history of Quebec's health system, and the best thing that's ever happened to patients," said Skrobik, who worked side by side with Barrette at Maisonneuve-Rosemont Hospital in the early 2000s, when Barrette was chief of radiology and she was an intensivecare physician. She said that if 85 per cent of Quebecers have a family doctor, the quality of health care in the province will be much improved. Doctors may be offended by Barrette's manner, and by what they see as an attack on their autonomy, Skrobik said, "but it's also true that he puts patient care in the forefront."

But Saoud also has priorities. She earned her first medical degree in Haiti, then had to obtain it again after emigrating to Montreal. There's a saying among those who work in the ER, she said: "We know when we go in, but we don't know when we will leave." Saoud, who won the Nadine St-Pierre Award for her research as a resident in family medicine in 2009, still loves being a doctor. "It can be frustrating, but it's really gratifying work. Helping someone is really the cherry on the sundae. But my priority is not that." She would rather not force the children to uproot, but she's skeptical doctors can meet the demands of the health reform. And possible sanctions in two years could force her to to make a tough choice.

"My male colleagues don't have that issue. The bill is discriminatory. I'm just asking for the right to be a mother and not simply a doctor." With her permit application process in motion, Saoud says she will go wherever her licence takes her. cfidelman@montrealgazette.com twitter.com/HealthIssues

Medical students from four major Quebec universities demonstrate against Bill 20 in March near the legislature in Quebec City. • VINCENZO D'ALTO, MONTREAL GAZETTE / Dr. Fanny Hersson-Edery, left, at a diabetes clinic she runs with nurse Jen Reoch. Hersson has a full schedule, from research to teaching and seeing patients.

He wants the OMA to return to the negotiating table and discuss lowering some of the 7,300 fees on the physicians’ pay schedule. He said the province has made no less than 80 offers since talks broke down two years ago — close to one a week — to no avail. If they don’t, he said he’s prepared to make another unilateral cut (even though the cuts imposed in 2015 have already sparked the second Charter challenge from the OMA this decade). “If necessary we will be forced to make those changes,” he said. Hoskins doesn’t want to cut back on all doctors’ pay, but create a more equal system that doesn’t go over budget every single years, as has historically been the case.

“The top biller, an ophthalmologist, billed more than $6.6 million last year. The top diagnostic radiologist billed more than $5.1 million and the top anesthesiologist billed more than $3.8 million,” a government fact-sheet states. That’s far above the average doctor’s gross payment of $368,000 a year. And though the OMA argues that often doesn’t account for overhead and staffing costs, the province also subsidizes pay in many indirect and direct ways, including allowing doctors to incorporate, which reduces tax and liability burdens. Ontario, unlike many provinces, covers 80 per cent of doctors’ liability insurance. Hoskins said the ministry even sometimes covers hardware costs like computers.

Hoskins says his goal is to make things more equal and better distribute the money going to certain specialists whose work has gotten easier. MRIs and CT scans used to take an hour, now they take 20 minutes. Same with cataract surgery — that’s why diagnostic radiologists and eye surgeons are so disproportionally represented on the list.

"You don't have enough time to sit and talk with them. It's always a rush. Everything has time constraints. You have to be in the dining room by 8:30; you have to be out by whenever; you have to have a shower today - I mean, that's their home. And you actually want to sit with them and talk with them, but you just don't have the time. You can't even get to know your residents. You know them by seeing them every day but you don't really get to know their background, or their history, you know, what they did before. You try to get to know them but you don't have the time to spend with them." If Bill 188 passes, all long-term care homes in the province will be required to stafftheir facilities adequately enough to provide a minimum four-hour standard of care for each resident each day.

Despite this being a newly introduced bill, Laronde said front-line care workers at long-term care facilities in Ontario have been fighting to have this for years. "This campaign (to legislate more time for individual long-term care residents) has been going on for many years and it's finally got a bill," said Laronde. MPP Gilles Bisson (NDP - Timmins-James Bay), explained, "It's a bill that has yet to be debated. It's been introduced. We're waiting for it to be debated." The fact the bill was introduced by a the health critic of the NDP doesn't mean the Liberals will automatically shoot it down as an act of partisan politics, said Bisson.

"There are a number of bills put forward, quite frankly, by members of the opposition that wind up becoming law," he said. "In fact, France Gélinas has been very successful in putting forward a number of private member's bills that the government adopted as their own bill." The Extendicare Timmins workers intend to hold information pickets again on Thursday and Friday. © 2016 Postmedia Network Inc. All rights reserved. Illustration: • Ron Grech, The Daily Press / Front-line care staffat Extendicare Timmins held an information picket Wednesday afternoon to express their support for Bill 188 which is currently going through the Ontario legislature. The NDPinitiated bill, referred to the Time To Care Act, would make a minimum four-hour daily care a legal standard for long-term care residents.

The penalties are assessed on a dollar-for-dollar basis, meaning they are equal to the amounts patients complained about paying for procedures. B.C. and Newfoundland were the only provinces assessed penalties for the last three years. When the 2013-14 annual report comes out soon, B.C. will once again be penalized, this time $224,000, said provincial Health Ministry spokesman Ryan Jabs.

Since 1994, the federal government has docked B.C. $3.2 million, slightly lower than the record-holder Alberta ($3.6 million). Since 1994, provinces have been assessed nearly $10 million in penalties for extra billing charges. A Health Canada spokesman could not explain why Quebec has never been penalized, even though it reportedly has a thriving private medicine sector. Ontario has also not faced any penalties.

Accordingly, a deduction of $4,610 was made to the March 2003 federal transfer payment. 2004: A $126,775 deduction was taken from B.C.'s March 2004 Canada Health Act payment, based on the amount of extra billing estimated to have been charged during the 2001-2002 fiscal year. Since 2005: $786,940 in cash transfer deductions have been taken from B.C.'s federal health transfer payments on the basis of charges reported by the province to Health Canada. January 2011: Vancouver General Hospital begins charging patients a fee when they elect to have robot-assisted surgery versus the conventional surgical alternative for certain medically necessary procedures. 2013: Deductions in the amount of $280,019 are taken from the March 2013 federal transfer payments of B.C. in respect to extra billing and user charges for insured health services at private clinics. Source: Canada Health Act Annual Report 2012-2013

In 2005, the B.C. government did not submit a dollar value to the federal government for such extra billing, so Health Canada bureaucrats based the penalty sum on news releases from anti-privatization unions and newspaper clippings about patients who accessed the private system. The Sun learned about that through a Freedom of Information request. The story detailed how discretionary the penalties appear to be and that they are based on "guesstimates" of user fees. Provincial Health Ministry officials often base their reports submitted to the federal government on complaints from patients who go to private clinics for expedited care and then try to collect the fees paid from government. One such patient is Mariel Schoof, who had sinus surgery at a private clinic in 2003. She paid $6,150 for the "facility fee" and then tried to recover the fee from the provincial government or the clinic. She is now one of the interveners in a private versus public medicine trial starting March 2 between Dr. Brian Day and the provincial government. Timeline of Canada Health transfer compliance in B.C.

Early 1990s: As a result of a dispute between the British Columbia Medical Association and the B.C. government over compensation, several doctors opt out of the provincial health insurance plan and began billing their patients directly, some at a rate greater than the amount the patients could recover from the provincial health insurance plan. May 1994: Canada Health deductions began and continue until extra-billing by physicians is banned when changes to B.C.'s Medicare Protection Act come into effect in September 1995. In total, $2,025,000 was deducted from B.C.'s cash contribution for extra billing that occurred in the province between 1992-1993 and 1995-1996. These deductions were non-refundable, as were all subsequent deductions. January 2003: B.C. provides a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts charged with respect to extra billing and user charges during fiscal 2000-2001 totalling $4,610.

The penalty to B.C. is paltry in relation to the province's $20-billion health budget announced Tuesday. It is also insignificant relative to the federal transfer payments B.C. will collect this year ($4.4 billion) and next ($4.7 billion). In 2006, the then-deputy health minister of B.C., Penny Ballem (now Vancouver city manager) questioned whether B.C. was really the only province where extra billing and private sector queue jumping was taking place. Jabs said Wednesday he can't comment on what happens elsewhere.

The branch investigates about 30 cases a year of extra billing, usually related to private surgical facilities or expedited visits to specialists. The government is not sure whether it will be penalized in the future for allowing Vancouver General Hospital to charge patients fees for robotic surgery. VGH spokesman Gavin Wilson says since 2012 patients choosing to have surgeons remove their prostates using the robot have been charged on a partialcost-recovery basis. The B.C. government allows the extra billing because robotic surgery is discretionary, not medically necessary, and there are higher costs associated with it. In 2012, however, Health Canada began examining the Canada Health Act implications of patient charges for robotassisted surgeries. The process convinced the health minister that VGH should stop charging for robot-assisted surgeries as of Jan. 1, 2015. Vancouver Coastal Health collected $345,000 a year for the procedures; most recently, the patient fee was $5,700. Sun health issues reporter pfayerman@vancouversun.com

Auditor Calls Quebec Extra Billing Out of Control Doctors Call on Health Minister Jane Philpott to Illegal Billing Practices in Quebec TORONTO (May 12, 2016) – Extra-billing in Quebec medical clinics are “excessive” says Auditor General Guylaine Leclerc, but Federal Health Minister Jane Philpott has yet to act on calls to enforce the Canada Health Act and bring them under control.

Wright, who has diabetes and underwent a triple heart bypass three years ago, was in good health when she and two daughters drove to Vancouver and then Squamish, B.C., in August for a family wedding. On the return trip, the trio stopped for the night at a motel in a small town of fewer than 4,000 people called Vermillion, about 200 kilometres east of Edmonton. There, Wright took ill. She couldn't breathe and was having a difficult time walking, so her daughters rushed her to the local hospital.

When she got back to Garson, she and her husband, Jim, hitched up their trailer and went camping for two weeks. They had a wonderful time, but when they returned, there were two envelopes in the couple's mail box. One was a bill for several hundred dollars for examinations by three different doctors in Alberta. The other was a whopping $6,380 bill from an air ambulance company called STARS (Shock Trauma Air Rescue Society). Quite fittingly, Jean Wright was shocked when she opened the envelope, because she thought the flight was covered, she said in an interview at her Garson home.

Wright and her daughters had heard about the Alberta woman who was visiting family near Timmins when she went into early labour and had to be air-lifted to Sudbury. That woman was billed about $10,000 by Ontario's air ambulance service. After Amy Savill went public with her story, the Alberta and Ontario governments agreed to split the bill for the air ambulance. When Wright received her bill, she called one of her daughters and said the younger woman "almost fainted" when she heard the amount. Wright thought: "If I have to pay this bill, they're going to wait a long time. I don't have that kind of money." She is a retired school bus driver and her husband an Inco pensioner.

Wright visited the constituency office of her MPP, Nickel Belt New democrat France Gelinas, who is also her party's critic for Health and Long-Term Care. Gelinas wrote Health Minister dr. Eric Hoskins on Oct. 8, saying provincial governments should "pay the bill as a hospital emergency service when a patient is forced to take air or ground ambulances to the nearest hospital for the necessary emergency treatment. "Hospital and physician services are supposed to be free to all Canadians," wrote Gelinas. The Ontario Legislature is recessed this week and Gelinas hasn't received a reply from Hoskins, she said Thursday. She intends to speak with Hoskins about it Tuesday when the Legislature resumes sitting.

Wright contacted the Edmonton hospital about the smaller bill for doctors' services she received and was told to discard it. She hasn't contacted STARS, but Gelinas said her constituency staff will stay on the case. Gelinas wants Ontario's health minister to establish a policy in which air ambulance transportation for Ontarians out of province is paid by government if ordered by a physician. If Ontarians travelling outside the province require air ambulance transportation, and know they have to pay for it, many will not get the treatment they need because of that cost, said Gelinas.

"This is wrong," said Gelinas of someone like Wright being billed for transportation to get emergency care. The basic tenet of medicare is that all Canadians have access to good health care "no matter the thickness of their wallets. Gelinas, Nickel Belt federal NdP candidate Claude Gravelle and Sudbury federal NdP hopeful Paul Loewenberg have scheduled a news conference for Friday at 11 a.m. in front of Health Sciences North to talk about how the NdP health plan will improve health-care delivery for people in Northern Ontario.

Jean Wright shows off an invoice for more than $6,000 for an Alberta air ambulance ride on Thursday. Wright required medical care involving an air ambulance while on vacation in Alberta.

Of the 19 tests and assessments Copeman set out in its 2012 schedule for standard patient testing, 16 are covered by Alberta Health. On an initial visit for men over aged 50, for example, the cost absorbed by the province for lab analysis alone reached $347 per patient.

Patients are also billed for the tests, allowing them to claim the costs against health spending accounts, or, in some cases, as tax deductions in their personal tax filings. A patient bill shows tests administered at the Copeman private medical clinic in Calgary. (Tracy Johnson/CBC) More than a dozen patient receipts obtained by CBC News show lump sum charges of over $1,000 for the lab and diagnostic work, all of which is cited as "physician prescribed." That language means the cost of eligible analysis work would be borne by the province.

CBC News also obtained a patient bill that shows a $1,283 charge for a "physician consultation, assessment, interpretation and report. Physician follow-up consultation(s). Continual care."

"I'm here to listen to the province's eight million people, not the 8,000" general practitioners, Barrette told reporters on Nov. 28, the day he made public one of his more controversial proposals - threatening doctors with penalties of up to 30 per cent of their income if they don't see more patients.

Most people who observe the health-care system would say something had to give, something needed to be done," said Antonia Maioni, a professor in McGill University's Institute for Health and Social Policy.

During a heated exchange in the National Assembly with Diane Lamarre, the PQ's health critic, Barrette insinuated that she might be suffering from a "form of epilepsy" after she kept repeating the same questions about Bill 10. That remark drew a rebuke from House Speaker Jacques Chagnon.

But it's not Barrette's zingers that have made him so polarizing as health minister: it's his plans to overhaul the public system and the way he's gone about it.

Barrette, by comparison, announced his reforms only four months after being appointed health minister. None of his proposals - from abolishing regional health agencies to penalizing doctors financially - were alluded to in the Liberal election platform.

The reforms were unveiled in quick succession as Bills 10 and 20, with no public consultation beforehand.

Barrette has had a hard time garnering widespread support for Bill 10, his effort at restructuring Quebec's health system. The bill has two goals: to downsize Quebec's costly, Byzantine health bureaucracy, and to streamline the governance of its institutions.

Critics have assailed Bill 10 not so much for its goal of cutting administrative costs by more than $200 million a year as its objective to eliminate the boards of directors of many health institutions - from rehab centres to hospitals. Quebec's anglophone community is particularly concerned that many bilingual institutions would vanish in "one fell swoop," as former Liberal MNA Clifford Lincoln has warned. The bill would also confer on the health minister - in this case, Barrette - the power to hand-pick members of so-called mega boards.

140 amendments in December

continue to make services available in English - a measure that critics contend is still no guarantee for the anglo community. The relatively high number of amendments - even for a complex piece of legislation like Bill 10 - would suggest that Barrette underestimated both the opposition to his reforms and the possible unintended consequences.

In November, Barrette tabled Bill 20, which the minister himself described as "first the carrot, now the stick."

Like his first piece of legislation, Bill 20 has two goals: to compel both medical specialists and family doctors to follow more patients or risk being docked their pay; and to no longer cover in vitro fertilization under medicare.

Many couples and fertility specialists are also incensed by his plan to de-list IVF from medicare, denouncing his proposals as draconian and hastily formulated. There's no doubting that Barrette's proposed reforms are part of the Liberal government's austerity agenda. But beyond that, it's not so clear what his overall vision might be for Quebec's beleaguered health system, critics argue. And that lack of vision might mean the difference between whether those reforms succeed or fail.

The annual report from Genworth, which sells policies to cover long-term care, looks at costs for a variety of services, including adult daycare, and home health aides. And nursing home bills are rising at the fastest pace, twice the rate of U.S. inflation over the last five years. One year in a nursing home now costs nearly as much as three years of tuition at a private college. For its report, Genworth surveyed 15,000 nursing homes, assisted living facilities and other providers across the country in January and February. It found wide differences from state to state. In Oklahoma, for instance, the median cost for a year in a nursing home came out to $60,225. In Connecticut, it was $158,775. Alaska had the highest costs by far, with one year at $281,415. So, who pays the nursing-home bill? "A lot of people believe Medicare will step in and cover them, but that's just not true," said Bruce Chernoff, president and CEO of The Scan Foundation, a charitable organization. Medicare will cover some short visits for recovery after a surgery, for instance, but not long-term stays.

Often enough, experts say senior citizens wind up spending their savings until they hit their last $2,000, and at that point they can turn to Medicaid, the government's health insurance for the poor, to help cover the bill. As a result, Medicaid pays for more than half of the country's long-term care bill. That cost accounts for more than a quarter of Medicaid spending, according to the Kaiser Family Foundation. Genworth and other insurers offer long-term care policies to help people shoulder the financial burden. But people have to be healthy enough to qualify for coverage. Those who take out policies find their insurance bill rises steadily as they age. Caldwell described Genworth's survey as essentially a marketing pitch. "Of course they want people to see how much it costs to sell long-term care insurance," he said. "What they're not telling you is that the long-term care coverage is becoming more and more unaffordable for middle-class families." Mounting costs have also pushed many insurance companies out of the business. Four of the five largest providers have either scaled back their business or stopped offering new policies. The largest provider, Genworth, has struggled under the weight of old policies. Less-intensive care remains much cheaper than staying at a nursing home, according to Genworth's survey. One year in in an assisted-living facility runs $43,200. A year of visits from an agency's home health aides runs $45,760.

It would also require the Ministry of Health to publish a statement of the amount each physician receives through OHIP billings, explaining the figures do not represent a physician's net income. "Had the sunshine list been applied to ORNGE and had the ombudsman been allowed oversight, we would not have witnessed the tragedies that resulted from the destruction of our air ambulance services," said Gelinas. "The people of Ontario deserve assurances they can trust their health-care services whenever and wherever they need it."

According to the registry, 527 patients were billed a total of $40,775 between Feb. 15 and Aug. 2015. Respondents noted feeling indignant about the injustice of having to pay amounts they considered exorbitant for medical care. Some said they couldn't afford to pay - they needed the money for groceries or rent. User fees for insured medical services covered by the provincial health insurance board are illegal. But there's a grey zone, and for years many physicians and clinics have quietly been applying extra, arbitrary or excessive fees for exams and medications covered in hospitals. Led by the clinic's Comité de lutte en santé, the registry also showed that rates for medical services levied on patients varied among professionals, the clinic's co-ordinator Luc Leblanc said Sunday.

"It's a two-tiered system. One for those who can pay and one for those who can't," he said. Data analysis shows the average amount demanded by family doctors was $63, and the average for specialists was $91. The biggest category is medications or anaesthetics, followed by administrative charges like photocopies or filling forms. Adopted last week, Quebec Health Minister Gaétan Barrette's Bill 20 included a set of amendments to legalize fees charged to patients in clinics for insured services, commonly called "accessory fees." The list of regulated ancillary fees will come later, after the government hires an independent accounting firm to determine real costs.

But Leblanc noted the public wasn't consulted because "initially Bill 20 made no mention of the possibility of accessory fees," Leblanc said. And there are no prior government studies or surveys to determine the scope or impact of current fees on patients, he added. The introduction of user fees is a serious threat to universal care, critics said, including the Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, and Médecins québécois pour le régime publique (MQRP), who asked Barrette to hold offon regulating fees in October.

Charging patients at doctors offices and clinics for medically necessary care isn't acceptable, said Isabelle Leblanc, president of the pro-medicare group, Médécins québécois pour le régime publique. It strikes at the heart of the principle that access to health care should be based on need rather than ability to pay, she added. The clinic's health committee is calling on Barrette to suspend extra fees and on the new federal Health Minister Jane Philpott "to act immediately to force Quebec to respect the Canada Health Act," said Louis Blouin of the committee. The committee is continuing to document billing in its online registry. It can be found on the Pointe-Saint-Charles clinic website cfidelman@montrealgazette.com twitter.com/HealthIssues

When the Canada Health Act passed in the House of Commons in 1984 with unanimous support from all political parties, its primary purpose was to put an end to extra billing like this. Charging patients at the point of care for medically necessary services strikes at the heart of the principle that access to health care should be based on need rather than ability to pay. It undermines equity, increases system costs and reduces commitment to the public health care system. It's also illegal.

Why are we not hearing resounding denunciations of Barrette's plan from our federal politicians? Research has consistently demonstrated that forcing people with less money to pay a fee to access care means they might not seek out medical attention until later in the course of their illness. This means patient outcomes are likely to be worse and treatment more complicated and costly. Given higher levels of illness among people in poverty, these fees also shift costs to those who use the system most but can least afford to pay.

Doctors in Quebec and across the country have expressed alarm at Barrette's amendment to Bill 20, which regulates extra billing rather than prohibiting it. The Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, Médecins Québécois pour le Régime Publique, and the Quebec College of Family Physicians have all come out against this decision, joining patient groups, all of Quebec's opposition parties, and Raymonde Saint-Germain, the independent Quebec Ombudsman. The measure was passed on Oct. 7, with no public debate. Bill 20 is currently before the National Assembly and is expected to become law this fall.

Barrette is effectively bringing user fees in through the back door. Rather than introducing user fees charged by government, he would let clinics do so. This further fragments care and makes access even more inequitable.

In this federal election campaign, the talk has been around reducing barriers to access by improving coverage of prescription medicines, home care and mental health care. Yet at the same time that our federal parties are committing to such muchneeded expansion, they are silent on protecting the core of medicare: publicly funded doctor and hospital services.

Any party that claims to be committed to the Canada Health Act should immediately state its position on the amendments to Bill 20 in Quebec. To do less is to skirt the core federal responsibility for medicare in Canada. Ryan Meili is a family physician in Saskatoon and an expert adviser with the Evidence Network. Danielle Martin is a family physician and vice-president Medical Affairs and Health System Solutions at Women's College Hospital in Toronto. Both are members of the board of Canadian Doctors for Medicare.

JACQUES BOISSINOT, THE CANADIAN PRESS / Health Minister Gaétan Barrette has put forward a measure that would regulate extra billing rather than prohibit it. It will become law when Bill 20 is adopted.

QUEBEC — Extra fees charged in private clinics for procedures covered by medicare are not being controlled and may be abusive, the province’s auditor general said in a report Tuesday. Extra billing has been in dispute ever since the government of Quebec adopted Bill 20 in November. The bill aimed, among other things, to regulate add-on fees by creating a standardized price list. The situation remains ambiguous, confusing and misunderstood, auditor general Guylaine Leclerc wrote in her report. Neither the health department nor Quebec’s health insurance board (RAMQ) has a firm grip on these add-on fees, which are estimated at $50 million a year, she noted. For example, the report said, Quebecers are charged between $300 and $400 for a colonoscopy, $125 to $225 for a vasectomy, $51 to $100 for a biopsy and $5 to $50 for an excision, depending on the clinic. 

Lawyer Jean-Pierre Ménard insisted last week Quebec is the worst offender when it comes to over-billing patients, and that the fees are creating a two-tier health-care system that may violate the Canada Health Act. With Ménard’s help, various patients’-rights groups have come together to launch legal action against the federal government to make sure the Canada Health Act is applied in Quebec and other provinces. Reacting to the report Tuesday, Health Minister Gaétan Barrette reiterated his recent promise to abolish add-on fees by possibly rolling them into doctors’ salaries. “For care that is medically required, there won’t be any fees,” he told reporters.

Parti Québécois MNA Diane Lamarre said Barrette’s “about-face” is the result of relentless criticisms by her and the PQ. “When we started studying Bill 20, we were fighting the fact that the minister introduced an amendment that authorized accessory fees,” Lamarre said. “It was a new opportunity to charge, legally, new medical fees. … We asked the minister many times to (scrap) his amendment and he refused. “(It) was a way to introduce accessory fees and make some patients with no money unable to have access to medical services, which is completely against the law. Now we’re proud that he changed his mind,” she said. Both Lamarre and Coalition Avenir Québec MNA François Paradis said they are concerned Barrette will not be able to convince doctors’ associations to include the fees in their remuneration. If doctors’ salaries are boosted by an additional $50 million in the next contract agreement, for example, it will mean that collectively we will all be paying the fees indirectly, Paradis said.

The AMPs require physicians to work an average of 12 hours per week in a "priority" service, such as an emergency room, a hospital ward, a rehabilitation centre or home care. Every hour that physicians spend fulfilling AMP requirements is an hour that they are not available at their primarycare clinic seeing their own family medicine patients. In addition to AMP hours and family medicine patient care, family physicians are also called to assume administrative duties and engage in medical teaching, both of which take time away from patient care. Bill 20 requires family physicians to register patients to their clinic with the intent of offering continuity of care, known as "prise-en-charge." This offers the patient a home base from which to seek health care, always first contacting that particular physician or group, as opposed to going to a walk-in clinic or emergency room, but physicians are to be penalized if too many of their patients choose to seek health care elsewhere, such as a colleague's clinic, a walk-in clinic or an emergency room. The law provides no exceptions if patients who live and work in two different areas seek health care from two different clinics, one near their place of work and one near their place of residence. Part-time physicians will be specifically punished, as they will not be able to provide continuity of care to the required number of patients. This includes physicians who are in the process of retiring and downsizing, working parttime due to personal or family reasons, on maternity leave, or on sick leave or disability.

"This is not about rolling back contracts. This is about working together to find solutions as we go forward that reflect the fiscal circumstances that we're in," he said, noting the government is "staring down" a $7 billion revenue hole. AUPE President Guy Smith said the repeal of Bill 45 means "one of the most odious remnants of the (Alison) Redford era" will be gone. Smith said he made it clear to Prentice that front-line workers "are not the problem" and discussions on the negotiations framework and essential service legislation "have to happen in consort with each other."

HSAA President El i sabeth Ballermann said she was encouraged by the "sign of good faith" as the "punitive, mean-spirited legislation to repress labour unrest" was killed. She said HSAA is prepared to proceed in good faith. Prentice confirmed the government will repeal Bill 45 "immediately" during this spring session. It is expected that Prentice will call an early spring election shortly after the government presents its budget on March 26.

Mr. Duma fell through one of the biggest cracks in Canada's fractured home-care system - a crack that has still not been repaired, despite all the attention political leaders have showered on the issue recently. The problem is that home care is not covered in the first two to three months after a patient moves to a new province. The federal, provincial and territorial health ministers made home care a priority at their meeting in Toronto last week and the Liberal government has singled it out as the only area of health care in line to receive new money from Ottawa.

But that reciprocal billing deal covers only "medically necessary" services guaranteed by the Canada Health Act. Home-care services do not count, even for patients such as Mr. Duma, who had less than three months to live. Mr. Duma, a maintenance planner for Suncor, had active hepatitis B and liver cirrhosis before a liver cancer diagnosis led surgeons to remove 60 per cent of the organ in October of 2015. In May, he was back in hospital in Fort McMurray, Alta., when the wildfires swept through, forcing him to travel with hundreds of other patients to Edmonton. Terminally ill and unable to return with his wife, Ana, to their Fort McMurray home, Mr. Duma decided to move back to Windsor to be with Laura, 29, a nurse practitioner, and his younger daughter, Andreea, 27, a registered nurse. "He spent the majority of the last year of his life in a hospital," Laura said. "It was the last place he wanted to die." But Mr. Duma's family quickly discovered how hard it would be to fulfill his final wish. He did not qualify for any services provided by his local Community Care Access Centre (CCAC), the public agency that co-ordinates home care in Ontario. That meant no nursing care, no help from personal support workers and no access to publicly funded equipment, such as a hospital bed.

Darren Cargill, the palliativecare leader for the Erie St. Clair Regional Cancer Program, found out about Mr. Duma's dilemma from his daughters. He did his best to help, asking nurse educators from the Hospice of Windsor and Essex County to support the family by phone and rummaging through the hospice's basement to find used equipment to donate to Mr. Duma. In the end, Dr. Cargill bent the rules to secure a bed for Mr. Duma at a hospice in Leamington, about 45 minutes from Windsor. Hospice services are also excluded from the interprovincial billing agreement. "It's a little bit tragic," Dr. Cargill said. "In the eyes of the Ministry [of Health and Long-Term Care,] he wasn't even in that bed. We never admitted him. We kind of snuck him in on a weekend, took care of him, and gave him a peaceful death." Mr. Duma was not the first dying patient Dr. Cargill has treated who did not qualify for home care because of a recent move. The doctor had already raised the issue with Lisa Gretzky, the NDP MPP for Windsor West, who wrote a letter to Health Minister Eric Hoskins about the problem last January, six months before Mr. Duma died. On Tuesday, Ms. Gretzky intends to introduce a private member's bill called Dan's Law that would amend the Home Care and Community Services Act to waive the three-month waiting period for home care for patients who move to Ontario from another province where they qualified for public health insurance. Opposition private member's bills rarely become law. In an e-mailed statement, Dr. Hoskins said he and Premier Kathleen Wynne have "indicated that this is an issue of concern for our government," but that Ontario on its own cannot close the temporary gap in home-care coverage.

He said the provincial and territorial health ministers have formed a working group to "modernize and expand" their reciprocal billing agreements. But Ms. Gretzky said that "we can't wait for them [health ministers] to actually sit down, have this conversation, and really get this done."

However, until now no federal government has had the nerve to take on serial offender Quebec. Quebec has been allowing its doctors and clinics to charge extra user fees since 1979. The province's current health minister, Gaetan Barrette, freely acknowledges this. In some cases, these fees were truly exorbitant. The Montreal Gazette reported last year that some colonoscopy clinics were charging patients an extra $600 for medications - on top of the publicly paid medicare fee. Many Quebecers were outraged. The provincial Liberal government's somewhat peculiar response was to pass a bill codifying the practice of extra-billing but giving itself the authority to regulate it. In March 2015, the then-Conservative government in Ottawa formally notified Quebec that it would be looking into the issue. This March, Liberal Philpott sat down with Barrette to discuss the practice. On Sept. 6, she sent her provincial counterpart a letter threatening cutbacks to Quebec's health transfer. A few days later, Barrette announced that extra billing will end as of next January.

It is hard to gauge the importance of Philpott's threat. User fees have become widely unpopular in Quebec. That alone may have been enough to drive the provincial government to disavow them. Still, it was bracing to see a federal health minister publicly standing up for the principles of medicare. It is not an everyday occurrence. It is particularly interesting that she targeted a province that is notoriously touchy about what it sees as federal interference. Perhaps she will do more. Certainly, more needs to be done. The latest annual report on the Canada Health Act filed with Parliament notes that private MRI clinics in British Columbia, Alberta, Quebec, New Brunswick and Nova Scotia are charging user fees to patients. It says some hospitals are avoiding the ban on charging for drugs by routing the sick through outpatient clinics - which do charge. It also notes that the portability requirement of medicare, which allows Canadians to receive care outside their home provinces, is routinely ignored.

Quebec routinely refuses to fully reimburse other provinces that provide health services to Quebec residents. Yet it has never been penalized by Ottawa for this. Nor have an unspecified number of other provinces that, at one time or another, did the same. Except for Prince Edward Island, the report says, no province appropriately reimburses residents who obtain medical care outside Canada. Such patients aren't necessarily entitled to the full cost of their out-of-country care. But they are entitled to be reimbursed for the amount it would have cost them to be treated in their home province. To work as a national program, Canadian medicare needs two things. First, the federal government must put up enough money to give it a real financial role in the system. The 2002 Romanow royal commission suggested that Ottawa provide at least 25 per cent of medicare funding. That figure still makes sense. Second, Ottawa has to use its financial clout to enforce those few national standards that do exist. A former Liberal health minister, Diane Marleau, tried to do this back in the 1990s. She was sandbagged by Jean Chrétien, the prime minister of the day. Let's hope Philpott has better luck.

It was bracing to see a federal health minister stand up for medicare principles, writes Thomas Walkom.

Along with the health unions, the doctors' British Medical Association, the Royal College of Nurses and the Royal College of Midwives are now all demanding the bill be scrapped.

Cameron and Lansley insist they don't plan to privatise the NHS, of course. But that's exactly what's happening on the ground even before the bill hits the statute book. The first private company to take over an NHS hospital, the Tory-linked Circle Health, won the contract to run Hinchingbrooke hospital in Cambridgeshire in November, even as it admitted it may not be able to "provide a consistent level of service to its patients".

And the government has been in talks with international health corporations about taking over 20 more, while private companies are already running local doctors' services and preparing to administer the clinical commissioning groups of GPs

Add to that ministers' announcement last month that they would raise the cap on the proportion of income English hospitals can raise from private work from about 2% to 49%

whereas the existing law allows private provision, the coalition bill will require it

it also opens the way for the privatisation of funding, the introduction of charging and top-up payments for services that are currently free, and the cherry-picking of patients by commissioning groups