L’Affaire Bolduc

The honeymoon is over. Three months more or less to the day after having been voted into power in Quebec City with a shiny new majority, Philippe Couillard’s government finds itself embroiled in its first, honest-to-god political scandal. It seems that Yves Bolduc, a physician, who is now in Cabinet as the Minister of Education, but who was Minister of Health under Jean Charest, racked up $215 000 worth of bonuses as a practicing physician while he was in opposition. The opposition, and a good part of the chattering classes, are now clamoring for his head. No less a figure than Claude Castonguay, the father of Quebec’s system of public health insurance, wrote an open letter to Philippe Couillard calling upon the Premier to sack his Minister.

Some context: somewhere close to 30% of Quebeckers do not have a GP. In order to attempt to lower that number, the Charest government (with Bolduc as Minister of Health) instituted an incentive scheme to get general practitioners and family physicians to take on more patients. They were to be paid somewhere north of $100 for every new patient they took on on a long-term basis, over and above the “paiement à l’acte” that they routinely claim from the Régie de l’assurance maladie du Québec (RAMQ). It seems that Dr. Bolduc, a self-professed workaholic, took on 1500 or so in the period that he was on the opposition benches.

It is important to get straight on what, if anything, is objectionable here. Let’s get one item off the agenda right from the start: it is clear that after the Liberals were reelected, Dr. Bolduc had to abandon some of the patients he took on before the one-year cut-off that would have been required in order for the “long-term” condition to have been satisfied. About $60 000 of the bonuses he received were thus paid out for patients that Bolduc took on but did not really follow. It seems that he has accepted that he will have to pay that amount back to RAMQ.

Many accusations have been leveled at the Minister, however, even once this amount is set aside. Some pundits have claimed that, though he acted within the rules, what he did in claiming what the incentive scheme allowed him to claim was unethical. Others (and this is at the core of Claude Castonguay’s accusations) have argued that he could not possibly have been doing both his job as an MNA and his job as a physician responsibly, as they are both full-time jobs that require full-time attention. Others still claim that in times of austerity, when school teachers, fire fighters, and police officers are asked to tighten their belts, it was unseemly for Dr. Bolduc to accept his (nearly) $100 000 remuneration as an MNA, the $150 000 he claimed from RAMQ for the various medical acts he performed, and an additional $215 000 of bonuses.

Was it unethical for Dr. Bolduc to claim the money for the patients that he did follow for more than a year? It is at least arguable that it was not. If a set of rules is in place that allows physicians to claim these bonuses, then on the face of it, there is nothing wrong with their availing themselves of the benefits conferred by those rules. It might have been supererogatorily admirable, that is, beyond the call of duty, for Dr. Bolduc to have declined the bonuses to which he was entitled. But what we standardly require of our professionals and our public officials is that they not violate rules, not that they act more admirably than the way in which the rules in place require that they act.

Some have argued that Dr. Bolduc was after all not an ordinary physician: he was the Minister in the government that instituted the rules from which he then benefited. According to this view, he should have refrained from benefiting from rules that he put into place, lest the impression be created that he instituted these rules in order to then benefit from them. That seems like a stretch: after all, when Dr. Bolduc was a member of the government that passed this incentive scheme, he did not expect that he would be returned to his status as a lowly opposition MNA in a matter of months. Could he be accused of lack of prudence or foresight in having taken on patients after the Liberals were voted out of power in the context of a highly volatile minority government situation? Perhaps. But that hardly seems a hanging offense. And again, he has said that he would reimburse whatever amount he received for patients who he was not able to follow for at least a year.

Should he be condemned for having had two full-time jobs while he was an opposition MNA? If there are no rules prohibiting it, then he should not be condemned a priori. The question that should be asked is not whether he was holding down two jobs, but whether he was fulfilling the requirements associated with both jobs. I abstain from any judgment as to whether he was or not. The point I want to make is that in the absence of clear rules, it is the latter, rather than the former question that is the right one.

I acknowledge that this whole business smells bad. But the source of the bad odor does not seem to me to lie in Dr. Bolduc’s behavior, but in the rules that legitimated that behavior in the first place. There are at least two sets of rules that seem to pose a problem here. The first has to do with the incentive scheme itself. Clearly, Quebec has a problem when it comes to GPs and family physicians. But it’s pretty clear that the kind of incentive scheme that was put into place under the Liberals was replete with perverse incentives. Paying physicians bonuses up front to take on patients is a recipe for shoddy care, especially when what it means for a physician to have taken on a patient on a long-term basis is that they take on that patient for a mere 12 months. This particular incentive scheme encouraged physicians to take on patients above and beyond their capacity to care for them effectively, and it dialed down the requirement of what it means for a physician to take on a patient to a ridiculous extent. Clearly, the Liberal government was motivated more by its desire to be able to claim that it had reduced the number of Quebeckers without a GP than it was by any real wish to improve the quality of care that Quebeckers received. I have nothing against using incentive schemes in order to achieve socially desirable ends. But this one was a disaster waiting to happen.

The other set of rules that Quebeckers may wish to revisit in the wake of the Bolduc “affaire” has to do with the freedom that MNAs have to moonlight. I happen to agree with those who claim that the job of an MNA should occupy all of a person’s time and energy, and that they should while they are in office be entirely devoted to the general interest, rather than having sideline jobs that might divert them from the general good. But if that’s what we want, we should constrain the ability of MNAs to work outside of the National Assembly more than we presently do. Again, if Dr. Bolduc was doing something that we don’t like, but that that the rules permitted, in working as a physician while he was a sitting MNA, then we should change the rules rather than chastising Dr. Bolduc.

Since I am probably making an argument here that will be vastly unpopular, let me finish, in the spirit of “go big or go home” with what will probably be the most unpopular of the proposals for reform that I think we ought to consider when the dust settles on the Bolduc episode. We ought to pay MNAs and MPs more than we presently do. Many of the people who we want to have in our legislative assemblies will be coming from professions where they are better remunerated than they would be as elected officials. Some people may very well be so motivated by the desire to serve the common good that they are willing to take a salary cut. But many will not be so inclined. And if the rules allow those who do make the jump to feather their nests by moonlighting, then they may very well do so. The prohibition on elected officials at the provincial and federal government holding down other jobs should be accompanied by increases in pay.

We in Quebec, and perhaps elsewhere, have a tendency when these kinds of scandals emerge to personalize them to too great an extent. We look for bad guys, and then engage in self-righteous finger-wagging when we think that we have found them. We do not do the heavy lifting that consists in trying to determine whether the systems of rules that we have put in place through our democratic institutions are in some way responsible for patterns of behavior that we deplore. This was the message of the second volume of the Gomery commission report. Its recommendations were largely ignored. Again in the case of Dr. Bolduc, debate is entirely focused on whether or not he acted rightly or not, whereas it should be focused on the systems or rules and incentives that allow him to claim, with at least some degree of credibility, that he did nothing wrong.


L’Affaire Bolduc — 1 Comment

  1. Something really bothers me with your argument. Don’t shoot the doctor, you say, fix the law. Well, this ignores the central point of the “Affaire Bolduc” which is the fact that the guy making money of the policy is the very same one who wrote it and passed it. Not only that, but Bolduc appears to be one of the very few doctors (about 5 of them according to the RAMQ) who milked the system to such an extent.

    So what is this policy about? That doctors accepting “new patients” should get bonuses, in a way that is presented to the public as an “incentive” to get more Quebecers to have family doctors. Hey, what? Yes, a bonus for doing you job. One of your patients dies, you replace him, bingo, there’s your bonus (I know, the law is a bit more complex, but you get it, still). Can you imagine teachers getting bonuses for having new students (that sort of happens every year) or cops for arresting “new criminals”? Waiting rooms are full, physicians are overworked, now there’s a solution: just work more! Heck, work faster!

    Now, stop for a minute ant think about who is actually going to benefit from this law in a big way. Sadly, if you are a busy MD doing the job everyday, not enough of your patients will move or die in a single year so that replacing them will get you in a new BMW: this law is not for you. But for whom then?! Well, Bolduc is a prime example! Here’s the recipe: be a physician, abandon all your patients, go do something else for a while (travel around the world, have a baby, heck! get elected and be a minister). After a while, come back, get a bunch of “new patients”, keep them for a year and a day and you are done. Have another kid, get back in the government or whatever else fancies you (and justifies dropping all of your patients in order to prime the pump for the next round). Yes, you get a bonus for new patients but you can drop patients for free.

    From what I can gather from the statements made by the RAMQ in the last few days, only a handful of physicians have struck gold since the law came out. Something like 4 or 5, that’s it. One of them is Bolduc, the very guy who wrote the law. The remainder of some 8500 Quebec GPs either were too busy to bother or already had more than enough patients on their hands to contemplate recruiting another few hundreds.

    Now, how about Dr. Bolduc. There is a basic tenet of life in a democracy that people will be truthful and honest in their dealings with the law; can we believe that Bolduc was? First, some numbers: the average Québec family physician has 700 patients (Institut de la Statistique du Québec, 2012). Dr. Bolduc got bonuses for 1,500 patients, that is more than twice that figure. So, assuming he was being truthful, he expected to work twice as hard as the average Quebec physician while at the same time performing his duties as an elected MP. When I see my family physician, I can guess he works 50 to 60 hour weeks: long hours, I often left his office after 9pm and the waiting room was not even empty. Thus Dr. Bolduc implied, by submitting his list of new patients to the RAMQ, that he was going to work over twice the average physician, that is, 100 to 120 hours per week with his patients. But wait, he has a second job! Now, last time I voted for a provincial MP, I recall that they receive an 89,850 $ “basic annual indemnity” (http://www.assnat.qc.ca). This is not just prize money for gaining the election/popularity contest, this is an actual indemnity that we collectively pay in order to allow our MPs to actually work for us. And for that much money, I do expect my MP to put in at the very least 40 hours per week. Adding that to the 100-to-120 hours above, can we really believe that Bolduc was counting on working 140 to 160 hours? I know I don’t. If you do I’d love to hear your argument.

    Now, let me summarize. (1) Bolduc passed a law that was at the very best stupid, and at worse an incentive for twisted MDs to milk the system. (2) While he passed that law he could not ignore that, were Charest’s government to be defeated, he would in a position to profit handsomely, many times more than 99.95 % of his fellow physicians still on the frontline. And (3), he milked everything he could when he returned to plain vanilla MP. Oh, and I forget: (4) when all this came out and was pointed out to him, all he had to say is that he “broke no law”.

    Of course, the law needs to be improved. Or eliminated. But politicians resign not just when they break a law, there are other reasons. For Dr. Bolduc, the situation is crystal clear. It’s even too late to just refund the 215,000 $.