LESPÉCIALISTELE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC

Vol. 15 no. 3 | September 2013

DAY-TO-DAY MYTHS AND

REALITIESSee text p. 36

ACTIVITY-BASEDFUNDING:A PANACEA?

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5vol. 15 no. 3LS

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TABLE OF CONTENTS

7 PRESIDENT’S EDITORIALO Canada, in Canada

9 IN THE NEWS

10 A WORD FROM THE VICE-PRESIDENTUnemployed medical specialists, is it possible?

11 FEDERATION AFFAIRS

12 DID YOU KNOW...

15 LEGAL ISSUES

32 GREAT NAMES IN QUÉBEC MEDICINEDr Brian Bexton, psychiatrist

34 CONTINUING PROFESSIONAL EDUCATION

35 PROFESSIONALS’ FINANCIAL

36 SOGEMEC ASSURANCES

38 L’ÉDITORIAL DU PRÉSIDENT Ô Canada, au Canada

39 MEMBER SERVICESCommercial Benefits

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

Le Spécialiste is published 4 times per year by the Fédération des médecins spécialistes du Québec.

EDITORIAL COMMITTEEDr Harold Bernatchez

Dr Karine Tousignant

Maître Sylvain Bellavance

Nicole Pelletier, APR

Patricia Kéroack, c. w.

DELEGATED PUBLISHERNicole Pelletier, APR Director, Public Affairs and Communications

RESPONSIBLE FOR PUBLICATIONSPatricia Kéroack, Communications Consultant

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LEGAL DEPOSIT3nd quarter 2013 Bibliothèque nationale du Québec ISSN 1206-2081

The mission of the Fédération des médecins spécialistes du Québec is to defend and promote the economic, professional, scientific and social interests of the medical specialists who are members of its affiliated associations.The Fédération des médecins spécialistes du Québec represents the following medical specialties: Adolescent Medicine; Anatomical Pathology; Anesthesiology; Cardiac Surgery; Cardiology (adult or pediatric); Clinical Immunology and Allergy; Colorectal Surgery; Community Medicine; Critical Care Medicine (adult or pediatric); Dermatology; Diagnostic Radiology; Emergency Medicine; Endocrinology and Metabolism; Forensic Pathology; Gastroenterology; General Pathology; General Surgery; General Surgical Oncology; Geriatric Medicine; Gynecologic Oncology; Hematological Pathology; Hematology; Infectious Diseases; Internal Medicine; Maternal-Fetal Medicine; Medical Biochemistry; Medical Genetics; Medical microbiology and infectious diseases; Medical Oncology; Neonatal-Perinatal Medicine; Nephrology; Neurology; Neuropathology; Neurosurgery; Nuclear Medicine; Obstetrics and Gynecology; Occupational Medicine; Ophtalmology; Orthopedic Surgery; Otolaryngology-Head and Neck Surgery; Pediatric Hematology/Oncology; Pediatric Emergency Medicine; Pediatric General Surgery; Pediatrics; Physical Medicine and Rehabilitation; Plastic Surgery; Psychiatry; Radiation Oncology; Respirology (adult or pediatric); Rheumatology; Thoracic Surgery, Urology and Vascular Surgery.

All pharmaceutical product advertisements are previously approved by the Pharmaceutical Advertising Advisory Board (PAAB).

The authors of signed articles are solely responsible for the opinions expressed therein. No reproduction without previous authorization from the publisher.

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7vol. 15 no. 3LS

PRESIDENT’S EDITORIALDR GAÉTAN BARRETTE

LS

O Canada, in CanadaSo, 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 medically-assisted 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 !

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IMS Brogan

Comparaison Québec – Canada, 2012

Source : IMS Brogan et l’Index canadien des maladies et traitements.

POUR DE PLUS AMPLES RENSEIGNEMENTS : 1-888-400-4672 | www.imsbrogan.comUne importante source d’information, d’analyse et de consultation pour les secteurs de la santé au Canada

LES DIX RAISONS PRINCIPALES POUR LES VISITES AUX MÉDECINS EN 2012

LES VINGT MÉDICAMENTS LES PLUS PRESCRITS EN 2012QUÉBEC TOTAL DES ORDONNANCES

EN 2012 (000S)% VARIATION

2011 À 2012

SYNTHROID 8 303 5,6

CRESTOR 3 515 -25,2

D-TABS 2 587 44,2

NEXIUM 2 182 -7,9

PRO-AAS EC-80 2 154 5,6

LYRICA 2 146 19,2

ATORVASTATINE 1 900 24,3

ATIVAN 1 634 0

COUMADIN 1 497 -8,8

RATIO-ATORVASTATINE 1 454 154,7

PRO-METFORMINE 1 443 7,1

APO-ATORVASTATIN 1 431 -0,7

COVERSYL 1 395 14,4

SANDOZ-BISOPROLOL 1 283 -18,4

AMLODIPINE 1 226 15,2

PMS-AMLODIPINE 1 159 13,1

CELEBREX 1 126 1,8

PANTOPRAZOLE 1 116 23,1

ELAVIL 1 106 47,3

ALESSE 1 102 5

CANADA TOTAL DES ORDONNANCES EN 2012 (000S)

% VARIATION 2011 À 2012

SYNTHROID 14 788 7

CRESTOR 6 906 -39,1

APO-ATORVASTATIN 5 473 0,5

APO-FUROSEMIDE 4 222 11,5

COVERSYL 3 832 15,7

CIPRALEX 3 243 27

APO-HYDRO 3 179 -5,7

ELAVIL 3 040 13,7

NEXIUM 3 023 -17,8

TEVA-AMOXICILLIN 2 920 -16,9

LYRICA 2 911 16,9

TARO-WARFARIN 2 890 5,9

ATIVAN 2 849 0,9

TEVA-VENLAFAXINE 2 836 61,7

ZYLOPRIM 2 710 17,8

CELEBREX 2 679 -1,9

D-TABS 2 675 47,5

APO-SALVENT CFC 2 540 15,1

VENTOLIN HFA 2 530 -10,8

ELTROXIN 2 464 -1,5

QUÉBEC NOMBRE DE CONSULTATIONS (EN MILLIERS) : 74 992

Hypertension 4 166

Bilan de santé 2 762

Diabète sans complications 2 433

Dépression 1 739

Anxiété 1 671

Hyperlipidémie 1 283

Infection aiguë des voies respiratoires 1 161

Trouble de dé�cite de l’attention 971

Otite moyenne 964

Oesophagite 959

CANADA NOMBRE DE CONSULTATIONS (EN MILLIERS) : 323 195

Hypertension 19 306

Bilan de santé 10 186

Diabète sans complications 9 823

Dépression 8 175

Anxiété 6 425

Surveillance normale de la grossesse 5 355

Infection aiguë des voies respiratoires 5 230

Hyperlipidémie 4 195

Oesophagite 3 866

Otite moyenne 3 412

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15

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9vol. 15 no. 3LS

IN THE NEWS

On the Political FrontFROM QUEBEC’S NATIONAL ASSEMBLYFall 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 OTTAWAThere 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 activi-ties, 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.

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10vol. 15

no. 3LS

A WORD FROM THE VICE-PRESIDENTDR DIANE FRANCŒUR

LS

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 physi-cians 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.

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.

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 addi-tional 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.

YOUR AFFILIATED MEDICAL ASSOCIATIONSMUST KNOW YOUR PRESENT AND FUTURE

NEEDS FOR THE MEDICAL MANPOWERPLANS FOR 2016-2020 ON WHICH WE

WILL START WORKING IN THE FALL.

11vol. 15 no. 3LS

FEDERATION AFFAIRS

The respite that makes a differenceWhat 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.

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 orga-nizations to make their respite activities a reality.

CAREGIVERS IN QUEBECMore 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 vulne-rable members of our society,” says Dr Barrette.

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 DISASTERJuly 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 organi-zational 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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At the time we took this vacation,our son […] wasn’t doing well. Hehad his 17th birthday in August

and was in full crisis […]. We weretired out and at the end of our rope.

12vol. 15

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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 endocrinolo-gues 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.

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 physiologist-researcher 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 Sainte-Justine 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.

DOCTORS WITHOUT BORDERS

Dr Joanne Liu, a pediatrician at Sainte-Justine 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.

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En choisissant un hôtel Jet-Set de Vacances TMR, vous bénéficiez des avantages suivants, sans aucun frais supplémentaires:

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• 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

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• 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

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13vol. 15 no. 3LS

THANKS TO OUR SPONSORS

DID YOU KNOW...

BRONZE CATEGORY

• Canadian Medical Protective Association

• Association des optométristes du Québec

• BCP

• Desjardins Insurance (Life, Health, Retirement)

• Desjardins

• 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

• SSQ Financial Group

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.

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.

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ARMAND-FRAPPIER FOUNDATION OF INRS UNIVERSITY AWARD

Dr Jacques Montplaisir, a psychiatr ist and the founding director of the Center fo r Advanced R e s e a r c h i n S l e e p 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.

WOMAN OF MERIT AWARD FROM THE YWCA IN QUEBEC CITY

Dr Marie Plante, an onco-logical gynecologist at the CHU de Québec is the winner in the Women of Merit contest, in the Health category. This contest seeks to promote women

who transform their environment and distinguish themselves through their commitment, leader-ship, creativity and determination. Dr Plante took an active part in the development of the radical trachelectomy.

SOCIÉTÉ QUÉBÉCOISE DE RHUMATOLOGIE AWARD

Dr Jean-Pierre Pelletier, a rheumatologist, and Johanne Martel-Pelletier, Ph. D., bo th re se a r-chers 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 contribu-tion to their area of research.

NEW RELEASE

LA RÉTINOPATHIE DIABÉTIQUE(DIABETIC RETINOPATHY)

Dr Jean Daniel Arbour, an ophthalmologist at the CHUM-Notre-Dame and Dr Pierre Labelle, an ophthalmologist 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.

PLATINUM CATEGORY

GOLD CATEGORY SILVER CATEGORY

8TH EDITION OF THE MEDICAL FEDERATIONS’ GOLFTOURNAMENTIN AID OF THE QUEBEC PHYSICIANS’ HEALTH PROGRAM

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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.

• Chirurgiens et anesthésiologistes : plus que des partenaires obligésSession 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

• Les troubles du sommeil : quand Morphée relâche son étreinteSession associative : cardiologie, neurologie, ORL, pneumologie et psychiatrie

• Thérapies endovasculairesSession associative : chirurgie vasculaire et radiologie

• Les complications ophtalmologiques de pathologies endocriniennesSession associative : endocrinologie et ophtalmologie

• Tumeurs de la base du crâne : controverses et nouveautésSession 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 centrauxSession associative : chirurgie générale, pédiatrie et pneumologie

• La maladie d’Alzheimer : mieux la comprendreSession associative : gériatrie et neurologie

• Cessation tabagique : comment passer à l’actionSession associative : pneumologie, psychiatrie, santé communautaire

• Anaphylaxis and drug allergies : diagnosis, treatment algorithms, post-interventions studies and referral for work-up after screeningSession associative : allergologie et immunologie clinique et anesthésiologie (Présentation en anglais, diapositives bilingues)

Vendredi 15 novembre 2013PALAIS DES CONGRÈS

DE MONTRÉAL

• 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

Cette journée a été rendue possible grâce à une subvention à visée éducative de :

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TARIF SPÉCIAL POUR INSCRIPTION AVANT LE 15 OCTOBRE

AU PROGRAMME CETTE ANNÉE

INSCRIVEZ-VOUS DÈS MAINTENANT EN LIGNE

fmsq.org/jfi

• L’expertise et le médecin spécialiste : une longue carrière fait-elle de vous un expert ?

• Pour éviter de faire la une du journal : gestes de base en réanimation

• 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

• Les dix situations médico-légales les plus fréquentes de la pratique du médecin spécialiste au Québec

• La planification de la retraite, à court et à long terme - les aspects financiers (tarification spéciale pour les conjoints)

• 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)

15vol. 15 no. 3LS

BY MAÎTRE SYLVAIN BELLAVANCEDirector, Legal Affairs and Negotiations – FMSQ A major investment

LEGAL ISSUES

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 ACTIVITIESA 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 ACTIVITIESThe 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 MEETINGSMeetings 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 ACTIVITIESAll 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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DOSSIERDOSSIER

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ACTIVITY-BASEDFUNDING:A PANACEA?

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.

17vol. 15 no. 3LS

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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T2A: the French ModelOf 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 BEGINNINGUp 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 inconve-niences: failure to act and hospital activities not adapted to the needs of healthcare.

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’informa-tion 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.

The T2A architecture was developed based on the PMSI, the informa-tion 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 MECHANICST2A 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 homoge-nous groups of patients (groupes homogènes de maladesor 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.

BY RICHARD-PIERRE CARONSenior Consultant Public Affairs and Communications – FMSQ

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A BIT OF USEFUL INFORMATIONIn 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.

Source: Le panorama des établissements de santé - édition 2011. Direction de la recherche, des études, de l’évaluation et des statistiques (DREES)

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.

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TRANSITION AND FEE STRUCTURETransitional 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.

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 STRUCTURETo 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 preca-rious 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.

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.

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, LONG-TERM CARE AND FORMER LOCAL HOSPITALS.

ACTIVITY-BASED FUNDING:A PANACEA?

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ESTABLISHING FEES AND CODING MEDICAL ACTIVITIESThe National Cost Study (Étude nationale des coûts or ENC) for MCOs is performed each year by the ATIH. Institution parti-cipation 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 require-ments 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 infor-mation departments (départements d’information médicaleor DIMs) have now taken on a central role, without having been prepared in reality nor supported in terms of training and human resources.

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.

Practitioners have also highlighted the heavy responsibility that rests on their shoulders in an area outside their compe-tence: 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 per formed 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 effi-ciency 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 insti-tutions. The organization and operation of institutions being variable, some have had recourse to a centralized coding within DIMs, while others perform these tasks within depart-ments themselves (with the DIMs ensuring control of the files).

CONTROL MEASURESThe funding of institutions rests indirectly on the billing infor-mation they send to the Health Insurance. This system involves ensuring the rules of coding and billing are respected, medico-administrative 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.

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.

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FINANCEMENT À L’ACTIVITÉ :LA PANACÉE ?

THE FAULTS AND IRRITANTS ASSOCIATED WITH THE MODELThe inflation effect is one of the main risks generally associated with activity-based fees, since T2A encourages the develop-ment of activity in order to stockpile additional receipts. It is 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 finan-cially for the institution to proceed with two stays separated by a few days and thus be remunerated for two GHS. The director general in charge of the offer of care estimates that T2A tends to “develop activity beyond what is medically necessary on a given territory.”

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 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.

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 LITTLE VALUE.

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RECOMMENDATIONSThe 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 patho-logies 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.

REVIEWING THE BOUNDARIESAND THE FUNCTIONING OF T2A IN MCOsThe 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.

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.

SOME OBSERVATIONST2A 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 complemen-tary 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 architec-ture 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.

23vol. 15 no. 3LS

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 invest-ments 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 institu-tion 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 PATIENTST2A 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 necessary for the case management of patients to evolve, especially since the number of hospitalizations, in particular of the elderly, are avoidable.

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.

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”.

T2A CAN BE AN OBSTACLE TO COOPERATION BETWEEN INSTITUTIONS, SINCE THESE WILL NOT BENEFIT FROM SHARING THE ACTIVITY.

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.

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25vol. 15 no. 3LS

ACTIVITY-BASED FUNDING:A PANACEA?

ACTIVITY-BASED ACTIVITY-BASED FUNDING:FUNDING:A PANACEA?A PANACEA?

ACTIVITY-BASED ACTIVITY-BASED FUNDING:FUNDING:A PANACEA?A PANACEA?

Other experiences around the globeActivity-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“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...”

“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 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.

FEES AND BUDGETSThe 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.

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 AUSTRALIAAt 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.

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IN NORWAYIn 1997, the population of Norway was 4.4 million. Activity-based funding was intro-duced 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 repre-sented 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, regu-lations, 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 procee-ding 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.

IN DENMARKIn 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, direc-tions 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 acti-vity-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 esta-blished DRG rate if the patient is admitted.

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ACTIVITY-BASED FUNDING:A PANACEA?

IN SWEDEN At the start of the 1990s, Sweden had 8.6 mi l l ion inhabitants. Three decision-

making 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 indi-viduals. 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 activi-ties. 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 CANADAOne study1 made for the Canadian Health Services Research Foundation (CHSRF) dealt with the hospital funding mecha-nisms. 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 SYSTEMSImplementing 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 care assoc iated wi th a g iven group can be divided into several subcategories to take into account the severity or the complexity of cases, procedures, etc.

According to the literature, the use of HRGs (Healthcare Resource Groups) in the United Kingdom and of DRGs in the United States, in Scandinavia and in Australia, generate two problems. To start with, these classification systems were only designed to describe the care required by patients either admitted to hospital or on an ambulatory basis (Day Case Basis). Secondly, there is no classification system that can perfectly group patients on the basis of the resources required by a typical group. Since each case is different, it is difficult to establish uniform categories. For example, HRG B13 is used to classify all patients who undergo a procedure to extract a cataract and insert an intraocular lens. All cases are classified under code OPCS C712. On the other hand, the HRG E03 (cardiac valve procedure) covers up to 48 different procedures, while the HRG E04 (coronary bypass) covers 52 of them.

DETERMINING THE COST OF A CARE EPISODEThe 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, examina-

tions, laboratory, operating room, housekeeping, pharmacy, medica-tion, nursing staff, medical supplies, etc.). Once added up, these costs are associated with one of the medical specialties. In all cases, these can involve direct or indirect costs, such as the operating costs of a surgical suite that varies according to the specialty or the type of case.

In Austral ia, calculating costs is per formed according to the “bottom-up costing method”. This three-step method consists essen-

tially of compiling information by specialty centre based on data issue from the clinical pathway taken by the patient during his or her hospitalization: diagnostic tests, blood tests, radiology, nursing care, time and procedures in an operating room, etc. Are taken into account indirect costs (expenses associated with infection-control measures, sterile materials and domestic services) and the direct costs of the stay where each product or service used has been weighted or has a relative price established for it. For example, all nursing care required and performed for each type of patient is detailed and sequenced for each work shift. In summary, in this model, material resources and services used are directly linked to the patient.

IT SHOULD BE NOTED THAT IN FRANCE, IN PARTICULAR, ESTABLISHING

RATES FOR PROCEDURES OR FOR CASE MANAGEMENT CANNOT BE

DONE BY ANYONE OTHER THAN THE PRACTITIONER WHO PROVIDED THEM

OR ON HIS OR HER INSTRUCTIONS. COULD IT BE OTHERWISE IN QUEBEC?

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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.

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.

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.

In the United Kingdom, the transition from global budgets to activity-based funding resulted in costs associated with super-vision 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.

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.

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.

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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 under-stood 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 SUPPORTAny 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.

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 STRUCTUREActivity-based funding requires that the institution bill its services to a paying agent who needs to perform the appropriate verifi-cations 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.

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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 activi-ty-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 OTHERWISEBefore 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.

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).

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.

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

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.

3- CHOOSING THE GROUPS

Once the areas of activity chosen, it would be necessary to choose the groups, the fundamental bases on which the model of coding and the rates would rest.

4- ANALYSING COSTS

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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A True Gentleman

GREAT NAMES IN QUÉBEC MEDICINE

BY PATRICIA KÉROACK

DR BRIAN BEXTON

Psychiatrist

DR BRIAN BEXTON

Psychiatrist

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 depriva-tion. 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 stimu-lation 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.

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.

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.

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.

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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 expe-riences, 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 under-stood by a number of clinicians.

A CAREER ABOUT-FACEAs 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 scien-tific 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 misun-derstanding 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 psychia-trists 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 asso-ciation 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.

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.

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A WELL-EARNED TRIBUTESome 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

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 specia-lists 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 PDOThe 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 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 pwade@fmsq.org.

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 innova-tive 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 perso-nally 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 ETHICSThe 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 fina-lizing 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 profes-sional development.

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.

The Professional Development Office will be working in coope-ration 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 asso-ciation CPD activities in section 3. Requests for certification can be sent to us directly by your association. These section 3 acti-vities 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.

BY SAM J. DANIEL, MDDirectorOffice of Professional Development - FMSQ

MOC: IMPORTANT CHANGESThe 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.

Patricia Wade

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Evolution in CPD

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OUR SUBSIDIARIES

Disciplined savings

THE solution to reachingyour financial goals for retirement

BY BENOÎT CHAURETTE, B. SC., PL. FIN.Analyst, Financial Planning

PROFESSIONALS’ FINANCIAL

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.

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.

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.

As you can see, the projection predicts a constant increase in retirement savings. Once the mortgage is paid and the children financially autonomous, household savings should reach close to 25% of gross revenue. Although savings at the beginning of one’s career are less important, it is still important to start investing early in order to benefit from capital growth over the long term.

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:

1- Take advantage of increases in revenue that exceed inflation to increase your savings.

2- Once one of your loans is completely repaid, invest an amount equal to its previous payments.

Maybe your career is well underway at present and you wish to know if your current savings are sufficient, taking your age into account. The best way to ensure your financial situation is on target to reach your financial goals for retirement is to consult a financial planner, who will provide you with a detailed projection of your retirement income. To provide you with an approximate idea, the following graph illustrates an estimate of gross savings needed according to age, as a percentage of your revenues.

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.

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40 years Times 1

50 yearsTimes 2.5

60 years Times 5.5 Approximately 7 times

revenues for a peaceful retirement

36vol. 15

no. 3LS

OUR SUBSIDIARIES

True or False?

Day-to-day Myths and Realities

SOGEMEC ASSURANCES

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.

RECENTLY DIVORCED, CHANTAL LEAVES ON VACATION. SHE HAS HOWEVER FORGOTTEN THAT HER EX-HUSBAND 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 uninter-rupted 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.

BY CATHERINE FELBERFinancial Planner

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.

37vol. 15 no. 3LS

NOS FILIALESOUR SUBSIDIARIES

PUBLICITÉ DEMI PAGE

Sogemec Assurances

REPEAT OUI OU NON

At Your Service for the Last 35 Years!BY MAURICE GIROUX

General Manager

SOGEMEC ASSURANCES

Ever since Sogemec Assurances was created in 1978, we have been involved as much in the field of personal insurance (life, disa-bility 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 MEMBERSIn 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.

• Vie

• Invalidité

• Frais généraux

• Maladies graves

• Soins de longue durée

• Médicaments

• Maladie

• Dentaire

• Automobile

• Habitation

• Entreprise

SOGEMECASSURANCESÉVOLUE AVEC VOUS

POUR TOUS VOS BESOINS D’ASSURANCES

SOGEMEC ASSURANCESfiliale de la

Grâce auSERVICE PRÉFÉRENCELAISSEZ LIBRE COURS À VOS PASSIONS

POUR EN SAVOIR PLUS :1 800 361-5303514 350-5070 / 418 990-3946 Par courriel ou Internet : information@sogemec.qc.cawww.sogemec.qc.ca

4575_SOGA_annonce_FMSQ_2012_montgolfiere_7x4.5(8)_Layout 1 4/2/12 2:25 PM Page 1

38vol. 15

no. 3LS

L’ÉDITORIAL DU PRÉSIDENTDR GAÉTAN BARRETTE

LS

Ô Canada, au CanadaTiens ! 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 confé-rencier, 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 ! ! !

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 exacte-ment 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 !

Pour tout savoir sur les avantages commerciaux

réservés aux membres de la Fédération des

médecins spécialistes du Québec et pour connaître

nos nouveaux partenaires commerciaux, visitez le

portail de la FMSQ au fmsq.org/services.

Pour plus d’informations : fcadieux@fmsq.org ou 514 350-5274

Nos partenaires méritent votre confiance.

Vous gagnez à les découvrir !

SERVICES AUX MEMBRES

AVANTAGES COMMERCIAUX

SERVICES AUX MEMBRES

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fprofessionnels.com 1 888 377-7337

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IL NE MANQUE QUE VOUS !

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