Response to the Quebec Order of Physicians Proposal to Ban Private Practice

Viewpoint showing that when countries encourage coexistence between the public and private systems, a common approach in the majority of OECD countries, the population has better access to health care

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Bannir la médecine privée, une mauvaise idée (Le Soleil, April 11, 2025)

This Viewpoint was prepared by Emmanuelle B. Faubert, Economist at the MEI. The MEI’s Health Policy Series aims to examine the extent to which freedom of choice and entrepreneurship lead to improvements in the quality and efficiency of health care services for all patients.

In February 2025, Quebec’s professional order of physicians (the Collège des médecins du Québec, or CMQ) published a brief on the topic of Bill 83, which aims to force new doctors to work in the public system during their first five years of practice.(1) In this brief,(2) the CMQ voiced its concerns regarding the growing presence of the private sector in Quebec health care, and went even further by recommending the prohibition of the status of non-participating physician, thus requiring all doctors in the province to practise exclusively under the public plan (RAMQ).

Such a measure would therefore eliminate the choice doctors currently have to opt out of the public plan. Combined with other major legislative changes, like the prohibition against using placement agency nurses in the public system,(3) it shows a tendency toward gradually reducing collaboration between the private and public sectors. Yet, contrary to what the CMQ and the current government believe, private medical practice supports the public system, contributing to a universal healthcare system with better access to care.

An Extreme and Unjustified Fear of Private Medicine

While each system works differently, the freedom of choice to practise in the private sector remains common in the majority of OECD countries (see Table 1).

For example, in the Netherlands, the country with the best access to care according to the Commonwealth Fund’s ranking,(4) the system is based entirely on a competitive private market made up of insurance companies and independent doctors.(5) Hospitals, for their part, are administered completely autonomously. The result of this approach based on market mechanisms and patient needs: 99% of the Dutch have access to primary care, compared to 86% of Canadians.(6)

In France, doctors can freely practise in the public and private systems, financed by a mix of the social security insurance program, complementary private insurance, and direct payments from patients.(7) The private sector, equally present in family medicine and in the hospital system, can allow patients to receive care more quickly than in the public system.(8) The independent administration of private hospitals allows them to specialize, and the quality of care provided in many of these facilities is widely recognized.(9)

These examples, which are far from unique, demonstrate that when countries encourage coexistence between the public and private systems rather than opposing it, the population has better access to care. Prohibiting non-participation in the public plan would moreover be a step in the completely opposite direction from that taken by the majority of OECD countries, isolating the Quebec healthcare system even more.

Instead of further restricting collaboration between the public and private sectors, it would be more beneficial to encourage it. Indeed, current restrictions force doctors to choose between the public and private sectors, pushing a number of them to disaffiliate themselves from the public plan.(10) In the countries mentioned above, and generally speaking in the rest of the OECD, doctors have the option of practising simultaneously in both sectors, which is known as mixed practice. Note that this is not prohibited by the Canada Health Act (CHA), but by the province. Therefore, not only should Quebec allow this practice, but it is fully within its rights to do so, without violating the CHA.

Many international examples where mixed practice is allowed show that doctors who take advantage of the option generally do not devote less time to public sector patients than those who practise exclusively in the public system.(11) This is the case in Australia, for instance, where nearly half of specialists practise in both the public and private sectors.(12)

In Denmark, a study of surgeons and anesthesiologists did not find any significant differences in the average number of hours worked in public hospitals between doctors in mixed practice and those working exclusively in public hospitals. This study also showed that increased hours worked in the private sector did not seem to lead to an intention to reduce the number of hours worked in the public sector.(13)

In short, the possibility of practising in both sectors would encourage many doctors to increase their number of hours worked, by adding hours in the private sector on top of those already devoted to their patients in the public system.

Conclusion

The CMQ brief is right about one thing: the coercive measure to prohibit doctors from disaffiliating themselves for the first five years of practice does not address the factors that make the public sector so unattractive for many young doctors, and so easy for them to leave.(14) Prohibiting independent medical practice, however, would be an even more extreme approach than the one proposed in Bill 83, without doing anything more to address the real causes of the problem.

In the current context, Quebec doctors must choose between practising in the public sector or disaffiliating themselves from the RAMQ to practise in the private sector. Authorizing mixed practice, rather than restricting medicine to the public sector alone, would lead to an increase in treatment capacity through a better use of resources, in addition to offering doctors greater professional autonomy.