Changing the way doctors are paid is necessary in Quebec, experts reiterate, but they argue this is a false debate, since all parties already agreed on this point.
Furthermore, it is argued that Bill 2 does not go far enough and that doctors should be made employees of the network, as is the case for most other health professionals.
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Currently, approximately 70 per cent of Quebec doctors’ total remuneration comes from fee-for-service payments. With Bill 2, this rate would drop by more than half. The remainder of a physician’s salary would be based on capitation (the number of patients on their list), with another portion linked to an hourly rate and performance targets, the latter of which has drawn criticism from physician associations.
Anne Plourde, a researcher at the Institute for Research and Socioeconomic Information (IRIS), believes that reviewing the way doctors are paid is essential.
“In some respects, what is proposed in the bill, if we exclude the whole issue of performance targets and pressure to increase volume—which we don’t think is very positive—but let’s say we question the fee-for-service portion to introduce capitation and hourly pay, that’s positive,” she says.
Plourde welcomes the idea — as proposed by Québec solidaire — of paying doctors a salary so that they are no longer self-employed.
“(With Bill 2), we are not questioning the status of physicians as private entrepreneurs within our healthcare system,” says Plourde. “Even if we change the method of remuneration, physicians remain private entrepreneurs who sell their services to the public system. And in our opinion, this hinders access to services because it hinders the real integration of doctors into the public system, into the multidisciplinary teams of the public system.”
Performance indicators are not necessarily a bad idea, but it is the concept of linking them to remuneration that is problematic, according to Mylaine Breton, Canada Research Chair in Clinical Governance of Primary Care Services and full professor in the Department of Community Health Sciences at the University of Sherbrooke.
She would like to see physicians and the government work together to identify these performance indicators.
“First and foremost, this data must be returned to professionals, not for coercive purposes, but to truly support reflective practice, like a report card. We’ve had report cards since elementary school to see where our strengths and weaknesses lie and how we can improve. When you don’t have any data, you have no idea whether you’re good or not,” explains Breton.
She is critical of the current state of the network.
“We have a front line that is sinking. And now we’re helping them (the doctors) sink even further,” she says.
She believes that with Bill 2, the government is not helping doctors fulfill their mandate. To achieve this, decision-makers must first put in place the infrastructure to collect data, then work with doctors to identify indicators where they can improve, “but not for the purpose of linking them to individual compensation.”
According to Plourde, no additional money would be needed to undertake this major shift that would make physicians salaried employees. The current budget already covers social insurance benefits, as physicians set aside part of their salary to contribute to their pension funds or other types of social protection.
“Currently, if we take the example of medical specialists in Quebec, they are paid an average of $460,000 per year. That’s six times more than the average full-time salaried employee in Quebec. It’s enormous. In fact, this ratio is the highest of any OECD country. So, with the current budget, we could very well offer doctors a perfectly adequate salary while also providing them with social protection and a pension fund,” argues Plourde.
The problem with Bill 2 is the coercive way in which it is being imposed.
“It’s a false debate because everyone agreed on changing the way doctors are paid. […] Even the FMOQ [Fédération des médecins omnipraticiens du Québec] was very open to it. As we know, these are much more modern terms, and with fee-for-service or capitation alone, there are very significant disadvantages in both settings,” explains Breton.
Breton points to another issue in physician remuneration: the 30 per cent bonus granted to general practitioners for office expenses. This bonus was initially to be reduced in Bill 2, but Health Minister Christian Dubé decided to maintain it in an effort to reach out to physicians.
Some doctors have difficulty covering all their administrative costs with the 30 per cent premium, but others pocket the difference once all expenses are covered by the premium.
“In a context where we want to promote family medicine, we certainly don’t want them to earn less. […] We want them to invest in this infrastructure. I think we need to think about how we can become consistent because it’s clear that in a transformation, removing funding from infrastructure and individual remuneration is a good idea,” says Breton. “I think it was poorly constructed 30 years ago, but now we have to do it in a transitional way, and we certainly don’t want to do it in a way that causes GMFs to go bankrupt and makes it less attractive as a practice environment.”
–This report by La Presse Canadienne was translated by CityNews
