A new bill that overhauls the compensation system for doctors in Quebec is causing an uproar and could soon be challenged in court by doctors’ federations. Health Minister Christian Dubé says the reform is necessary because the status quo is not serving Quebecers’ needs and “urgent” action is needed to improve health-care services. But the federations say the new law is akin to a “Soviet prison” for doctors that radically changes how they are paid and imposes strict monitoring and penalties to ensure they comply. Some doctors have already said they are planning to leave Quebec as a result. Here’s what is in the bill. What is Bill 2? Bill 2, An Act mainly to establish collective responsibility with respect to improvement of access to medical services and to ensure continuity of provision of those services, is a piece of special legislation that was passed shortly before 4 a.m. Saturday in the National Assembly. How was it passed? Bill 2 largely follows the framework set out in Bill 106, first introduced by the Coalition Avenir Québec (CAQ) in May but went nowhere as contract negotiations with the doctors’ federations dragged on. They were vehemently opposed to the proposed law, which was the main reason why the talks stalled between the Fédération des médecins spécialistes du Québec (FMSQ) and the Fédération des médecins omnipraticiens du Québec (FMOQ), which represents 10,000 family doctors in Quebec. Their members have been without a collective agreement since 2023. After they rejected four offers from the province, Minister Dubé tabled the special legislation known as Bill 2 on Friday. To expedite the passage of the bill, the CAQ government invoked closure, a parliamentary tool that helps fast-track a bill with limited debate and a forced vote. The 120-page bill was passed with a vote of 63 to 27, with Premier François Legault present for the vote. All of the opposition MNAs who were present voted against it. Bill 2 marked the eighth time the Legault government has invoked closure in the Quebec legislature since coming to power in 2018. How does Bill 2 affect doctors’ pay? Instead of paying doctors on a fee-for-service model, Bill 2 introduces a new system called capitation. Under a primary care capitation model, doctors would be paid a fixed, upfront sum per patient assigned to them. The payment would also be adjusted higher if a patient has more health risks. Patients’ vulnerability levels would be classified under four categories: healthy, minor chronic health condition, moderate health condition, and major health condition. Olivier Jacques, an assistant professor at the Université de Montréal’s Department of Health Policy, Management and Evaluation, says that is one of the positive aspects of the bill, but paying with capitation alone is not enough because there are not enough incentives to see more patients. What is worrying for doctors is another new mechanism that links 10 per cent of their pay to performance indicators. That target was lowered from 25 per cent after pushback. The so-called “collective supplement,” according to the bill, would be paid to general practitioners and medical specialists upon meeting certain medical objectives that improve access to care. If those conditions aren’t met, doctors’ pay would be clawed back. For example, one objective is for general practitioners to accommodate 17.5 million appointment slots per year. Another target is to have 75 per cent of patients who show up in emergency rooms to be seen by a doctor within 90 minutes of the time they are triaged. The bill also stipulates that 95 per cent of oncology surgeries must be completed within 56 days, and specialists will have to perform at least 97 per cent of surgeries within 12 months. These targets or objectives are collective, can vary by region or territory, and are entirely set “in a discretionary manner by the government, which is not great from doctors’ point of view because they may lose money and it may not be their fault if these targets are not met,” Jacques said in an interview with CTV News. He said he is concerned by the way in which the law, which he described as “authoritarian,” was rammed through at the last minute. “So forcing people to implement change [is] not necessarily the best way to implement change. And I’m not convinced that the performance targets are the best way to improve care,” Jacques said. Under the law, the collective supplement would not apply to physicians 65 and older. What penalties can doctors face? Bill 2 also includes a section that prohibits doctors from engaging in what the government considers “concerted actions” to challenge government policies. A concerted action, according to the bill, would result in “stopping, reducing or slowing down the physician’s professional activity” or slow down training in the medical field. The provision puts an end to pressure tactics, such as the ones used by the doctors’ federations in recent weeks to oppose the new pay scheme when they called on their members to suspend teaching medical students. Other examples could include groups of doctors leaving the public health system for the private system or to another province. In the English version of the bill, the government defines it as one taken by two or more physicians and is “consistent with a proposal, suggestion, or encouragement from a representative group of physicians.” In French, the text says a concerted action is one carried out by “several physicians,” which is causing some confusion. Physicians can be fined up to $20,000 for each day an offence is committed. In the case of a group, the fines reach a maximum of $500,000. Fines are doubled for a subsequent offence. Some doctors fear harsh retaliation for merely speaking out against the bill or encouraging others to do so. Jacques again used the term “authoritarian” to describe this new measure. “It seems that the government is afraid that doctors would either leave towards the private sector or leave towards other provinces, and therefore put penalties,” he said. The new law also gives the Minister of Health the power to determine the number of years of practice to subtract from a physician’s record for participating in a concerted action, “at the rate of one half year for every day the participation continues.” Inspectors in doctors’ offices Bill 2 also gives the health minister special powers to authorize “any person” to act as an inspector to verify that doctors are compliant with the new law. According to the bill, an inspector can enter a physician’s office at any time and demand access to documents, including those related to a patient’s file. Specifically, the bill says: “no person may refuse to communicate to the inspector or investigator any information or document contained in the record of an insured person.” In addition, an inspector cannot be liable to prosecution for any act or omission done “in good faith” in the course of their duties. On Tuesday, more than 20 doctors stood outside the National Assembly with tape over their mouths in protest of the bill despite the threat of retaliation. The debate over the contentious bill does not seem to be ending any time soon, as the doctors’ federations say they intend to launch a legal challenge as soon as Wednesday. With files from The Canadian Press
