Primary care crisis deepens despite reforms

Tashi Farmilo

Quebec’s primary care system remains one of the least accessible in Canada, despite more than 20 years of structural reforms, increased public investment, and a growing supply of family physicians. A new report from the C.D. Howe Institute finds that the province’s top-down, coercive approach has not only failed to improve access but may be driving physicians away from the public system.

The study, authored by policy analyst Tingting Zhang, presents a stark assessment of Quebec’s repeated efforts to reshape primary care. Roughly one in four residents still lacks a regular primary care provider, and emergency departments continue to treat large volumes of patients for conditions that could be managed in a clinic setting. This, Zhang argues, is not due to a shortage of doctors but to how the province structures their work and compensation.

Quebec has more family doctors per capita than most provinces and some of the highest physician pay in the country. Yet physicians are burdened by mandatory hospital shifts, restricted by regional staffing quotas, and disincentivized from working in team-based models that are proven to improve outcomes. Many family doctors work only part-time in primary care, choosing instead to focus on hospital roles or narrow specialties.

Policies such as the PREMs, which control where new doctors can practise, and AMPs, which require hospital hours, have made family medicine less appealing to new graduates. At the same time, Quebec remains the only province where doctors can fully exit the public system and practise privately, an option an increasing number are now taking. More than 1,100 physicians have left the public insurance plan entirely, a 45 percent rise in less than a year.

Recent legislation has attempted to curb this exodus through measures like Bill 83, which forces new doctors to work in public institutions for five years or face daily fines. But Zhang warns that such restrictions are more likely to alienate future physicians than solve access issues. Medical school applicants are already declining and Quebec has seen a surge in unfilled residency positions.

The province’s reliance on fee-for-service pay further limits collaboration, discouraging doctors from working with nurse practitioners or pharmacists. Even though Quebec has more interprofessional teams than any other province, their potential is undermined by financial structures that reward volume over quality. Team-based care remains underused, while patient needs go unmet.

Tingting Zhang recommends overhauling Quebec’s primary care system by adopting a blended payment model based on risk-adjusted capitation, incorporating performance incentives and outcome-based accountability. She calls for reducing mandatory hospital work for family doctors, fully integrating nurse practitioners and pharmacists into care teams, and ensuring mandatory patient enrolment. She also urges a structural shift that separates high-level planning and funding from local care delivery, allowing local teams to design services based on community needs while holding them accountable through transparent performance measurement.

Without such structural changes, the report warns, Quebec will continue to face high costs, deepening inequities, and worsening health outcomes.

“Incremental tweaks will not solve this crisis,” Zhang says. “Without bigger changes, Quebec risks deeper access gaps, higher costs, and worsening outcomes for patients.”