Increasing Remuneration for Publicly Covered Eye Examinations in Québec

Abstract

Key Messages

Brief Description of the Health Policy Reform

History and Context

Optometry is a regulated profession in Canada, with each province having a distinct regulatory college and set of regulations for practice. Each province also has a professional association which advocates for optometrists at the policy, regulatory, and public levels. In Québec, this body is the AOQ, which was formed in 1966 and is the designated representative for Québec’s optometrists when negotiating with the provincial government concerning matters such as RAMQ coverage, billing codes, and procedures (AOQ n.d. a).

In most Canadian provinces, routine eye exams may be provided by either optometrists or physicians, though the vast majority are provided by optometrists due to the highly specialized equipment required (Wang and Sweetman 2020). As such, privately operating optometrists provide most eye exams in Québec.

Coverage for optometric services varies across population groups and jurisdictions. Basic optometric services were publicly insured in most provinces following the Canada Health Act, 1984, but many gradually delisted eye examinations for the general adult population throughout the 1990s and early 2000s. Québec enacted this change in 1993, after which coverage for certain optometric services remained only for people over age 65, people under age 18, diabetics, visually impaired persons, and recipients of government welfare (Government of Québec 2020).

Since then, healthy adults aged 18-64 and not on welfare pay out-of-pocket or through private insurance for a routine eye exam, with fees set at the discretion of the optometrist (AOQ n.d. b). In 2022 (the oldest year on record publicly), recommended fees were $125 for a full exam and $70 for a partial (subsequent one); given that recommended fees tend to increase by $5 a year, we can infer a full exam was recommended at around $90 in 2015 and $100 in 2018, at the time of the studied policy move.

However, when they treat a publicly covered patient (as defined above), the optometrist has to charge the fee that has been agreed upon by the AOQ and the provincial government (the patient does not pay anything and the optometrist charges the provincial plan). These fees are negotiated between the AOQ and the Government of Québec and are usually set for five-year terms. Agreed-upon fees are much lower than the recommended ones for privately paying patients: they were at around $25 for a basic full exam before the resolution of 2018 (see Table 2 below for more detail), or approximately one quarter of private fees. These public fees are renegotiated over time to account for inflation, increases in operational costs and other factors, usually tending to increase though fee decreases are possible and may be appropriate in the event of technological or efficiency improvements. Prior to the Renouvellement de l’entente 2015-2020, the most recent Renouvellement occurred in 2013. The fee increases at this time were minimal, with the remuneration for a basic eye exam increasing by $2.25 (RAMQ 2013).

It is not permissible under the Canada Health Act for health care providers to charge patients additional fees for services paid for through the public plan (Polèse 2012). However, in Québec and several other provinces, if providers choose to opt out of the public plan, they may charge whatever amount they wish directly to patients (Flood and Archibald 2001). To opt out, Québec optometrists must notify RAMQ of their intent and wait 30 days for the status change to take effect (RAMQ 2020). If they opt out, they can only serve patients who agree to pay out-of-pocket or through private insurance; they cannot see both publicly covered and non-publicly covered patients.

The Policy-Making Process

News coverage and press releases issued by the AOQ provide a timeline of events in the policy-making process. In a press release on 7 February 2018, the AOQ announced that after a year of unsuccessful negotiations about 2015-2020 remuneration rates, they had formally exited their talks with the Québec government (AOQ 2018a). Furthermore, they announced that 90% of optometrists would opt out of the public regime, effective after the 30-day waiting period, in protest of continued poor remuneration and negotiation deadlock.

There was significant coverage of this announcement in both the anglophone and francophone news media in Québec. Coverage of the issues further increased later in the month after Gaétan Barrette, Québec’s Minister of Health and Social Services, issued a ministerial decree that blocked the optometrists’ ability to opt out of the public system – an announcement that was met with substantial resistance from optometrists.

Subsequently, the AOQ announced in a press release that they would be appealing the decree in Québec’s Superior Court (AOQ 2018b). They argued that Section 30.1 of the Health Insurance Act, under which the ministerial decree was issued, grants the minister limited power that only covers health professionals who provide “medical services,” namely physicians. They argued that optometrists provide optometric, not medical, services. Between February and June 2018, the AOQ issued several more press releases drawing attention to perspectives like the impact of the issue on at-risk groups; however, media coverage on the topic generally quieted during this period.

In mid-June 2018, the AOQ issued a press release announcing its members had ratified an agreement with the provincial government to increase fees for several publicly covered optometrist services, including annual eye examinations (AOQ 2018c). This release stated that the agreement was reached on 13 June 2018, only one day before the two parties had been set to meet in the Superior Court. The press release also stated that the provincial government would be withdrawing its ministerial decree and the AOQ would withdraw its appeal.

Although the agreement was originally intended to cover the period from 2015 to 2020, as its name implies, the agreed-upon fee changes only came into effect upon their inclusion in the Optometrists’ Manual in August 2018.

Timeline of key events

Influential factors: institutions, interests, and ideas

The “3-i” framework uses three factors to explain public policy development processes: ideas, interests, and institutions (Gauvin 2014). In the context of health policy analysis, it is “useful both retrospectively and prospectively, to understand past policy choices, and to plan for future policy implementation” (Walt et al. 2008, 308). As such, this section uses the framework to assess the factors influencing the agreement that was reached between the Québec government and the AOQ.

Interests

Under the 3-i framework, interests are defined as the “agendas of societal groups, elected officials, civil servants, researchers, and policy entrepreneurs” (Pomey et al. 2010, 709). In the context of the Renouvellement, the interests of Québec optometrists and the government officials involved in the negotiations will be considered, as well as the media strategy that was employed by the AOQ advance their interests.

Optometrists’ primary interests are to operate their clinics profitably while providing optometric services, requiring both sufficient compensation for such services and a sufficiently high volume of patients. Generally, optometrists are incentivized to remain in the public system to maintain a larger base of clients through serving publicly covered risk groups. This incentive is not trivial, as youth and seniors alone make up about 40% of Québec’s population (Government of Québec 2024), not even considering diabetics, visually impaired persons, and those on social assistance outside of those age groups who also qualify for public coverage. When optometrists consider the public remuneration to be too low, they can either raise what they charge to their private patients (those covered by patients’ private insurance or paying out-of-pocket) to compensate and reach their desire profit rate, or opt out entirely of offering public services (and increase their private volume to compensate). Patient composition likely varies across practices, meaning that patient volume may affect certain optometrists more than others should they opt out of the public system. Regardless, it is generally in the interest of optometrists for remuneration to increase and to remain a part of the public system.

The AOQ’s self-described “public relations campaign” aimed to highlight the difficult position that many optometrists reported to be in due to an imbalance between escalating costs and stagnant remuneration. This effort was designed to sway public opinion in their favour and to exert pressure on the Québec government and its policy-making. Notably, several media outlets reported that optometrists had experienced a 150% rise in operating costs over 30 years, compared to a 56% increase in remuneration by RAMQ during the same period (AOQ 2018a). Additionally, the Montreal Gazette published an op-ed by a practicing optometrist explaining his difficult choice to leave the public system after 40 years because he faced losses on each publicly covered eye exam he delivered. Personal accounts such as this from individual optometrists reinforced the sentiments in the AOQ’s official statements and further appealed to the public’s emotions. As a whole, the public relations campaign emphasized that the threat to leave RAMQ was out of desperation and that an increase in remuneration would help protect the financial viability of operating an optometry clinic.

In addition to optometrists’ self-interest, the AOQ asserted that it was advocating for the interests of the risk groups whose eye exams were publicly covered. One AOQ press release specifically pointed out the critical shortage of optometrists in rehabilitation centres, emphasizing the urgent needs of patients with low vision (AOQ 2018d). It was argued that the low remuneration associated with these publicly covered services discouraged optometrists from serving high-need patients. In this light, the AOQ was able to make a case that low remuneration was not only harming optometrists but also redirecting practitioners away from the vulnerable populations who need their services most. By framing their campaign with this altruistic perspective, the AOQ aimed to enhance its appeal and garnered greater sympathy from the public – ultimately serving its own self-interest.

As elected officials, the Québec government is invested in preserving positive public opinion. Doing so may involve limiting additional health care spending in the name of fiscal responsibility, or in investing in public health care infrastructure (the importance of which to Canadians is discussed in the following section). In a statement to the Montreal Gazette, Health Minister Gaétan Barrette downplayed optometrists’ threats to leave RAMQ and alleged it was part of a “pre-electoral dance” to draw attention to the issue ahead of provincial elections approaching that fall (AOQ 2018c). Voters would likely perceive an agreement to increase fees as a promise to increase health care spending, which the government also likely hoped to avoid before an election. However, it is worth noting that optometrist services accounted for only about 1% of the health ministry’s budget prior to the fee increases (Québec Optometrists 2018).

Ideas

Ideas refer to “knowledge or beliefs about what is (e.g., research knowledge), views about what ought to be (e.g., values), or combinations of the two” within the 3-i framework (Pomey et al. 2010, 709), thus this section will first discuss ideas in terms of knowledge, and then in terms of values.

There is limited evidence to suggest that remuneration increases were based on any empirical research or body of knowledge on the topic. The AOQ website states that early in their negotiations with the Québec government in February 2017, they presented a white paper on the optimization of the role of optometrists, but this document was not readily available online or by request (AOQ n.d. b). Additionally, in 2012, the AOQ and Québec government jointly commissioned a study by an independent accounting firm, which found that optometrists worked at a loss when treating patients covered by the public plan (AOQ 2018f). According to the AOQ’s website, the government acknowledged the results of said study in 2013, but five years later they still failed to pass any regulation addressing the issue (AOQ 2018c). It is unclear to what extent the results of the study and content of the white paper played a role in the remuneration agreement ultimately reached in June 2018.

The prospect of optometrists exiting the public system raises important equity concerns among advocacy groups and practitioners, especially given the context of a steady increase in physicians opting out of RAMQ over the past 25 years (Contandriopoulos and Law 2021). The equity and access concerns of “opting out” are quite comparable to concerns about the impacts of delisting services from public coverage, when financing shifts from the public to the private sector, but more severe, as the affected populations are deemed at risk and vulnerable; it is therefore a tricky move from the profession, as it can be accused of putting the health of vulnerable fellow citizens at risk.

The impact of delisting on the private price of a service is unclear. Wang and Sweetman (2020) theorize that prices charged to private patients may drop due to declining demand after delisting or increase since the monopsony power of the government is removed. While no academic studies have analyzed the prices of a province’s private optometric services after delisting, a survey by the Consumers’ Association of Canada (1996) recorded an average 30% increase in the cost of routine adult eye exams five months following their delisting in Alberta.

Regardless of the change in price of a private service for the general population, the price at point of service will unmistakably increase for the groups who were previously publicly covered. Thus, whether an individual can access delisted services is contingent on their ability to pay (Wang and Sweetman 2020). When this occurs, utilization is expected to decrease as many people are unwilling or unable to pay for routine medical care. Two studies that investigated the impacts of delisting eye care in Ontario demonstrate this: Jin et al. (2012) noted reductions in access for socially disadvantaged groups, while Kiran et al. (2013) observed a decline in screenings for individuals aged 40-65 years with diabetes following the cuts. Given the preventative nature of annual eye exams, a reduction in utilization raises concerns about downstream health impacts and costs. As such, public coverage maintains both access to and utilization of an important form of preventative eye care for risk groups in Québec.

Linking access to medical services with an individual’s ability to pay starkly contradicts the principles of universal health care, a point of national pride for many Canadians. Consequently, any reduction in access for risk groups who are guaranteed public optometric services would be inconsistent with public opinion on access. This was demonstrated in the media coverage of the negotiations between the AOQ and the Québec government, which did not include any discussion of whether currently covered services under RAMQ should remain covered. Rather, the prospect of most optometrists opting out of public coverage stirred a panic that was covered across francophone and anglophone media sources in early 2018. There was an implicit consensus in the media coverage that those under 18, over 65, and on welfare should be able to access these services through RAMQ, and that losing this access would be a great loss.

Institutions

Institutions are defined as “the formal and informal rules, norms, precedents, and organizational factors that structure political behaviour” (Pomey et al. 2010, 709). As such, when examining reimbursement in Québec, it is essential to address the rules and norms that guide the fee negotiations. At the most basic level, the fee-for-service model makes up the backbone of optometrists’ compensation for their services. This model relies upon regular negotiations to adjust fees to account for inflation, changes to costs of the service, and other factors. Generally, the government is motivated to set fees that are satisfactory to optometrists, such that most optometrists would not be financially incentivized to opt out of the public system. So, while individual practitioners maintain the right to opt out of public reimbursement, a goal of mutually agreed upon fees is to prevent optometrists from opting out en masse from the government’s public coverage. These norms are critical importance to the functioning of the fee-for-service model as it is implemented in Québec.

Within any negotiation, each party has levers of action which may be employed to influence the other side to move closer to their position. Within fee-for-service compensation and the accompanying negotiations, the policy instruments available to the government act as levers of action. For example, the delisting of many optometric services in the 1990s in Québec was a regulatory change passed by the provincial government applying to all optometrists. However, in 2018, when negotiations between the two parties were breaking down, the ministerial decree blocking optometrists’ threats to exit the public system was an unconventional policy instrument in the process which generally operates within a framework of negotiations. This raises the question of whether the current format of negotiations is an effective means to reach fair compensation if the threat of mass exit, considerable media attention, and public pressure were necessary for the government to properly respond to optometrists’ concerns.

Implementation and Evaluation

Strengths, Weaknesses, Opportunities, Threats

References