Quebec must work with, not against, physicians
In a misguided bid to improve access to physicians, the Quebec government has
inadvertently triggered an exodus of doctors from its borders. Reports suggest over 300 physicians have applied for licences in other provinces just days after the passage of Bill 2 on October 25 – provincial legislation that sets unrealistic performance targets,
and threatens punitive fines for non-compliance and protest.
If Quebec has any chance of meaningfully improving patient care, it must reverse
course and regain the trust of those who ultimately deliver it.
To be clear, certain aspects of Bill 2 are not necessarily controversial. Until recently,
physicians in the province were mostly paid via a fee-for-service [FFS] model. Simply put, this means physicians were paid according to the specific care provided. Bill 2
switches things around by paying physicians according to capitation – i.e., a set fee per patient, with some adjustments for health risks.
This is not necessarily problematic.
While payment based on the type and complexity of care is the norm for hospitals in
high performing systems, international evidence suggests that things are a bit different for physicians. In fact, both methods are widely used by our international peers. Fraser
Institute research (conducted by the author of this column) found that a blended system was more common among primary care physicians, whereas FFS was more predominant for outpatient specialists (no clear trend was observed for inpatient specialists). In other words, while each method is used, they are employed to varying
degrees depending on physician type.
However, Bill 2 imposes capitation across the board, ignoring the fact that it may be more suitable for some types of physicians but not others. Bill 2 also earmarks about 10 percent of physician pay to certain indicators or performance. Again, pay for performance is widely used by our international peers, and
empirical evidence suggests that it may even result in improved quality of care.
The problem is that this is not being introduced as an add-on payment to incentivize performance, but rather as a claw back mechanism. Moreover, the province has tied these payments to admirable – but unrealistic targets – without any indication that the government will provide the necessary resources and staffing to help physicians have a reasonable shot of attaining them.
Consider one target requires 3 in 4 ER patients to be seen by a doctor within 90 minutes of being assigned a level of urgency (i.e. triaged). Given that the current average wait time in the waiting room is almost 4.5 hours, the government is effectively docking physicians 10 percent of their pay for a situation they have little control over. In
fact, a recent study by the Montreal Economic Institute found that almost half a million Quebeckers left the ER without being seen at all.
But perhaps the most egregious aspects of Bill 2 relate to severe financial penalties for protest.
Doctors who take “concerted action” to signify their displeasure with the recent changes can be fined up to $20,000 per day. And while some physicians can (and are) choosing to leave the province in protest, the government previously introduced legislation that
would impose fines of up to $200,000 a day for newer doctors who received their
training in Quebec but choose to leave within the first five years of their career. In other
words, newly graduated Quebec-trained doctors are effectively locked into the system without any viable alternatives.
Quebec’s health care system is clearly in shambles. Wait times in the province have
almost doubled since Premier Legault came into power – from just under 16 weeks in 2018 to around 29 weeks last year. During that period the government has imposed a series of
increasingly restrictive laws on physicians that has already led to a marked increase in doctors leaving the public system (for private alternatives), and is now resulting in physicians leaving the province entirely.
Quebec is already facing an estimated shortage of 2,000 family doctors, and the
government’s most recent salvo is only going to make matters worse. The Legault
government must work with physicians, not against them, in order to turn the tide and improve care for patients.
Bacchus Barua is the Research Director at SecondStreet.org.
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