Increasing Remuneration for Publicly Covered Eye Examinations in Québec
Katja Lemermeyer
McGill University, Montréal, Québec, Canada
Abstract
In Canada, fees for publicly covered health services are negotiated between professional associations and provincial governments, usually for multi-year periods. Whereas almost all services provided by physicians are publicly covered, some professions, such as optometrists, serve both publicly and privately paying patients. For these professions, the gap between what they are paid for both types of patients looms large in their negotiation with the government. Moreover, they can threaten to walk out and refuse to treat publicly covered patients altogether, which increases their bargaining power vis-à-vis the government. The failed negotiation between optometrists and the Québec government between 2015 and 2018, and its resolution in 2018 is therefore a case study that offers valuable insights about the relationships between public payers and professions in a context where publicly covered services are only a portion of the profession’s income. Amid stalled negotiations, thousands of optometrists announced they would collectively opt out of the public system. However, this move was blocked by the Québec government via a ministerial decree which was then legally challenged by the Québec Association of Optometrists. The escalation of this dispute attracted considerable media coverage, garnered public interest, and mounted pressure on the Québec government. Ultimately, an agreement on an updated remuneration was reached ahead of the court date, and the new fees came into effect in August 2018.
Au Canada, les tarifs des services de santé couverts par le système public sont négociés entre les associations professionnelles et les gouvernements provinciaux, généralement pour des périodes pluriannuelles. Alors que la quasi-totalité des services fournis par les médecins sont couverts par le système public, certaines professions, comme les optométristes, s’adressent à la fois à des patients bénéficiant d’une couverture publique et à des patients bénéficiant d’une couverture privée. Pour ces professions, la différence entre ce qu’elles sont payées pour les deux types de patients représente un contrainte considérable dans leurs négociations avec le gouvernement. En outre, les membres de ces professions peuvent menacer de quitter l’accord et de refuser de traiter les patients couverts par le système public, ce qui accroît leur pouvoir de négociation vis-à-vis du gouvernement. L’échec des négociations entre les optométristes et le gouvernement du Québec entre 2015 et 2018, suivi d’une résolution en 2018, est donc une étude de cas qui offre des indications très utiles sur les relations entre les payeurs publics et les professions dans un contexte où les services couverts par le système public ne représentent qu’une partie des revenus de la profession. Face à l’impasse des négociations, des milliers d’optométristes ont annoncé qu’ils se retireraient collectivement du système public. Toutefois, cette décision a été bloquée par le gouvernement du Québec au moyen d’un décret ministériel qui a ensuite été contesté juridiquement par l’Association des optométristes du Québec. L’escalade de ce conflit a attiré une couverture médiatique considérable, a suscité l’intérêt du public et a fait monter la pression sur le gouvernement du Québec. Finalement, un accord sur une rémunération actualisée a été conclu avant la date du procès, et les nouveaux honoraires sont entrés en vigueur en août 2018.
Key Messages
- Stalled negotiations between the Québec Ministry of Health and the Québec Association of Optometrists delayed a decision on 2015-2020 fees for publicly covered optometric services until mid-2018.
- Québec optometrists leveraged their ability to opt out of the public system en masse to apply pressure on the government amid unsuccessful negotiations.
- Media coverage played an important role in further mounting public pressure on the government.
- The escalation of events between the Québec government and the Québec Association of Optometrists raises the question of what alternative policy instruments may be appropriate following unsuccessful negotiations.
- Le blocage des négociations entre le ministère de la Santé du Québec et l’Association des optométristes du Québec a empêché la prise d’une décision sur les tarifs 2015-2020 pour les services d’optométrie couverts par le système public jusqu’à la mi-2018.
- Les optométristes du Québec ont tiré parti de leur capacité à se retirer massivement du système public pour faire pression sur le gouvernement, alors que les négociations n’aboutissaient pas.
- La couverture médiatique a joué un rôle important dans l’augmentation de la pression publique sur le gouvernement.
- L’escalade des événements entre le gouvernement du Québec et l’Association des optométristes du Québec soulève la question des instruments politiques alternatifs qui pourraient être appropriés après des négociations infructueuses.
Brief Description of the Health Policy Reform
On 29 August 2018, Québec’s public health insurance plan, the Régie de l’assurance maladie du Québec (RAMQ) put the Renouvellement de l’entente 2015-2020 into effect, which laid out the agreement for substantially increased rates of remuneration for publicly covered optometric services. Fees were increased by almost 60%, representing a major shift in the valuation of optometric services by the government of Québec and a breakthrough in optometrist-government relations after years of unsuccessful negotiations. The update came following an intense public relations campaign carried out by the Association des optométristes du Québec ([AOQ] n.d. a).
As part of such a campaign, Québec optometrists were threatening en masse to remove themselves (“opt out”) from participation in RAMQ in lieu of a substantial increase to their remuneration. Had this occurred, patients who were eligible for publicly covered optometric services – namely, youth, seniors, and those receiving government welfare – would be forced to pay out-of-pocket or subscribe to private insurance to access such services. However, the Québec government was hesitant to increase health care spending due to a prevailing commitment to cost containment at the time. As such, the Renouvellement aimed to increase remuneration by the minimum viable amount to keep Québec optometrists participating in RAMQ – limiting health care expenditure on the government’s part, but retaining access to vision care for risk groups.
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
Date | Key event | ||||||||
---|---|---|---|---|---|---|---|---|---|
February 2017 | AOQ presents its demands for the 2015-2020 renewed fee agreement | ||||||||
September 2017 | AOQ begins internal and external PR campaign for fee increases | ||||||||
7 February 2018 | AOQ breaks negotiations with Québec government, announces decision of 90% of its members to leave RAMQ (effective March 10) | ||||||||
16 February 2018 | Ministerial decree issued by Québec Minister of Health to block optometrists from leaving public system | ||||||||
25 February 2018 | AOQ announces their appeal of the decree | ||||||||
13 June 2018 | Agreement reached between AOQ and Québec government | ||||||||
16 June 2018 | Agreement ratified by AOQ members in General Assembly | ||||||||
31 August 2018 | Changes implemented in optometrist’s manual, with initial increase (retroactively) effective from 1 April 2018 | ||||||||
1 April 2019 | Second stage of fee increase effective; the fee for a basic complete eye exam almost doubles compared to its prenegotiation value | ||||||||
31 March 2020 | End of billing period for which negotiations were taking place | ||||||||
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
The newly agreed-upon rates were added to the Optometrists’ Manual: Agreements and Fees at the end of August 2018 and were set to be increased in two stages, as presented in Table 2. Retroactive fee increases would be applied to the reimbursement for services delivered from April to August 2018.
Billing code | Previous fee (pre-2018) | Updated fee (2018-2019) | Updated fee (2019-2020) | ||||||
---|---|---|---|---|---|---|---|---|---|
9001 Complete eye exam (basic) | $28.55 | $40.00 | $54.75 | ||||||
9007 Field of peripheral vision exam | $8.00 | $8.00 | $8.00 | ||||||
9021 Supplement fee (patients aged 75 and older) | $5.70 | 6.25 | $7.00 | ||||||
9020 Dilation of posterior segment | $20.73 | $26.25 | $33.15 | ||||||
9024 Supplement for tonometry and/or biomicroscopy | $4.00 | $4.00 | $4.00 | ||||||
Maximum remuneration for annual eye exam | $66.98 | $84.50 | $106.90 | ||||||
Source: Data from RAMQ (2017a and 2023b). |
Correspondence with the AOQ in 2021 confirmed that the 2019 increase had in fact come into effect. Further, although the agreement only officially applies until March 2020, as of the current time of writing, there has been no subsequent Renouvellement, and the updated fees from 2019 are found in the latest edition of the Optometrists’ Manual published in July 2023.
Evaluation
No completed or planned evaluation of the fee increase was found. However, an evaluation of the increase in fees over 2015-2020 may provide valuable insight for future negotiation. In doing so, it would be valuable to compare how the public fee compares to the average private fee.
Strengths, Weaknesses, Opportunities, Threats
The strengths, weaknesses, opportunities, and threats of the updated remuneration for optometrists in 2018 are presented in Table 3. Stakeholder perspectives are indicated in parentheses.
Strengths | Weaknesses |
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|
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Opportunities | Threats |
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