The Decibel - Why Quebec doctors are threatening to leave the province

Episode Date: October 30, 2025

Last weekend, Quebec passed new legislation that would impose a new contract on doctors, who have been in negotiations with the provincial government since March, 2023. Known as Bill 2, it sets out targets that Quebec doctors must meet in order to achieve the government’s health care goals, including access to primary care for all Quebeckers by January, 2027.The catch? If doctors don’t meet these targets, they can be penalized by having up to 15 per cent of their pay clawed back.André Picard, Globe health reporter and columnist, is on the show to break down why Bill 2 is drawing controversy, how doctors are responding to it, and what that means for patient care in Quebec.Questions? Comments? Ideas? Email us at [e-mail] Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

Finding a family doctor anywhere in Canada can be difficult. But that's especially true in Quebec. 1.5 million people in the province don't have access to primary care right now. And the provincial government has promised that every Quebecer will have a primary health care provider by January of 2027. It's an ambitious goal, and the government is attempting to meet this target with the introduction of new legislation. Bill 2 imposes a new contract on doctors who have been in negotiations since March of 2023. The problem, the bill is very controversial,

so controversial that doctors are talking about leaving the province en masse. So today, Andre Picard is on the show to break this down. He's a health reporter and columnist for the globe. I'm Cheryl Sutherland, and this is the decibel from the Globe and Mail. Hi, Andre, thanks so much for joining us today. Hi. To start, I think it's worth just going over how exactly doctors are paid in Quebec, because the systems do differ from province to province,

and it isn't exactly straightforward. So how do doctors get paid in Quebec right now? Yeah, so like most provinces, the vast majority of doctors in Quebec, in the public system are paid principally fee for service, so they get set fees for specific medical acts. And these fees are negotiated in contracts. they vary a bit by province. What's different in Quebec is that doctors are allowed to opt out of the system, and many have.

So many work, about 600 doctors work entirely privately in Quebec, and in the rest of Canada altogether, there's only about a dozen. So the Quebec government passed a bill over the weekend that will change how doctors in the public system get paid. And this is called, quote, 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, or bill two for short. Andre, it's quite a meltful, but what exactly is in this legislation? Yeah, so there's a lot of stuff in this bill. There's tons of stuff. The main things are, as you said, they want to change how physicians are paid. And then the controversial stuff is that if you don't achieve targets, they're going to claw back some of their money. And essentially, if they complain about

the bill, which has been imposed, that negotiations failed, then they can face these whopping fines. So there's a lot of things going on, good and bad, in this bill. Interesting. Okay. Yeah, I believe the most controversial aspect, which you kind of touched on, is that the province could set targets for a number of patients, doctors treat, and then reduce payments by up to 15% if not achieved. Yeah, that's right. And there's various targets for various specialties. And for some specialties, the clawback could reach 40% because of the way fees are calculated. So it is quite draconian as legislation goes. And as you can imagine, doctors are very unhappy. Why does the government say that they want to do this? Well, I think they're

frustrated. The doctors have been without a contract for more than two years. Everybody's frustrated. There's been four attempts at negotiated settlements, which the doctors have all rejected, mostly because they don't like this clawback part. They like a lot of other things in the bill, but they don't like the clawback. So the government has finally said, we're fed up, going to impose this. We think doctors should work harder. They think they get paid a lot and they should get to work. So it's a pretty fundamental difference of opinion. And also, I mean, in Quebec, there's a huge number of people that are without primary care right now. So I guess it's a sense that the government wants to fix that problem by introducing

these new rules. Yeah, every province is struggling with this. You know, there's 6.5 million Canadians without a family doctor, 1.5 million of them in Quebec alone. So everybody's struggling to do this, but if, you know, Quebec and Ontario, for example, are doing this very, very differently. Quebec has sort of taken a stick and said, everybody's going to get a doctor or else, you know, doctors will be punished. Ontario has, you know, hired Jane Phil Pot to come up with a plan. They've sweetened the pot by almost $2 billion for family doctors. They have all kinds of carrots. So it's a very fundamental difference in approach from two conservative governments. Do we have a sense as to why Quebec is kind of going this route of people?

versus the carrot approach. I think it comes down to the Premier. The Premier is personally invested in this. He has a long history. You know, everything in Quebec has a history. And this is no exception. The current Premier, Francois LeGo, is from CACC, Coalition Avenir Quebec. But he used to be in the Partsiqueque, where he was the health minister.

So way back in 2003, when he was the health minister, he had a similar fight with the doctors. He took a hard line. He was overruled by his boss. a premier. He was humiliated, quite humiliated publicly. He lost his job. This is his revenge. This is 20 years later. People have no doubt that he finally saying, I'm going to show these doctors. I didn't the last time, but I'm going to do it this time. So there's a lot of personal animosity here, a lot of politics. So, Andre, the Quebec government is introducing this legislation, in part because they say there needs to be more accountability because some doctors aren't pulling their weight. What have doctors

said about this claim? Well, this is a really interesting claim. Quebec has published some actually really interesting research of how doctors work, which we don't have in a lot of senses. So every province is struggling with this. How do you get accountability for, you know, they pay out a lot of money to doctors. Most doctors work very hard, but a tiny percentage did on. So this Quebec research showed about one in four doctors work less than 10 months a year. Okay. So there's a big chunk of time they don't work. So he's saying, well, you know, these people aren't pulling their weight. This profession should be forcing them to work more.

And if you're not going to, I'm going to do it. So that's sort of a lot of what this legislation is about. What he doesn't talk about too much is the other end of the spectrum, where about 25% of doctors essentially don't take any time off less than a week. So there's some really hardworking physicians. And like every profession, there are some slackers, right? Now, the other problem about this research is we don't know exactly what people are doing in their time off. Like maybe they're doing wonderful things.

Maybe they're at Medici Saint-Franter, saving children and developing countries. We don't know. Maybe they're professors. So there's a lot of debate about this. But essentially doctors say we should be able to work the way we want. We're independent practitioners. And, you know, if we work less, we get paid less. So what's the big deal?

But he says, that's not good enough because I want every patient to have a doctor. So you have to all get out there and work all the time. And this legislation actually, it punishes all doctors, right? So it's not just like one specific doctor. If we're not meeting this target, it's all doctors that get punished. Yeah. So that's the issue is the punishments or the clawbacks are based on the collectivity, not on individual performance.

So you could, and it goes down, it can be provincial, it can be regional, or it can go right down to a clinic level. So you can have 10 doctors in a clinic, eight of them work really, really hard, and two of them do nothing. and it looks bad and they don't meet their target, then they all get punched, right? So on the surface, it doesn't seem fair. Now, Quebec, you know, believes more in the collectivity than individuality than the rest of the country, but it remain to be seen if the public sees it that way, that they should go that far.

The contract will also impose capitation on family doctors. Can you explain what that is and how that would work? Yeah, so I think it's important to say there's a lot in this bill that doctors like. everybody, I think there's sort of universal agreement that the way doctors are paid is not working very well. So since the 1950s, we've had fees for service. You go see the doctor. They get paid a set amount, $42 or something like that for the visit. And then they have to, you know, run through a whole bunch of visits to get enough money to pay their rent, etc. So that's been going on for the long time. But patients are getting more complex. They take more time. So you need to be paid

differently. So capitation is you get paid a set amount per patient. Let's say you have 2,000 patients in your practice, and then you get paid a set amount. And in this new law, it ranges from about $4 per patient for ones who don't need anything to $41 for more complex patients. So you get this big chunk of set money. And then on top of that, you get your fee for service. You can get a fee. And now in this new legislation, you can also get an hourly wage for doing administrative tasks. So doctors really like this mixed model of care. But again, they don't want it to be clawed back. They want this freedom to practice differently. Why do doctors like it? Like, what makes this more appealing than the fee-for-service model? Yeah, what's good about capitation is you get more money for

patients who take more of your time. So that's a real push in the Quebec legislation is to get these patients who they call vulnerable to get with doctors. They're the ones least likely to get a doctor. So imagine you're getting a set fee, you're getting $40 and you're seeing someone with five chronic illnesses, as opposed to you're seeing a person who needs a birth control prescription. One of them takes 45 seconds and the other one takes an hour and a half. So what doctors have done traditionally is sort of balance that out, what works out. But now that they have more and more complex patients, you know, they can make $25 an hour and still have to pay their rent, etc. So that's why we need these different ways of paying for different patients.

Right, right. So this recognizes basically that it takes a lot longer for some patients. And so, you know, if you fit in less patients but they're more complex, then you're getting a more equitable amount of pay for these complex patients. Exactly. Let's talk a bit more about the patient targets and the penalties outlined in this bill. What are the targets doctors have to meet? Well, there's a whole bunch of targets for different specialties.

So I can give you a couple of examples. You know, the key, again, is everybody, they want everyone to have a family. doctor by 2027. So the government has said that family doctors have to provide 16.5 million visits per year or else they'll get this rollback of pay. Now what's the exact number now? It's a little bit less than that at 16 point something. But essentially they have to add quite a number of visits and for it to happen without adding more doctors, obviously doctors will have to work more. So that's the sticking point, the rubbing point. Another example, it's a little easier to do the calculations in specialties. So in the bill, it says 98% of surgeries must be

completed within a year. And the doctors say, great, we'd love to do that. We'd love to do 100% of surgeries, but we don't have the resources. So there's 147,000 patients waiting on surgical wait lists in Quebec right now. And 22,000 of them have been waiting more than a year. So how are you going to fix that without more people? So that becomes the main debate in this. Doctors are saying, we're not against targets. What we're against is clawbacks and what we're against is being clawed back when we don't have the resources to possibly do this.

They say it's just not fair. And I think they're right. We'll be right back. It sounds like one of the main issues that the Quebec government is trying to fix here is access to primary care. And in Quebec, over 25% or about one and four people don't have a family doctor compared to the national average, which is about 13%.

So why is this problem so bad in Quebec? I think there's no simple explanation. I think these rates vary a lot across the country. Quebec, its health system has been struggling for a long time. It does have the language issue. You know, most doctors speak French, those who don't can leave easily. Quebec for many years was the lowest pain among doctors. They've really fix that. In recent years, Quebec has among the highest paid doctors now. And that's another part of this. The health minister said, you know, we've listened to you. We've increased your wages dramatically, but you're not delivering more. So why did we do it? Right. So there's a lot of,

again, everything comes back to history. Quebec has more poor people. You know, a lot of health access depends on economics, on the social determinants of health. So we know the poorer provinces have the poor access problems. As I explained earlier, nobody wants to take on high needs patients because they lose money. So there's a whole bunch of reasons that add up to sort of a crisis in primary care. Can we talk about the timing of this legislation? Why is Quebec Premier Francois Legoe putting this forward now? Well, I think it's about legacy. You know, I talked about his history. He wants to get his revenge. He knows his days are numbered. This government is extremely unpopular. There was a poll this week that showed that 75% of people say he should resign.

He's at nothing in the polls. The Petsu Kibikwa is very high in the polls, but we're still a year away from an election, or a little less than a year. It'll be October of next year. So the other parties are lining up. So he's trying to get stuff out of the way. If he can meet a promise like everyone with a family doctor, that looks pretty good on the campaign trail because no one else in the country has done it. Yeah, yeah. I mean, is it possible, though? I mean, that's a, that's a huge number of people to get doctors by, or was it, January 2027? Well, you know, everything is possible in theory, if you put your mind to it, but I don't think it's possible by using a stick to beat doctors into working more. What has the reaction to Bill 2 been like

from doctors so far? Well, you know, doctors have been stewing for a long time. They've been years without a contract. It's been a whole series of measures. We didn't talk about other things that the government has done to doctors, you know, forcing medical students to practice in the province, not allowing doctors to practice where they want to, you know, they only license them for rural and remote areas. There's a whole series of things. And this is kind of, I was going to say this is the straw that broke the camel's back, but this is kind of a big stick that broke the camel. So doctors are very, very angry. And they're doubly angry because the legislation says you can't take any action against the government to protest this, right?

You can get these whopping fines at $500 to $2,000 a day for an individual if they say something like, I'm going to go practice in Ontario because I hate this bill. You can theoretically be fined. Or if you say my colleagues should go and join me in Ontario. If someone is already there, they could get a whopping fine for doing that. The associations could get fines up to $500,000 a day if they counsel doctors to do something like work to rule. Like, doctors can't strike, but they can do things like slowdowns that can protest. A good example of how angry doctors were.

Within hours of this bill being announced, the health minister, Christian Dubet, was invited to a TV show, to Le Monde-Apal, Quebec's most watched TV show. With an hours noticed, 400 doctors showed up to protest outside the building when they found out he was going to be there. There's going to be some mass protests of doctors. It's going to be interesting in the coming week. but we'll see what happens. You know, will they put their differences aside and actually negotiate something?

I think ultimately that's what the government wants. They've taken this really dramatic action in the hopes that they'll say, okay, let's come to our senses and have a deal, which hopefully will happen. So, Andre, what could we see from doctors as a result of this legislation? Well, I think there's two big fears. One is that they leave, that there's an exodus to other provinces. You know, the liberal leader Pablo Rodriguez said, the happiest person in the country about this legislation is Doug Ford because he's going to have

a lot of doctors coming to Ontario. So that's a zinger and it's probably true. The other part is a fear of retirement. A lot of doctors are saying, you know, I'm fed up. I'm just going to retire earlier, get out of this mess. And what's interesting about the legislation is it has an exception for people over the age of 63. So they are opted out of these things. And it's sort of a recognition that this is a punishment and that people are going to be fed up. So it's a very odd little tidbit of the legislation, I think, that they really do recognize that people are going to leave. There's a real tension here, Andrea. It sounds like doctors are really not happy with these conditions, but they also have an ethical imperative to care for their patients, which, you know,

you mentioned that they can't strike, and that's part of the reason. What position does this put Quebec doctors in? Well, I think they're in a bind. I think they really would like to strike. I think they're at that point of anger. Another good example of this is two weeks ago, the head of the college of physicians in Quebec reminded doctors, like his job is to do the regulation. And he said, you know, I remind you you have an ethical responsibility to do your work because one of the protests doctors had done as they had stopped teaching medical students.

And this is a very punishing. There's about a thousand students who will probably not graduate on time because they didn't get teaching for a few weeks. Now, when he said this, they went crazy. They demanded his head, you know, that he should be fired for saying. And, you know, others in the profession reminded them, listen, you do have an ethical responsibility to do things like teach, but you have it at all costs becomes a question. So it will be interesting to see what they do to protest without harming patients. That's their dilemma.

Because no doctor wants to harm their patients. I think just no doubt about that. Just lastly here, Andre, where does this all leave patients in Quebec? Well, you know, in these disputes, the patients always come out the loser, right? What we'd ultimately like is for every patient to have a family doctor and that we get to that goal in a collectively responsible fashion, the government and the profession agreeing. And we're seeing that in Ontario.

What's happening in Ontario is remarkable. Tens of thousands of people have a new family doctor this year because the government made a decision to do it. So I think that's the double frustration. is we know this can be done, but this is not the way to do it. So I think the public is watching this. And, you know, I think the public have some sympathy for the government, you know, this argument, we're paying you a lot more and we're not getting more return for our money.

That's a compelling argument. People see doctors as well paid and wealthy and, you know, why are they whining? So there's a lot of that. So the government's banking on that, but I think they've misplayed their cards on this one. Andre, thanks so much for coming on the show. Thank you. Always a pleasure. That was Andre Picard, a health reporter and columnist for the globe. That's it for today. I'm Cheryl Sutherland.

Our producers are Madeline White, Michal Stein, and Ali Graham. David Crosby edits the show. Adrian Chung is our senior producer, and Angela Pichenza is our executive editor. Thanks so much for listening, and I'll talk to you soon.