Quebec may be serious about health care reform, but its approach isn’t helping

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In a surprise move, the Quebec government has introduced legislation that would fundamentally revamp how doctors are paid in the province, including tying part of their pay to performance.

This follows earlier legislation that would force doctors trained in the province to practice in the public system for a least five years or face hefty fines, and another promise to prioritize vulnerable patients even if that means restricting access to physicians for healthier patients.

This upheaval is happening, notably, during contract negotiations. And it’s all in the name of an overarching goal: ensuring that everyone in the province has access to primary care by the fall of 2026. Or, more precisely, every citizen would be “associated” to a “care environment,” which could be a clinic rather than an individual practitioner.

Beneath this barrage of legislation, actual and threatened, there are some important policy issues and topics that warrant some serious discussion. But the government of Premier François Legault has put forward these ideas in such a ham-fisted and belligerent way as to make serious debate almost impossible.

Take the latest piece of legislation. At the heart of Bill 106 (“An Act mainly to establish the collective responsibility and the accountability of physicians with respect to improvement of access to medical services”) is a good idea: Pay doctors differently.

Most family doctors in the province (and the country) are paid on a fee-for-service basis; they bill for specific acts, and the amount reimbursed is set out in a fee schedule that contains thousands of codes. Because they do piecework, doctors are incentivized to churn through several patients hourly. Fee-for-service works if you want a lot of patients treated quickly for minor ailments. It’s not great for complex patients who need longer visits.

Quebec wants to shift from a largely fee-for-service approach to one where capitation – essentially, a set fee per patient, per year – is the main form of remuneration. That way, in theory, the patient who needs a five-minute visit gets one, as does the patient who needs an hour.

But under that model, you need to ensure there is a mix of patients and access for everyone. You don’t want a doctor collecting a whack of money just to oversee healthy patients who require little work.

So Quebec wants to introduce a colour-coding system that would categorize patients as green, orange or red based on complexity, and pay different capitation rates for each. But risk-stratifying patients is complicated because of the lack of reliable data, the complexity of individual patients and the general challenges of prediction.

There would also be an hourly wage for doctors, designed to offset the time needed to do paperwork.

Where the legislation really gets iffy is that it proposes that up to 25 per cent of family doctors’ pay would be based on performance. In other words, doctors would have to hit certain targets, or pay would be withheld.

Those targets would be collective, not individual, and negotiated as part of contract talks. Government targets might include ensuring that 90 per cent of vulnerable patients (coded red) are registered with a family practice, and that 20 per cent of appointments are available on weekends, during holidays and after 6 p.m. on weekdays.

Quebec family doctors already have more demands on them than those in other provinces, including mandatory hours in ERs, nursing homes and birthing centres, and this would add to the burden.

Still, doctors’ associations say they are not entirely opposed to the proposed changes, even pay-for-performance. But they argue that they can’t be expected to meet province-wide targets when there are roughly 2.1 million orphan patients, a severe shortage of doctors and crumbling infrastructure.

Physicians are also irked that the province is imposing this legislation rather than working co-operatively, and putting so much emphasis on accountability and productivity among doctors when there are few measures of accountability or productivity in the system overall. Doctors feel they are being made scapegoats for the failure of the government – and it sure looks that way.

There is, as always, some important history at play here, too. Way back in 2002, when François Legault was health minister in the Parti Québécois government, he introduced special legislation to force doctors to staff ERs 24/7. Long story short, doctors protested, the law went nowhere, and Mr. Legault was humiliated.

Since then, he has been a bit obsessed with punishing doctors. Revenge rarely makes for good public policy.

But it is also important that essential policy changes, including fundamentally rethinking how doctors are paid, need to be soberly considered and not lost in the haze of political bickering.