Is Bill 106 an attack on women physicians?
Let's examine how this law will hurt the medical profession and how it will hurt women physicians the most.
Here’s a quick rundown on Bill 106, the proposed changes to physician remuneration, and the unintended consequences that come as a result.
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The basis for this bill is an HEC Montréal study that argues there are more physicians per capita in Quebec than other provinces but access to medical care is harder.
The study’s authors do acknowledge the difficulty in defining a full-time physician. Thus, they settle on the Canadian Institute for Health Information’s definition, known as Full-Time Equivalent (FTE), which is more or less a measure of remuneration and not hours worked.
When using this metric, the study’s data argues that Quebec’s remuneration of FTE family physicians are the highest in Canada, when accounting for provincial cost of living.
Because the FTE metric is so limited, the study’s authors must dig into RAMQ billing data. This also proves to be limited as it does not include doctors on a mixed remuneration model or salaried doctors. The data simply does not exist.
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Bill 106 would make up to 25% of a physician’s remuneration conditional to performance targets set by the provincial government, but on a collective basis—at the regional and provincial level.
What those metrics are is anyone’s guess.
The remaining 75% of remuneration would be based on a mixed model, in three parts:
Capitation: per-person, flat-rate based on a patient’s level of vulnerability.
Hourly: based on time spent with patients.
Fee-for-service: The traditional model of billing.
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It is unknown what metrics will be chosen as indicators of success and what data they will be based on.
The government may arbitrarily choose metrics that are unattainable and therefore save up to 25% on physician remuneration. All the while increasing the number of patients attended.
The metrics may have the potential of incentivizing the wrong things.
One perverse incentive could be a loss in quality of care in exchange for quantity. Doctors may incentivize shorter and more superficial consultations to reach their imposed targets.
Another unintended consequence could be the loss of future physicians who choose to work in other provinces—a problem for future generations, I guess.
On the surface, Bill 106 could hurt all physicians but let's explore why women physicians stand to lose the most.
The Feminization of the Medical Profession in Quebec.
The impact of feminization has not been observable from the strictly quantitative analysis in the HEC study and its authors acknowledge this. Nevertheless, a growing body of evidence shows that women physicians spend more time per patient. Studies from the United States show that women physicians focus on a collaborative approach to patient care and focus more on preventative and psychosocial aspects of care. A Canadian study show women physicians spent more time with their patients and less consultations per day.
Let's look at some facts and figures:
What is Occupational Feminization?
Male-dominated occupations are perceived as technical, competitive, and prestigeous. Clerical jobs and teaching were once male-dominated and were both respected careers with good compensation. As women entered those fields and they became numerically dominant, the perceived value of these careers became devalued. Wage stagnation and decline followed even though educational requirements remained the same.
Maternity leave and “the second shift”
The HEC Study cited by Quebec's government as the genesis of Bill 106 does not look at the amount of care physicians give their patients and it certainly did not take into account the outsized responsibility placed on women in the household.
When it comes to parental leave among medical residents following the birth of a child, 98% of women took maternity leave compared to only 21% of men. Quebec’s gendered structure of parental leave makes this inequity an inevitable outcome. Women (or the birthing parent) have 18 weeks of maternity leave compared to men (or the non-birthing parent) who have 5 weeks of paternity leave. Both do have the option to share 32 weeks of parental leave.
RAMQ does not track data on how many nor how long physicians take a leave of absence following the birth or adoption of a child.
Long after childbirth or adoption, women are overwhelmingly involved in the lives of their children and the upkeep of the household. This is a leading explanation for why women physicians work less hours because they must accomodate their schedules to “the second shift.”
“The second shift” is a concept pioneered by sociologist Arlie Russell Hochschild in 1989. She found that dual-income households have women overwhelmingly performing unpaid labor at home, resulting in higher levels of emotional fatigue, time poverty, and slower career progression.
According to Statistics Canada, Quebec women reported an average of 3.4 hours per day of unpaid labor. Whereas men reported 2.4 hours per day of unpaid labor.
What are the potential consequences to physicians from disadvantaged communities?
The obvious consequence is a reduction in lifelong remuneration which will lead to higher levels of wealth inequality between genders (I wrote about this in an earlier blog post). It could also result in higher levels of wealth inequality among physicians from underrepresented communities.
To give one example of this, research from the United States shows that first-generation children of Latino immigrants are more likely to report child-to-parent financial assistance. Another study shows Asian and Latino children report a higher cultural obligation to provide intergenerational support.
First-generation, Quebecer-born physicians already have a greater deal of difficulty supporting their parents and building wealth for themselves—in addition to having children, buying a home and paying down student debt.
How can young physicians navigate these impacts?
The first step would be to re-think your personal finances and your financial priorities.
Here’s how I would approach it:
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Quebec physicians report having a median debt load of $75,000 at the end of residency. With the 90th percentile report having debt above $280,000.
A better debt repayment strategy could result in additional savings in taxes and interest payments, while maintaining your quality of life.
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Physicians need to recalculate the benefits of incorporation. With a reduced level of remuneration, the tax planning advantages of incorporation might be lost entirely in the early years of practice.
Accounts like the RRSP and FHSA can make it less appealing to incorporate.
As expenses in the household become more stable and your professional productivity increases, the benefits of incorporation become more tangible.
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With programs like Home Buyer’s Plan and the First Home Savings Account, the need for incorporation is greatly diminished in the early years. RRSP and FHSA contributions would allow for a large amount of your income to be tax-deductible.
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You cannot perfectly time your family. Sometimes kids come sooner rather than later.
Plan for child expenses before you make any major commitments like buying a home, incorporation or any projects that put strain on your cash flow.
