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Dr. Mark Roper has been questioning the methodology that the government uses to determine how many new family physicians are needed in Montreal since he was involved in the complex process more than a decade ago.

Quebec is the only province that dictates where doctors can practice using a restrictive permitting system known as PREMs, short for Plans régionaux d’effectifs médicaux. The aim is to ensure equitable access to care across the province — something Roper calls a “noble effort.”

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But Roper, now chief of the division of primary care at the McGill University Health Centre and an associate professor in the department of family medicine at McGill, has long argued the formula for assessing each region’s needs is seriously flawed and the results over nearly two decades have been skewed. When he first tried to point it out, everyone passed the buck.

“The chief statistician said, ‘It’s not a statistical debate, it’s a political one’,” he recounted this week. “So then I started a political engagement with health ministers. I think I met with four of them from 2010 to 2020. And then a politician said ‘It’s not a political debate, it’s a legal one.’ … And that’s why all the interest in pursuing a legal approach, which we’re into now.”

In 2019, Roper launched a court challenge of the PREM system. Though he lost the first round last fall, he and lawyer Julius Grey will be back at the Quebec Court of Appeal Thursday, armed with a trove of research that underpins his case. The numbers speak for themselves.

Amid a worsening doctor shortage, Montreal has the lowest rate of patients assigned to a family physician in the province. At 68 per cent, it is worse than the Quebec average of 77 per cent and short of the government’s stated objective of 85 per cent. The next-worst region is next-door Montérégie at 75 per cent.

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The best is Saguenay—Lac-St-Jean at 91 per cent, followed by Gaspésie—Îles-de-la-Madeleine at 89 per cent, two of the five regions of the province that have hit the 85-per-cent registration target and are “living the health-care dream,” as Roper put it during a symposium with Grey at the MUHC this week.

But there are even greater disparities at the subregional level. For instance, in the territory of the CLSC Charlevoix-Est, 96 per cent of the population has a family doctor. In the Rocher-Percé district of the Gaspé, it’s 95 per cent. Ditto for Lac-St-Jean-Est, rounding out the top three.

Meanwhile, the five districts with the lowest percentage of the population assigned to a general practitioner are all in Montreal. At the bottom is the Faubourgs-Plateau-Mont-Royal-St-Louis-du-Parc district at 57 per cent in 2022, followed by Côte-des-Neiges-Métro-Parc-Extension at 59 per cent.

According to Roper, there are several anomalies in the methodology used by a committee made up of officials from the health ministry and the Fédération des médecins omnipraticiens du Québec to figure out what each region needs. And the formula for distributing PREMs has continually disadvantaged Montreal over the years.

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For one, doctors who fill in occasionally in regions that have historically been underserved aren’t tabulated as part of the labour pool. And Gaspé, where 95 per cent of the population has a family doctor, had more than 14 “dépanneurs,” as they are known, in 2020. Quebec City had seven occasionals and Montérégie four. Montreal had zero.

“The dépanneurs pre-dated the PREM system and one wonders about its utility,” Roper said. “If the dépanneurs are given to the most underserviced areas, then perhaps they should go to Montreal and not a place that has a 94-per-cent registration rate.”

Another problem is that the total number of permits handed out each year is slightly lower than the cohort of students finishing their residencies (even though fewer students have been graduating from family medicine programs). In contrast, Roper said, Ontario recruits 20 per cent more new doctors than it produces.

Quebec also only replaces 75 per cent of departures when a doctor retires or leaves the province, he said. Then, once all the numbers are crunched, the health minister has discretion to tinker with the allocations.

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“A ministerial adjustment is not in any way justified by any data,” Roper said. “Montreal suffered a cut of 30 (PREMs) in 2021 and 15 in 2022 for no apparent reason.”

But according to Roper, the biggest problem with the formula is that it only looks at the number of people with a Régie de l’assurance maladie du Québec card who live in a given area, divided by the number of doctors. (The ratio is one physician per 1,500 inhabitants). This disproportionately hurts Montreal because there are more people in need of care who aren’t covered by RAMQ in the city, like irregular migrants, diplomats, international students or folks experiencing homelessness. It also ignores the fact that there are almost 400,000 people who live outside the city but still have family doctors in Montreal.

While Roper is not suggesting these patients should be limited to seeing a doctor closer to home, since the Canada Health Act permits choice and mobility, he does think this group should be factored in when deciding how many doctors Montreal truly needs.

He offered an example of how this glaring omission has muddled the calculations in the worst-off Faubourgs-Plateau-Mont-Royal-St-Louis-du-Parc district. By ignoring the 67,000 non-residents who have a family doctor in the district, the committee considers that it has a surplus of 28 physicians. But Roper said if that data were factored in, there would actually be a deficit of 45 physicians — which is more in line with the reality on the ground.

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“As you can see, that is statistically ridiculous,” Roper said. “So in summary, we have a number of errors that sometimes compound each other in certain regions of the province. We have a portability of health care that’s not counted. Non-resident populations are not counted. Dépanneurs are not counted. Departures are replaced at 75 per cent. The total number of PREMs are less than the graduating cohort. And there is a ministerial adjustment that is not based on need or clear data — and perhaps it’s done just for political reasons.”

PREMs are increasingly recognized as a deterant for young doctors choosing family medicine in the first place, practising in the public system or staying in Quebec to work, given all the extra hoops they have to jump through without any guarantee of getting a permit where they want. The government this fall made some minor tweaks to the application process in an attempt to attract more candidates.

When he appeared before Quebec Superior Court, Grey argued that PREMs not only infringe on the freedom and mobility rights of doctors, but that the deficiencies in how the permits are allocated are unfair to patients in Montreal, compromising their right to life, liberty and security of the person.

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The judge in the first instance, Justice Dominique Poulin, didn’t fully agree.

“What she said was, ‘Yes, at first glance. Dr. Roper’s right, there’s something wrong with it. But then they have this committee and a sub-committee and they all work on it and we have to assume that test that they have … is not a worse test than any other.’ Except that it’s absurd. Except that it doesn’t work. It’s not compatible with the notion of freedom of medical choice,” Grey said. “We’re living in an era of deference and restraint where courts are afraid to correct the government.”

On appeal, Grey will argue that besides upholding fundamental rights, the courts also have a duty to overturn bad policy.

“The basic principles of our legal system tell us that an unreasonable administrative decision cannot stand,” he said. “There’s a famous case … in which the court goes over and over again saying that a decision must be intelligible, it must be reasonable and it must be taken with natural justice.”

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