A parallel private-pay system will worsen access to publicly funded surgery

Key points

• In countries with a parallel private-pay health care system, patients can pay much more to receive quicker access to publicly funded services.

• Quebec has allowed physicians to fully opt out of publicly funded health care since 2005 and currently has more than 270 specialists working exclusively privately, creating more access challenges in the public system.

• Alberta will become the only province in Canada to allow dual physician practice, in which physicians can simultaneously provide both privately and publicly funded surgeries.

• Evidence from Canada and other jurisdictions indicates that a parallel private-pay health care system does not reduce wait times in the public system, because scarce human resources move into the private system and private-pay patients are prioritized.

The government of Alberta recently announced legislative changes allowing patients to self-refer and pay out of pocket for diagnostic and testing services covered by publicly funded health care. Alberta subsequently passed Bill 11, which allows physicians to engage in “dual practice” — that is, to work in and bill the public system while also taking on private work and charging other patients directly (https://www.alberta.ca/supporting-a-world-class-health-care-system). Initially, the focus is on elective surgeries. The Alberta government says the new legislation, which is unique within Canada, is intended to increase flexibility for patients, encourage innovation, and decrease wait times as patients willing to pay out of pocket remove themselves from the public wait-list and physicians choose to move to Alberta to practise. Other jurisdictions in Canada have experimented with allowing physicians to offer surgeries to patients willing to pay privately, and one-third of Organisation for Economic Co-operation and Development (OECD) countries allow surgeons to work in dual public and private practice. We discuss how such systems have affected access to services.

In Quebec, a 2005 Supreme Court of Canada ruling forced the province to develop a parallel private-pay system (https://decisions.scc-csc.ca/scc-csc/scc-csc/en/item/2237/index.do?q). Quebec requires physicians to fully opt out of working in the public system if they wish to engage in private practice, to reduce the potential to create access problems in the public system. Subsequently, hundreds of doctors, including 273 specialists, have left the public system in Quebec — especially since double billing was banned in 2017 — and surgical wait-times in the public system have worsened.^1,2 To combat these challenges, Quebec recently enacted a law restricting all physicians from opting out (https://www.publicationsduquebec.gouv.qc.ca/fileadmin/gazette/pdf_encrypte/lois_reglements/2025A/107433.pdf). With scarce physician resources, the private system in Quebec has not improved access in the public system. Alberta’s proposal goes further than what was enacted in Quebec, where dual practice is not permitted. Some proponents of private-pay surgery have suggested that banning dual practice for physicians is the source of Quebec’s access problems.

According to the Alberta legislation, physicians will be allowed to engage in both private and public practice. However, this approach has been tried before — and failed — in Canada. In the 1990s, Manitoba allowed dual practice for ophthalmologists who performed cataract surgery for public- and private-pay patients. According to a 2005 study, patients who paid for private surgery waited an average of 4 weeks, while patients paid for by the public system who saw providers not offering any private surgery waited 10 weeks.³ In contrast, patients paid for by the public system who saw dual-practice ophthalmologists waited 23 weeks, a difference that disappeared after Manitoba banned dual practice again.³

The United Kingdom, Norway, Denmark, Australia, and Germany allow surgeons to charge patients privately for surgeries covered by the public system. However, fundamental differences exist across these systems that make comparisons with Alberta difficult. For example, there are separate entirely private hospital systems that support private parasurgical services, and specific tax incentives or mandates to purchase health care insurance in these countries.

A 2023 systematic review of studies that examined private for-profit clinics offering cataract, hip, and knee surgeries paid for publicly found that patients treated in private clinics tended to be healthier and wealthier, and reported fewer symptoms related to their conditions before surgery than those treated in the public system.⁴ This suggests that both forms of private services may skim off the more straightforward cases (which can be completed faster and with fewer complications) and that some of these patients may have received surgery earlier than otherwise needed.

Without further recruitment, a parallel private-pay system will increase pressure on Alberta’s health workforce, as physicians and other staff choose to work in the private sector, where work hours are more predictable, leaving the public sector understaffed. Canada currently has a far smaller physician workforce than the aforementioned countries in which private systems operate (2.75 v. 3.26 to 4.58 physicians per 1000 people, and 9.51 v. 14.53 to 37.37 anesthesiologists per 100 000 people), according to OECD data.⁵ Moreover, Canada graduates half as many physicians annually. A relative staff shortage is likely to increase public wait times in the public sector, as has been observed for cancer surgeries since 2022, when Alberta began contracting out more low-risk, publicly funded surgeries to private for-profit clinics. ⁶ As sicker, more complex patients — who have more capacity to benefit from surgery — are left requiring support within public hospitals with fewer human resources, the public system will be increasingly ill equipped to serve them.

Other countries that allow physicians to engage in both public and private practice have found physicians prioritize their private-pay patients — who often pay much higher rates — increasing public wait times even further,⁷ as was observed in Manitoba. Furthermore, the Canadian Medical Association’s recent report on private care noted that a solid evidence base was lacking to support embarking on parallel-track private and public systems in Canada, but concluded that dual practice leads to poorer performance in meeting the health system Quadruple Aim.⁸

A key assumption made by those who would push for systems allowing private-pay surgery — that countries with more privately paid care have more efficient health systems — is not supported by the evidence from countries that allow it. When OECD countries are compared based on a composite of system performance and costs, overall system efficiency has been shown to increase in proportion to the public share of financing.⁹ Countries with more private financing also fare worse on 2 pillars of Canadian medicare, having lower universal coverage — fewer services are covered for everyone — and less equitable access to care.¹⁰

Given Alberta’s physician workforce challenges, and evidence from other jurisdictions that have allowed both publicly funded and privately paid surgical practice, the province’s new legislation is highly unlikely to reduce public wait times and almost certain to increase inequity. Alberta has stated that safeguards to protect the public system — such as limits on the time surgeons are allowed to spend on private care and minimum thresholds for practice in the public system — will be added in regulations rather than written in the legislation. While some countries have attempted to protect their publicly funded system with similar rules (e.g., private income limits, limited promotion opportunities, and ensuring that private work does not impede public work), this has been uniformly challenging to enforce, as discussed in a careful analysis a decade ago.⁷ It will be similarly difficult to enforce in Canada, where nearly all surgeons and anesthesiologists are independent contractors.

Other evidence-based strategies exist for addressing wait times for surgery in the public sector,¹¹ such as funding effective forms of nonsurgical care for patients with arthritis (https://gladcanada.ca/), reducing low-value surgeries, and using central access and triage with wait-lists prioritized based on urgency. Provinces should implement these solutions before considering a parallel private-pay system with dual physician practice. Provinces should also commit to increase health care workforce supply and diversity more in line with OECD norms, and make better use of publicly funded operating rooms. In England, the National Health Service expanded public operating room access and hours, which increased the number of elective surgeries per day by 20%;¹² savings of £372 million per year were estimated if the model was extended to all hospitals across the country.

If Alberta proceeds to enact this new legislation, which is more likely to exacerbate than alleviate the problem of long surgical wait-lists — according to accumulated evidence from many jurisdictions — it should allow private-pay surgeries to occur only after hours, and the province must monitor wait times in the public system to ensure access is not negatively affected. Other provinces should avoid following Alberta’s example.