The Canadian Medical Association says that a growing number of for-profit clinics are delivering specialty surgery, diagnostic imaging and primary care.David Jackson/The Globe and Mail
Canada should ban user fees for primary care and create a publicly funded “safety valve” that would force provincial governments to pay for care in other jurisdictions if waiting times become dangerously long, according to the organization that represents doctors across the country.
The Canadian Medical Association made the recommendations Tuesday in a draft paper tackling one of the thorniest issues in health policy: how to handle the rise of private, for-profit companies looking to fill gaps in the public system that were exposed and exacerbated during the pandemic.
The CMA notes that a growing number of for-profit clinics are delivering specialty surgery, diagnostic imaging and primary care, including virtual-care companies and private clinics that have responded to the shortage of family physicians by charging patients subscription or membership fees to access nurse practitioners.
The CMA’s 22 recommendations arose out of surveys, town halls and focus groups with more than 10,000 people who were asked how best to balance public and private health care. The main take-away was that medical care should continue to be distributed based on patients’ needs, not their financial resources, said Kathleen Ross, a British Columbia family physician and co-president of the CMA.
“I don’t want anybody to have to pay out of pocket to have their kid’s sore ear looked at,” she said. “That’s really unacceptable.”
Making that principle a reality can be challenging, Dr. Ross said, particularly when an estimated 6.5 million Canadians don’t have a family doctor.
The CMA paper notes that a national shortage of family doctors has led to an increase in for-profit companies offering virtual primary care. Some of those services are covered by provincial health insurance and others are not.
Primary-care clinics that charge patients subscription or other types of fees also appear to be on the rise, although data is scarce. Some are led by or include nurse practitioners, a profession that barely existed in 1984 when the Canada Health Act was adopted. The act, which covers medically necessary care provided in hospitals and by physicians, does not mention nurse practitioners.
Federal Health Minister Mark Holland has promised to issue an interpretation letter on the question of out-of-pocket fees charged by primary-care providers other than doctors, partly in response to a call from Ontario for a national crackdown on such charges.
The CMA agrees in its new draft policy that governments should, “enforce the Canada Health Act prohibition against user fees by clamping down on jurisdictions that allow the charging of membership fees, user fees or bundled payments.”
The association is also calling for a scaling up of interprofessional primary care teams that serve patients in local catchment areas, the way public schools do. The association wants 80 per cent of Canadians to have access to such teams within a decade.
One area of tension that emerged during the CMA’s consultations was whether patients with the means should be allowed to pay for, or buy private insurance for, medically necessary care when waiting times in the public system leave them in agony or threaten their lives.
The physicians’ group concluded that private insurance for care covered by the Canada Health Act should remain outlawed or severely restricted. Instead, the CMA recommends that if governments can’t meet clinically approved waiting times, they should pay to send patients to other provinces or countries for care, as B.C. began doing last year when it couldn’t provide timely radiation therapy.
The B.C. government paid for select cancer patients who wanted to cross the border for faster care to be treated in Washington state. “That’s a safety valve,” Dr. Ross said. “At the end of the day, we want to start thinking less rigidly and more innovatively.”
The CMA also advised provincial governments to proceed with caution when outsourcing surgeries to for-profit clinics.
The association said public money should only go to private surgical centres after an open tendering process that guarantees patients won’t be charged for the contracted services or subjected to “upselling” – the practice of telling patients they have to pay for a related product to access their publicly covered care.
The CMA’s other recommendations include ensuring that virtual care is publicly covered and that physicians who offer it be “remunerated commensurately with in-person services”; that governments ensure universal access to medically necessary prescription drugs regardless of patients’ ability to pay; and that a national ombudsperson for health care be appointed.