Bill 106 will not boost productivity of doctors: health policy expert

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There is scant evidence that the Quebec government's proposed bill to tie doctors' pay to their performance will lead to more patients being treated, argues a prominent health policy expert.
Damien Contandriopoulos, a professor of public health at the University of Victoria who had previously taught at the Université de Montréal, is highly critical of Bill 106, which proposes linking up to 25 per cent of a doctor's pay to performance targets as an incentive for them to take on more patients.
'It's a government that likes the notion of direct control, top-down, all the way from the ministry to the worker,' Contandriopoulos said in an interview Wednesday after he testified on Bill 106 at a National Assembly hearing.
'Centralized systems, data collection, heavy monitoring, and this kind of top-down, direct-control approach is generally not a great fit for super complex, extremely large systems like the health-care system,' he added.
Bill 106 has sparked an intense backlash in the medical community, with physicians charging that the legislation would drive some doctors away from the profession or the province — and worsen patient care. The bill follows Health Minister Christian Dubé's creation of Santé Québec in December to run the province's $65.5-billion-a-year public system. Despite opposition to Bill 106, Premier François Legault has said the Coalition Avenir Québec government intends to have the legislation adopted.
Dubé tabled the bill on May 8 amid contract negotiations with two Quebec federations representing physicians. The 25-per-cent pay figure tied to performance targets was calculated in a mathematical formula that Contandriopoulos described as 'complete nonsense.' Even if the performance targets aren't met, doctors would still receive 10 per cent, according to the formula written in the bill.
In Contandriopoulos's report on Bill 106, he wrote similar past incentives in Quebec have not notably increased doctors' capitation — which is the term used for the number of patients a physician has on their roster, and the new rules would only make it harder for them to do their jobs.
He illustrates that financial incentive systems are prone to 'gaming,' meaning doctors will try to exploit the system's flaws to their advantage.
He cited a recent initiative in Quebec, the 'Guichet d'accès pour la clientele orpheline,' which tied a payment incentive to the registration of new patients. Because of a flaw in the system, he suggested many doctors retroactively enrolled patients who had already been treated. This gave physicians the financial benefit despite the fact they didn't take on additional patients.
He also suggested that with Bill 106, doctors may be less motivated to take on complex cases that require extra attention and expertise if their remuneration were based largely on the number of patients they see. As a result, doctors may flood their schedules with patients who could be treated by nurses, social workers or other health professionals on their team as a way to maximize their patient load and increase their remuneration, Contandriopoulos said.
If a doctor delegated their straightforward patients to nurses and social workers, 'then they would be stuck with demanding, challenging, long visits,' he explained, adding that this approach would be effectively penalized under Bill 106.
'They would go bankrupt because the system doesn't reward them to do so. So if we want physicians to really focus on the work that they are the best trained to do and where the benefit for society is the highest, we need to incentivize them to really focus on (these complex cases), which we do not.'
Dubé said during a scrum Tuesday afternoon that Bill 106 won't be adopted this session of the National Assembly and he would like for discussions to continue.
Amid the hearings on Bill 106, Dubé reiterated he wants 100 per cent of Quebecers to have access to a health professional by the summer of 2026.

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