Differences between the healthcare systems of Quebec and France for the treatment of pain due to spinal disorders

Abstract

In Quebec, Canada, the public healthcare system offers free medical services. However, patients with spinal pain often encounter long waiting times for specialist appointments and limited physiotherapy coverage. In contrast, private clinics provide expedited care but are relatively scarce and entail out-of-pocket expenses. Once a patient with pain caused by a spinal disorder meets a pain medicine specialist, spinal intervention is quickly performed when indicated, and patients are provided lifestyle advice. Transforaminal epidural steroid injections are frequently administered to patients with radicular pain, and steroid injections are administered on a facet joint to control low back or neck pain. Additionally, medial branch blocks are performed prior to thermocoagulation. France’s universal healthcare system ensures accessibility at controlled costs. It emphasizes physical activity and provides free physical therapy services. However, certain interventions, such as transforaminal and interlaminar epidural injections, are not routinely used in France owing to limited therapeutic efficacy and safety concerns. This underutilization may be a potential cause of chronic pain for many patients. By examining the differences, strengths, and weaknesses of these two systems, valuable insights can be gained for the enhancement of global spinal pain management strategies, ultimately leading to improved patient outcomes and satisfaction.

Key Words: Spinal pain; Healthcare system; France; Quebec; Pain treatment

Core Tip: The public healthcare system in Quebec, Canada, provides free services; however, patients with spinal pain face long waiting times for specialist appointments and limited physiotherapy coverage. Spinal interventions, including transforaminal epidural steroid injections for radicular pain, are performed quickly upon consultation with a pain specialist. In contrast, France's universal healthcare system emphasizes physical activity and offers free physiotherapy; however, certain interventions, such as epidural injections, are underutilized, potentially contributing to chronic pain. Each system has advantages and disadvantages. Understanding these differences can inform global spinal pain management strategies and enhance patient satisfaction and outcomes.

TO THE EDITOR

We read the article by Wang et al[1] with great interest, in which the authors proposed a protocol for physicians to administer ultrasound-guided injections as treatment for spinal pain. Spinal pain is highly prevalent in the general population and often causes substantial suffering, many lost workdays, and high medical costs[2]. The healthcare system in every country has its preferred treatment strategy for spinal pain. Here, we provide our personal perspectives, aiming to introduce the strategies of the healthcare systems in Quebec and France, compare them, highlight their shortcomings, and provide potential solutions.

The first author is a resident in the Department of Physical Medicine and Rehabilitation at a university hospital in France and has been enrolled in an overseas resident training program in Montreal, Canada, since December 2023. In Montreal, we observed substantial differences between the healthcare systems’ preferred strategies, especially regarding pain caused by spinal disorders, each with their own advantages and disadvantages. The functioning of healthcare systems is very complicated and is influenced by social, economic, and political factors[3,4].

In Quebec, Canada, medical institutions (hospitals and clinics) are categorized as public and private institutions[5]. Public institutions ensure that citizens receive medical services without incurring fees for visits and treatments. On the other hand, patients who receive care from private clinics cover the costs of treatment and procedures by themselves and are rarely reimbursed by insurance companies. Although the number of private clinics is increasing in Canada, Quebec has few.

Although the public healthcare system in Quebec offers free services, patients often wait several months or even years for an appointment with a physician. Private clinics provide an alternative for patients who are unwilling to endure long waiting times by offering fast access to medical care. However, the availability of private clinics and range of medical services offered are limited. Despite the option to expedite care by paying privately, this remains a less common choice because of the scarcity of such facilities and the associated costs.

Once patients with pain caused by spinal disorders meet a specialist in pain medicine, they are quickly referred for spinal intervention, if necessary, and given lifestyle advice. Spinal interventions are performed using nonparticulate corticosteroids. Transforaminal epidural steroid injections are frequently administered to patients with radicular pain, and steroid injections are administered on a facet joint to control low back or neck pain. Medial branch blocks are also performed. If patients experience pain reduction via medial branch blocks, pain physicians normally recommend thermocoagulation.

Physiotherapy is not covered by the public healthcare system and is mainly conducted in private clinics, for which patients must pay out of pocket. Only a small proportion of outpatients have access to free physiotherapy, mainly in public health institutions. Therefore, education regarding physiotherapy and exercise for the treatment of spinal pain is not well implemented in Quebec.

In France, medical institutions are divided into public sector (public hospitals) and private sector (clinics or independent practices) institutions[6,7]. Few nonprofit private healthcare providers exist. The public healthcare system is based on health insurance schemes-a universal healthcare system that ensures that patients receive care, consultations, and treatments with controlled, fixed costs. The system covers 70% of medical consultation costs, with a one-euro fee per consultation, and is complemented by other insurance systems. Hospitalization costs are split, with health insurance covering 80% and supplementary plans covering 20%. The solidarity health insurance or State aid can exempt those who cannot pay these fees. Private health insurance schemes can handle upfront costs.

In terms of healthcare access, patients with spinal pain follow a care pathway guided by general practitioners for optimal management[8]. Accessing public or private specialized care has become more difficult owing to a shortage of medical professionals, leading to waiting times of 2 d for general practitioners and 52 d for specialists, excluding urgent cases.

When a patient with spinal pain is referred to a pain specialist, the diagnosis is first revisited, and the likely cause is identified based on the patient’s history[8]. Thereafter, the patient is provided counsel regarding physical activity, posture, lifestyle adjustments, muscle strengthening, and stabilization-exercise programs. Patients can receive physiotherapy at a physical therapist’s office, which is covered by health insurance, private assurance, or county assurance. In most cases, patients receive physiotherapy at no cost.

If the patient continues to experience severe pain or pain that does not improve during follow-up appointments, spinal intervention may be considered, with the specific type of treatment chosen according to patient-specific clinical factors. Caudal epidural injections are recommended for patients with radicular pain. However, in France, transforaminal and interlaminar epidural injections are not routinely administered because of their limited therapeutic efficacy and safety concerns. Pain specialists often use facet-joint infiltration to treat low back pain.

For chronic or recurrent spinal pain, comprehensive care may involve a rehabilitative stay at a day hospital for 3-6 wk, covered under standard hospitalization packages[8]. Such a program entails re-evaluation of various factors contributing to pain, addressing of the patient’s beliefs and lifestyle, and provision of nutritional and psychological support and daily physiotherapy sessions.

In Quebec, the public healthcare system provides free access to medical services, and the conventional pathway for spinal interventions tends to depend on the interventionist. However, long waiting times for specialist appointments, which lead to delayed treatment, and limited coverage of physiotherapy are significant drawbacks. Few private clinics offer expedited care, largely owing to the associated costs, making them an uncommon choice. To improve this situation, Quebec should consider improving the system’s efficiency or increasing funding to reduce waiting times and expand physiotherapy coverage.

France’s universal healthcare system ensures affordable access to care and follows a thorough care pathway for spinal pain management. It minimizes costs by reducing the frequency of early interventions and offers easy and free access to physiotherapy. However, the use of certain interventions is limited and a passive approach to acute low back pain can predispose patients to chronic pain. To enhance the functioning of the system in France, considering therapeutic efficacy and potential side effects of different spinal interventions, the indications for spinal interventions should be expanded for patients who experience severe pain.

The health systems in Quebec and France have their strengths and weaknesses in terms of spinal pain management. The system in Quebec is more focused on chronic patient care, whereas the system in France emphasizes physical activity based on spontaneous remission of acute cases. Considering the strengths and weaknesses of the systems in Quebec and France may assist other countries in determining their treatment strategies for spinal pain to enhance patient outcomes and satisfaction.