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Medicare Watch

November 29, 2010

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Want fast care? Slip an MD some cash

Montreal Gazette (November 27, 2010)
Want fast care? Slip an MD some cash
‘It’s systemic’. Privatization fosters black market, physician says
By Charlie Fidelman

Montreal Gazette (November 30, 2010)
College of Physicians to probe bribery report
Cash for care. Pleads for patients, doctors to come forward
By Charlie Fidelman

Radio-Canada (1 décembre 2010)
Hôpitaux du Québec : Des pots-de-vin pour court-circuiter les listes d’attente?

Montreal Gazette (January 19, 2011)
‘Concierge’ medical services under fire; Annual fee: $975
By Carlie Fidelman

Montreal Gazette (January 20, 2011)
Private clinics under investigation: Health board launches 11 probes
By Carlie Fidelman

Montreal Gazette (November 27, 2010)
Want fast care? Slip an MD some cash
‘It’s systemic’. Privatization fosters black market, physician says
By Charlie Fidelman

When their mother was diagnosed with pancreatic cancer, the twin sisters didn’t hesitate for a moment: They chose the surgeon they wanted and slipped him $2,000 in cash to bump their mother to the top of the waiting list.

“We wanted to save our mother,” Vivian Green said. “It was cash incentive, to buy our place ahead of everyone else.”

Green and her sister, Ora Marcus, say bribes are an open secret in the medical field. They grew up with a father who was an obstetrician at the Jewish General Hospital.

“If you have money, you live, and if you don’t, you die,” Green said.

Critics say the practice is illegal and unethical, but several patients who contacted The Gazette say offering envelopes stuffed with thousands of dollars to surgeons has become a way to speed treatment in public hospitals.

One high-ranking physician who works with doctors at several Montreal hospitals told The Gazette that obstetricians often accept cash offered by expectant parents to ensure their doctor attends the delivery, rather than having to depend on whichever doctor is on call.

“I’ve learned that it’s current practice. … Everyone within these hospitals knows about it,” he said of the hush-hush payments. “It’s systemic, and it has been so for a long time now.”

The prices?

Minimum $2,000 to guarantee that a woman’s doctor will be there for the birth. “And it can go up to $10,000,” he added.

For general surgery, the cost runs between $5,000 to $7,000 to jump the wait list into the operating room, he said.

For Green and Marcus, the $2,000 got their mother’s operation bumped up -but not the surgeon they wanted.

Green and her mother initially offered cash to a surgeon at the Jewish General. He accepted an envelope but returned it within days, saying the operation was beyond his expertise.

Green was then referred to a doctor at the Royal Victoria Hospital.

“We wanted to have the operation done by (someone) who we know is the best,” she said. She said she slid an envelope filled with $20 bills across the surgeon’s desk at the second appointment to set the surgery date.

“I gave it to him discreetly and he took it -he knew what was in the envelope,” she said. “He took the money and never showed up.”

Another member of his surgical team removed the tumour in September. Their 80-year-old mother died this month of the cancer.

The family plans to file a formal complaint, Green said, because patients are helpless. “Payment for services should be stopped.”

But patients who get what they want won’t complain, she noted.

Karine Rivard, press attache to Quebec Health Minister Yves Bolduc, said that the Health Department has never heard of the practice.

“But if this is the case, then it’s unacceptable,” Rivard said.

After consulting Bolduc, Rivard called back: “Minister Bolduc is urging people who are aware of it to report it to the Quebec College of Physicians.”

Paul Saba, a primary care physician at Lachine Hospital, said that not only has he heard of the practice but that he, too, has been offered gifts for quicker access to care.

“People have offered me money and I’ve refused it,” Saba said. “Today … one patient offered me cash. People are desperate for services and they want to move things along.”

The black market for care is encouraged by the privatization of services, he said. Doctors feel underpaid and the demand for medical services in the public system outstrips supply, he said.

But doctors shouldn’t accept such gifts, he said.

Quebec has to find solutions within the public system to relieve the pressure on operating rooms and diagnostic procedures, “so people don’t feel like they have to put money in an envelope to get a test,” he said.

“It’s unacceptable, but I don’t blame the patients. We need to find solutions -I don’t want to see my colleagues doing this, either.”

Disgusting, scandalous and indefensible, said Gaetan Barrette, head of the Quebec Association of Specialists.

“It makes me very sad,” he said, adding that patients should complain to Quebec’s physicians disciplinary board.

The Quebec College of Physicians said it condemns any form of kickbacks but it is not aware of any complaints about the practice.

The board’s main investigator, Francois Gauthier, has not had a single complaint, said newly elected president Charles Bernard.

“It’s not normal if this is happening,” Bernard said.

Another patient -who sent the Jewish General a letter of complaint last year about services not rendered following payment to a doctor -said she got a “donation” certificate acknowledging her “gift” in response to her complaint.

Nicolas Steinmetz, a former executive director of the Montreal Children’s Hospital, said he, too, is aware of extra payments made under the table.

“Disgusting,” he said. Years ago, patients would give their doctors tokens of appreciation -a bottle of wine or a fruit basket at Christmas, he said. “In the country, it would be a chicken, but that’s different -that won’t buy you a Mercedes.”

Michael McBane of the Canadian Health Coalition said the problem of greedy doctors exists everywhere, not just Quebec, but the medical profession polices itself.

“Doctors aren’t going to report on themselves -the fox is guarding the chicken coop,” he said.

However, illegal billing and queue jumping are clear violations of the Canada Health Act, he added.

Hospital officials at the Jewish General and the Royal Victoria hospitals have refused repeated requests for interviews. Both issued statements via email late yesterday.

“There’s no preferential treatment of patients. All receive best quality care. Furthermore the JGH has a policy on conflict of interest regarding possible gifts offered to staff by patients.”

The McGill University Health Centre “expects professional conduct from all staff. … This includes avoiding potential conflict of interest with respect to offers of cash or gifts.”

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Montreal Gazette (November 30, 2010)
College of Physicians to probe bribery report
Cash for care. Pleads for patients, doctors to come forward
By Charlie Fidelman

The Quebec College of Physicians has launched an official investigation two days after The Gazette revealed patients in Montreal routinely bribe doctors in exchange for speedy services.

The College of Physicians is also pleading with patients and doctors to step forward, warning that without formal complaints about the practice, black market medicine will never be eradicated, college secretary Yves Robert said.

The Gazette reported Saturday that patients who want to be bumped to the top of waiting lists often slip doctors envelopes stuffed with thousands of dollars to jump the queue. Patients said they paid for preferential access to the operating room and for obstetricians to show up for deliveries.

One high-ranking physician who works with doctors at several Montreal hospitals told The Gazette that the systemic practice is an open secret.

Hush-hush payments run from $5,000 to $7,000 to jump the wait list into the operating room, and between $2,000 to $10,000 to guarantee an obstetrician’s presence at a delivery, the physician said.

One doctor even gave his answering service a list of expectant mothers who paid, and those who didn’t.

“It’s not only illegal but unethical. It’s totally unacceptable,” Robert said. “You cannot overfill the patient for a service that is publicly funded.”

The practice contravenes the board’s code of ethics, he said.

Led by the board’s main investigator, Francois Gauthier, the investigation will initially target doctors at two hospitals named in the article.

“We were made aware of names involved and we will focus on them in particular. We were told a physician has been doing that since 1990. So our (investigator) will get in touch with him to get answers,” Robert said.

Meanwhile, a Quebec patients’ advocacy group is polling its 400 member user-groups across the province.

“We’ve launched an investigation. We’re doing an inventory, we want them to tell us about patients offering money or that have offered money in exchange for services,” said Paul Brunet, head of the Conseil pour la protection des maladies.

When their mother got sick, Vivian Green and her twin sister, Ora Marcus, say they slipped a doctor at the Jewish General $2,000 to bump their mother to the top of the waiting list.

“It was cash incentive, to buy our place ahead of everyone else,” Green said.

But the doctor returned the envelope within days, saying the operation was beyond his expertise. That’s when Green went to a doctor at the Royal Victoria Hospital. He also took the money -but he never showed up for the operation, Green said.

The only time bumping a patient is permitted is to make way for a more pressing medical emergency, the board’s Robert said.

“That’s the only reason it is accepted to make a change on a wait list -surely not for a kickback,” Robert said.

The board was not aware of these practices because of their clandestine nature, Robert said: “There is a kind of a contract between the patient and physician not to talk about it, because both benefit from it.”

The board is taking the allegations seriously and its investigator “will take every action necessary but it’s hard to go forward without names,” Robert said.

“To do his job properly he needs complaints by patients or colleagues. Any person who is aware of this kind of practice, should – and I would say must -inform our (investigator),” Robert said. “He can’t go on a fishing trip and investigate 20,000 doctors.”

The investigation will also look at obstetricians elected to the board, Robert said.

Results are to be made public once Gauthier has enough proof to file complaints before the board’s disciplinary council.

Critics, however, maintain that the medical profession is policing itself.

The investigation should be handled by the provincial police, the Surete du Quebec, said federal Liberal health critic Ujjal Dosanjh.

“I could never in my wildest nightmare imagine this happening here,” Dosanjh said in a telephone interview. “It’s very very unsettling and disturbing. If it’s happening in health care, where else?”

Bribes to jump the queue for medical care clearly violate the Canada Health Act, he added. “I’m urging an investigation by the police -and quickly.”

It’s not known whether the provincial police will get involved, said Karine Rivard, spokesperson for Quebec Health Minister Yves Bolduc.

“It’s a little early -I don’t have details from the College, but we’re not ruling it out,” she said.

Critics also raised the issue during question period in the House of Commons yesterday.

“Allowing illegal cash payments to continue will endanger the health of those Canadians who cannot afford extra billing, and the health of Canadians generally,” said New Democrat health critic Megan Leslie. “When will the government stop allowing two-tiered health care and stop letting those with enough cash to jump the queue?”

Health care is a provincial and territorial matter, replied federal Health Minister Leona Aglukkaq.

“If the member has information relating to that I would be happy to discuss those issues with the provincial and territorial ministers. As the member knows, we support the Canada Health Act and we will continue to work with the provinces to implement it,” she said.

To reach the Quebec College of Physicians, call 514-933-4441 or email info@cmq.org

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Radio-Canada (1 décembre 2010)
Hôpitaux du Québec : Des pots-de-vin pour court-circuiter les listes d’attente?

Le Collège des médecins du Québec a ouvert une enquête afin de déterminer si certains de ses membres acceptent des enveloppes bourrées d’argent pour permettre à des patients de court-circuiter les listes d’attente et de se faire opérer plus rapidement, confirme le quotidien The Gazette.

L’enquête est annoncée trois jours après la publication, par le quotidien montréalais, d’un article alléguant que cette pratique est courante dans les hôpitaux de la province, bien qu’elle soit illégale en vertu de la Loi canadienne sur la santé.

The Gazette rapportait notamment le cas de deux soeurs qui ont utilisé ce stratagème à deux reprises, à l’Hôpital général juif de Montréal et à l’hôpital Royal Victoria. Il cite aussi des médecins qui affirment que le recours au pot-de-vin est fréquent.

Coût de l’opération, selon le quotidien : de 2000 $ à 10 000 $ pour s’assurer qu’un obstétricien soit présent lors d’un accouchement, et de 5000 $ à 7000 $ pour obtenir une chirurgie régulière plus rapidement qu’autrement.

« Ce n’est pas seulement illégal, c’est contraire à l’éthique. C’est totalement inacceptable, a déclaré au quotidien le secrétaire général du Collège, Yves Robert. On ne peut pas surfacturer un montant à un patient pour un service financé par le secteur public. »

Yves Robert a confirmé que l’enquêteur du Collège, François Gauthier, se penchera d’abord sur les médecins des deux hôpitaux visés par l’article de The Gazette. « On nous a dit qu’un médecin fait ça depuis 1990. Notre enquêteur le contactera pour obtenir des réponses », ajoute M. Robert.

Le secrétaire du Collège, qui dit ne jamais avoir entendu parler de cette pratique auparavant, rappelle que seules des raisons d’ordre médical peuvent permettre à quelqu’un de devancer d’autres patients sur une liste d’attente.

Yves Robert invite en outre les Québécois à dénoncer cette façon de faire, afin que l’enquêteur du Collège puisse faire son travail. « Toute personne qui est au courant de ce genre de pratique devrait – je devrais dire doit – informer notre enquêteur », dit-il. « Il ne peut pas aller à la pêche et enquêter 20 000 médecins ».

Le porte-parole de l’opposition libérale sur la Santé à Ottawa, Ujjal Dosanjh, croit pour sa part que la Sûreté du Québec devrait s’en mêler. « Je ne pouvais imaginer dans mes pires cauchemars que cela se produit ici. C’est très très dérangeant et perturbant », a-t-il commenté.

La possibilité que la SQ enquête n’est pas écartée par Québec. « Il est un peu tôt. Nous n’avons pas les détails du Collège, mais nous ne l’excluons pas », a fait savoir Karine Rivard, porte-parole du ministère québécois de la Santé.

Quant au ministre de la Santé Yves Bolduc, il affirme n’avoir jamais eu vent de telles pratiques : « Je suis dans le milieu de la santé depuis 26 ans et je n’avais jamais entendu parler de ça », a-t-il dit aux journalistes.

– — – — –

Témoignage troublant

L’histoire originale de The Gazette repose sur le témoignage des soeurs jumelles Vivian Green et Ora Marcus, qui cherchaient à faire opérer rapidement leur mère, atteinte d’un cancer du pancréas.

Elles disent avoir offert 2000 $ à un médecin de l’Hôpital général juif. Ce dernier a accepté l’enveloppe, mais l’a rendue quelques jours plus tard, disant ne pas avoir l’expertise requise pour faire l’opération. Il a toutefois envoyé les soeurs à un collègue de l’hôpital Royal Victoria.

Au deuxième rendez-vous avec ce second médecin, les soeurs lui ont aussi offert une enveloppe contenant 2000 $, qu’il a acceptée. L’opération a bel et bien eu lieu plus rapidement que prévu, mais elle n’a pas été faite par le médecin qui avait accepté l’argent, contrairement à ce qui aurait été convenu.

Les soeurs disent avoir agi de la sorte pour sauver leur mère, mais affirment aujourd’hui que cette façon de faire doit cesser.

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Annexe: L’enveloppe du docteur, Le Soleil, 2 décembre 2010

Annexe: Pots-de-vin en santé – Chirurgie express, Le Devoir, 2 décembre 2010

Annexe: La RAMQ enquête sur de prétendus pots-de-vin dans deux hôpitaux montréalais,
             Le Devoir, 1 décembre 2010


Montreal Gazette (January 19, 2011)
‘Concierge’ medical services under fire; Annual fee: $975
By Carlie Fidelman

Immediate access to Montreal’s top pediatric services might sound like a parent’s dream, but it is available here -at a cost of $975 per year, per child.

The fee buys “concierge” health services at Medisys 123, a private clinic in downtown Montreal that is under investigation by the Quebec health insurance board for allegedly contravening billing regulations.

Medisys 123 is the latest of 11 clinics to come under scrutiny in Quebec recently. The RAMQ launched its investigation in early January, before federal Liberal health critic Ujjal Dosanjh called on federal Health Minister Leona Aglukkaq last Friday to look into the matter.

Dosanjh said Medisys 123 is billing patients for medically necessary procedures, which contravenes the Canada Health Act.

For an upfront fee, Medisys gives parents a doctor at their fingertips. Just one phone call will give access to a medical team that will arrange basic and emergency pediatric care days, evenings and weekends.

Marie-France Courtemanche, the point person for enrolment in the concierge service, said Medisys charges for “integrated” health care that cannot be broken down into parts. Fees, however, go to pay for uninsured services such as phone calls, she explained yesterday. Any face-to-face medical consults are billed to RAMQ, she added.

“We are not doing anything illegal. We are in full compliance with the regulations,” she said.

The Regie de l’assurance maladie du Quebec said it is concerned by the jump in the number of doctors and clinics in recent years that are trying to find loopholes to circumvent the law when it comes to billing patients for insurable services.

An annual forfeit or “block fee” paid in advance runs counter to the law, RAMQ spokesperson Marc Lortie said yesterday: “For them it may be legal, but we are investigating.”

More and more clinics are getting creative with their billing, Lortie said, for example, charging “club” or “block fees,” and also for checkups and fast access to physicians and laboratory results.

“We’ve never seen so many brought to our attention,” said Lortie, noting that the jump in hidden and new billings has prompted the RAMQ to send an open letter to Quebec’s family and specialty physicians, a “reminder about charging illegal fees.”

One of the consulting doctors at Medisys, Harley Eisman, also the director of pediatric emergency at the Montreal Children’s Hospital, told The Gazette in an email that concierge services help respond to patient needs in a situation where overcrowded hospitals easily become vulnerable to influenza outbreaks.

“What is clear is the imperative to continue to develop pediatric resources in the community,” he said.

Families aren’t necessarily looking for a physician for their children, he said, but “support and prise-en-charge … 365 days a year.”

But a membership at Medisys is no guarantee of a “golden key access” to the Children’s ER in case of an emergency, Eisman pointed out, because patients are triaged according to the severity of their illness and time of arrival.

But the company’s brochure implies preferential treatment: “Our medical team … address urgent medical situations as they occur. If we feel that a face-to-face assessment is required, our pediatric team will welcome you at our facilities where your child will be seen without delay.”

The Quebec branch of Canadian Doctors for Medicare says extra fees contravene the universality principle of health care, and have asked the provincial health minister to step in. “It’s another way of charging patients for faster access to a physician,” Marie-Claude Goulet, head of Medecins Quebecois pour le regime public, said yesterday.

Dr. YvesRobertof theQuebecCollege of Physicians said it’s not always clear what is not insured, and so violations continue to mount.

Some physicians try to make up for rising office expenses while others see a profitable opportunity in gaps of the public health system, he said.

Fees to gain access to a doctor should not be tolerated, he said.

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Montreal Gazette (January 20, 2011)
Private clinics under investigation: Health board launches 11 probes
By Carlie Fidelman

Stuck without a family doctor five years ago, Louis-Thomas Pelletier finally turned to a private Montreal health clinic and now pays $1,300 a year for an elite membership.

While Pelletier is happy with his express service at Plexo Clinique, adjacent to Outremont, the clinic is subject to one of 11 investigations launched by the Quebec health insurance board into billing contraventions.

The Regie de l’assurance du Quebec says that in its 40 years, it has never seen such a spike in extra fees for health services via various loopholes.

Investigations include:

  • Plexo, where $1,300 a year buys an annual checkup, including a battery of physical tests, laboratory work, vaccines and followup with a family doctor.
  • Clinique Globale Sante Express in Blainville, which charges nearly $400 for a “checkup” followed by an appointment with a family doctor.
  • Groupe Sante Physimed in St. Laurent charges $473 for a battery of basic tests -blood, urine, heart, lungs and ears -and additional tests are extra, followed by a meeting with a physician.
  • And as of this month, Medisys 123 (owned by Persistence Capital Partners, a health services investment corporation) charges $975 per child, per year, for “concierge” services and an estimated $1,500 a year for adults.

What’s interesting about Medisys is that Quebec’s former health minister Philippe Couillard negotiated a position with the firm just before quitting politics in 2008. He was still in cabinet when the government approved a set of approved fees for private health clinics like Medisys, but an investigation by the Quebec lobbying commissioner later cleared Couillard of any misconduct.

Clinics that refuse to comply with billing laws may face legal action, Regie spokesperson Marc Lorti warned yesterday.

Pelletier, a busy filmmaker, said he appreciates the fast, efficient and accountable service provided at private clinics like Plexo, with an approach that’s unparalleled in the public system: telephone access to a doctor 24/7, an annual checkup, a battery of tests and same-day results, complete with computer data charting his health information from year to year.

“It would take me a week of running around in the public system to get the same tests and then they tell you, ‘We’ll call you if there’s anything wrong,’ or ‘we lost your tests,’ ” he said. “I have a doctor. He knows me, he knows what worries me about my health -this is what a family doctor is supposed to do – and he tells me what to look after. I feel like I’m talking to a human being.”

Rather than argue about billing, health officials should focus on improving public health so everyone can be privy to good care, Pelletier said: “A checkup is no luxury.”

Pelletier said he would not consult a private clinic if the public system functioned smoothly. “I get paid by the hour. When I have to wait 10 hours in the emergency room, I feel like sending them a bill.”

He noted that he pays twice for health care -first as a taxpayer (calculated at $4,653 per person, per year, based on the percentage of the provincial budget that goes toward health care) and then Plexo’s annual fee.

“I’m not paying less taxes because I’m using those services – I’m paying double and I’m aware of that,” Pelletier said. “But at least I know what is happening with me.”

Plexo director of marketing Nicole Gruslin said she would not comment while her organization is under the Regie’s investigation.

The law is clear about billing infractions, and the problem lies with enforcing it, said Yves Robert of the Quebec College of Physicians.

The Regie looks at individual cases but its intervention comes after the fact, Robert said. “What’s needed is political intervention.”

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