Quebec discouraging pediatricians from seeing healthy patients

Many pediatricians are worried about changes to RAMQ billing that prioritize kids with urgent, chronic or complex health problems.

Montreal Gazette 7 minute read September 30, 2021

As for taking on new patients, Mitch Shiller, a West Island-based pediatrician asks: “If the only code we can bill is a followup, how do you bill a followup on a patient you have never seen? Everything is unclear.” Pierre Obendrauf / Montreal Gazette

Quebec pediatricians are being discouraged from following healthy children in private practices and the code that allows them to bill for that service will be abolished as of Dec. 1 — a move that is raising concerns among pediatricians and the family doctors who are supposed to fill the gap created by the new measure.

While the concept in principle has few critics, there are concerns about the timetable, the lack of a clear plan and clear directives for what will be allowed or not moving forward, and fears that children will fall through the cracks because there aren’t enough primary health-care workers to service them.

“The general examination for the assessment of the growth and development of a healthy child by pediatricians, whether in the office or in the hospital, will be effectively abolished on Dec. 1,” Marie-Claude Lacasse, a media relations co-ordinator for the department of health and social services, said in an email.

The change is being made so pediatricians can devote their time to children with urgent, chronic, special or complex health problems, she said.

The move was proposed by the Association des Pédiatres du Québec (APQ) last April and was originally supposed to take effect July 1, but that was pushed back. APQ president Marc Lebel said in an interview that the move just follows what has been evolving naturally over the last 15 years with the association’s 750 members.

“The lonely pediatrician in a private practice is no more,” he said, explaining that pediatricians are dealing with more complex cases and are more effective working in hospitals or as part of large mulitidisciplinary clinics.

However, he said pediatricians can continue to see patients who are in good health and take care of new patients after Dec. 1. The difference will be that if they continue to see children without problems, they will have to use a followup visit code (9129) that will pay $5 less.

In the more urban areas of Quebec, newborn babies have traditionally started visits with a pediatrician immediately and have been followed until they reach 18 with annual checkups and any other required care. While the APQ insists that pediatricians who still want to follow healthy babies in their offices will be allowed to, there is much concern among pediatricians that the government will stop funding such visits.

Jesus Ardila, a pediatrician in private practice in LaSalle, believes the APQ’s assurances are meaningless. “The only thing that counts is what RAMQ (Régie de l’assurance maladie du Québec, the provincial health insurance agency) wants and does,” he said in an interview.

Mitch Shiller, a West Island-based pediatrician, agreed. “In the end, RAMQ has the final decision and they can audit you even years later,” he said in an interview.

For example, he said, a visit for a four-month checkup is not a followup. So might RAMQ come back later and reject the 9129 code the pediatrician billed it under, which is for a followup?

As for taking new patients, which Lebel said is fine, Shiller has doubts: “If the only code we can bill is a followup, how do you bill a followup on a patient you have never seen?” he asked. “Everything is unclear.”

Jessica Yeates, president of the Council of Community-Based Pediatricians, said some pediatricians are definitely worried about the change. “The APQ is telling us we can use the 9129 code but some doctors are worried it won’t be accepted by RAMQ if it’s for a healthy child,” she said in an interview.

Indeed, cost-cutting does seem to be at the heart of the move. Lacasse said the decision was made in conjunction with the Institut de la pertinence des actes médicaux (IPAM), which in April said it was aiming to cut $240 million by March 2023.

According to RAMQ, the 9194 code that is being abolished would pay $59.80 for a general exam. The 9129 code that the APQ says can be used instead is for a followup at $54.60.

According to numbers provided by Lacasse, the number of times RAMQ was billed for code 9194 in 2017 was 104,685. In 2019 it was 87,711 and in 2020 it was 54,854 (the decrease there was attributed to COVID).

Lebel said there are about 650,000 outpatient visits in pediatricians’ offices every year. He said the need to reserve pediatricians for more specialized care is a result of more children surviving complex diseases or premature births that require more care.

“I know some pediatricians aren’t happy with that, but family doctors and nurse practitioners should be able to handle the primary care of children,” Lebel said.

They should be able to … but will they? In September 2020, there were 913 nurse practitioners in Quebec. The government aims to have 2,000 nurse practitioners by 2024-25. But Montreal in particular has a critical shortage of family doctors.

“It’s going to be tough (to fill the need) in Montreal and the 450 area code,” said Jean-Pierre Dion, director of communications and public affairs for the Fédération des médecins omnipraticiens du Québec (FMOQ), while acknowledging it makes sense for pediatricians to focus on more complex cases. “It will create even more of a shortage of family doctors. It’s not good news for us.”

Quebec is unique in Canada for having a serious dearth of family doctors. Last year alone, Dion said, 75 spots for family medicine residencies were left vacant in Quebec, while there were only 20 vacancies across the rest of Canada.

In Quebec, people have to register with a family physician access centre to be assigned a GP. Each person is assigned a priority rating based on their state of health. On the island of Montreal, the figures show that as of July 31 there were more than 163,000 people registered to see a GP across all priorities. The average waiting time for those registered on the island of Montreal, in the three highest priorities, ranged from 274 days to 387 days.

Lebel said the problem with access to a GP is “only” in the greater Montreal area — but that represents about half the population of the province.

Still, many in the medical community believe the idea makes sense.

Sarah Wizman is the medical director at ELNA Tiny Tots Medical Centre on Décarie Blvd. and she believes healthy children should be followed by first line health-care workers and pediatricians should act as consultants. That’s mainly how it works at her clinic, which comprises 16 pediatricians and 19 family doctors.

She’s fine with the APQ’s assurances that pediatricians can still follow children in good health, although she acknowledged doctors’ concerns about billing are justified because RAMQ “has come back to us many times to say you can’t bill for this.”

She believes that pediatricians will be allowed to continue to see patients they have started with, but that they won’t be allowed to take on new healthy patients.

“Pediatricians should focus on complex cases, it’s the way it should be,” she said.

Ardila worries that “in the absence of family doctors, kids will only be taken to clinics when they’re sick and the annual exams will stop.”

He does not expect all the kids he sees now to be accepted under the new code and believes some pediatricians will be forced to close their practices.

“The idea of having family doctors and nurse practitioners following kids is fine,” Shiller said. “The problem is that finding one willing to take on new patients is very difficult.”

He said pediatricians aren’t worried about billing for $5 less per visit, but what the removal of the 9194 code really means: “The message is they don’t want us billing for this.”

The absence of a plan on how this will work and the lack of clarity are the problems, he said.

“I don’t have a clue what will happen with my practice,” he said. “I will bill for 9129 until I’m told I can’t, at which time I will tell patients I can’t see them for well baby care.”