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In L’Affaire Bolduc, the real scandal is the bonus system itself

In 18 months, Dr. Yves Bolduc took on 1,600 patients while he was moonlighting at a clinic in Quebec City.

Clement Allard/The Canadian Press

In recent days, L'Affaire Bolduc has dominated the political news in Quebec.

The short version is this: Yves Bolduc, a former provincial health minister, is also a physician. When the Liberal government was defeated in September, 2012, he returned to medical practice part-time, while retaining his job as an opposition Member of the National Assembly. When the Liberals took power again in April, 2014, and Dr. Bolduc returned to the cabinet (as education minister), he stopped practising.

The "scandal" revolves around what happened in the 18 months Dr. Bolduc was moonlighting at a clinic in Quebec City. In that period, he took on 1,600 patients, a significant caseload for a part-time doctor.

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But these were no ordinary patients. They were "orphan" patients (people without a regular family doctor) and "vulnerable" patients (people with chronic illnesses who did not have a regular doctor).

Under an agreement signed with the Quebec Federation of Family Physicians – a deal struck when Dr. Bolduc was minister – doctors who took on orphan patients were eligible for a $100 bonus, and $208.60 for vulnerable patients, on the condition that they keep them as patients for at least a year.

If you do the math, Dr. Bolduc was paid roughly $215,000 in bonuses, in addition to his regular fee-for-service payments, believed to be about $150,000 a year. He was also paid a salary of $89,950 as a MNA.

So, what is the scandal?

The technical one is that Dr. Bolduc took on roughly 400 of the 1,600 new patients in the year before the election so he clearly did not meet the terms of the agreement. But he has said he will repay those amounts, somewhere between $40,000 and $60,000.

More broadly, opposition members accused Dr. Bolduc of double-dipping and even triple-dipping, and there were calls for his resignation. A former health minister who had his hand deep in the Ministry of Health cookie jar doesn't look good on a government that has vowed to clean up the chronic corruption that has plagued Quebec for years, and which is being exposed in sickening detail at the Charbonneau commission.

Many have made the point that being an elected politician is a full-time job, if not more. Elected officials get good salaries, based on the assumption that it is a full-time job. The ethics code of the National Assembly states that MNAs cannot be paid by publicly funded organizations, but there are exceptions. Elected politicians are allowed to teach university courses and do some medical work to retain their professional credentials, if it does not interfere with doing their job as a politician.

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What is unusual is that Dr. Bolduc worked 20 to 30 hours a week in a medical clinic – evenings, weekends and all-day Monday, when the National Assembly does not sit – in addition to his role as an elected official. But it needs to be said the arrangement was approved by the ethics commissioner.

Dr. Bolduc has vigorously defended his moonlighting, saying that he is a workaholic, that the only thing he is guilty of is trying to help people, and that he respected the letter of the law.

All that may be true, but the whole arrangement still stinks to high heaven.

Like many doctors – about 4,000 of Quebec's 8,500 family physicians received bonus payments – Dr. Bolduc took advantage of a government program that was ripe for the picking. He just did so with more enthusiasm than most: On average, doctors took on 30 orphan patients; only a couple of dozen physicians took on 500-plus patients. (The law has since been changed to limit doctors to bonus payments for a maximum of 150 patients.)

What is interesting is that Dr. Gaétan Barrette, the current Liberal Health Minister, has been one of the most outspoken critics of the measure.

As he has rightly noted, paying doctors between $100 and $208.60 to take on orphan patients is an incentive to register patients, not an incentive to treat them, or to treat them better.

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Since the orphan patient program began in November, 2011, about $75-million in bonuses have been paid out, which presumably means that about 700,000 patients have found a doctor.

But there is pretty good evidence that the "patients" who are being recruited and earning bonuses for doctors are healthy and do not especially need a family physician. The "vulnerable" patients with chronic illnesses who really do need ongoing care and management are still having trouble finding a medical home.

There are also still more than 330,000 people on waiting lists for a family doctor in Quebec.

Doctors are already paid to treat patients – and fairly well at that. If hundreds of thousands of people can't get a doctor's appointment when they want one, then there is a pretty fundamental problem that is going to be resolved by doing more of the same-old same-old.

Canada continues to cling rather pathetically to the outdated fee-for-service payment scheme, which rewards volume of individual medical acts over getting results. In addition, most primary care is still delivered uniquely by family doctors, instead of employing nurse-practitioners and multidisciplinary clinics, for example. Not to mention that the way we negotiate doctors' fees is patently ridiculous.

These are huge issues that cannot be resolved overnight. But at some point – sooner rather than later, hopefully – they have to be tackled. We can't continue to patch over problems by placating doctors with dubious bonuses and the like.

Dr. Bolduc's gaming the system and his sense of entitlement in defending his actions is irritating, and it makes for juicy headlines. But the real scandal here is that the bonus system itself: It's a perverse incentive and a waste of money, regardless of who is being paid.

And the larger scandal is that we have a primary-care system in Quebec (and many other parts of Canada) that is failing the public and in desperate need of transformation.

That's where the opposition should be squarely aiming its guns, rather than settling for another round of petty politics and personal attacks.

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About the Author
Public health reporter

André Picard is a health reporter and columnist at The Globe and Mail, where he has been a staff writer since 1987. He is also the author of three bestselling books.André has received much acclaim for his writing. More

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