Quebec’s family physicians reached an agreement last month with the provincial government to delay implementation of a controversial bill that would have, among other things, linked physician pay to performance targets.

The agreement favors incentivizing family physicians to take on an additional 500,000 new patients by June on a voluntary basis. The original legislation, known as Bill 2, would have required them to cover an additional 1.2 million patients.

The provincial government is expected to introduce a revised bill before a February 28 deadline.

“We have always said that Bill 2 could be improved. It was therefore necessary to postpone its entry into force to give ourselves the necessary time to amend it and ensure that it reflects the agreement in principle reached with the Fédération des Médecins Omnipracticiens du Québec [FMOQ],” former Quebec Minister of Health Christian Dubé, said in a press release.

Dubé resigned shortly after the agreement was reached, citing difficult negotiations with physicians’ unions as a key factor in his decision. Sonia Bélanger, who was junior health minister, was sworn in as Quebec’s new health minister on December 19.

Team-Based Care

“All the articles [of Bill 2] that were really contentious won’t come back. So this issue is settled to a certain extent,” said Marie-Dominique Beaulieu, MD, professor emeritus of family and emergency medicine at the University of Montreal in Montreal. In general, “it is good for the patients of Quebec that this thing was stopped….Clearly, it was not good for anyone.”

Alan V. Pavilanis, MD, associate professor of family medicine at McGill University in Montreal, agreed. “When you look at the statements of Mr Dubé, he said he was going to shake up the whole [healthcare] system. But basically, his shake-up boiled down to an attack on all doctors, not just family doctors.” Many family physicians were concerned that taking on too many patients would cause quality of care to suffer, he said.

The shift outlined in the agreement away from a fee-for-service model toward mixed remuneration — including capitated payments — “has the possibility of improving care by increasing team-based care,” said Beaulieu.

Team-based primary care is essential because not every medical problem must be handled directly by a family physician, said Pavilanis. Instead, nurse practitioners, pharmacists, physiotherapists, and psychologists can take care of many aspects of care. “So physicians can work in teams and collaborate in many ways that can decrease the pressure on family physicians,” he said.

Orphaned Patients

Bill 2 had originally provided that all Quebec citizens would be assigned to a family physician clinic by the end of the year, which Beaulieu said “did not make a lot of sense,” given the shortage of family physicians in the province. Of the 500,000 patients who are now expected to be taken on by family physicians by June, around 180,000 will be vulnerable patients, she said.

However, this leaves an estimated 700,000 orphaned patients in the province: people without a family physician or a specialized primary care nurse practitioner. These patients can still access care through the province’s Primary Care Access Point, which helps them find health services that meet their needs. At worst, they can visit the emergency department.

But Pavilanis is more concerned that a growing number of patients will seek care in private medical clinics. “More people are turning to physicians who are not accepting Medicare but who are taking cash payments,” he said, “and more of my colleagues are abandoning Medicare.”

“I’m not opposed to the competition provided by physicians off Medicare, but they should not be a desperation choice,” he said. In addition, “[orphaned] patients who are really suffering are the people who don’t have the means to go to private clinics.”

Pressing the Offensive?

Beaulieu emphasized that the agreement between the FMOQ and the Quebec government would stand for 5 years. “During the next few months, the financial aspect of it — where the money will go — will be negotiated between the government and the FMOQ.”

It would be surprising if the family physicians asked for more in the future because “they have what they want,” she said.

Pavilanis agreed. “I don’t think they will be emboldened to be more aggressive because they actually won most of their points,” he said. “It was really quite a stunning turnaround.”

However, the contentiousness that led up to the creation of Bill 2 is likely to have a long-lasting impact on the province.

“For the 10,000 family physicians, trust with the government has been shattered for a very long time, and there will be a lot to rebuild,” said Beaulieu. “Physicians have suffered [throughout this]. It has had a personal impact on so many.”

Beaulieu and Pavilanis reported having no relevant financial relationships.

Shawn Radcliffe is a freelance health and science journalist based in Ontario with more than 15 years writing about general health, medical research, mental health, and other topics for print and online publications. Prior to this, he did laboratory and clinical research and research administration at universities in Philadelphia and Portland, Oregon. He has a master’s degree in science education from Drexel University.