Ontario family physician perspectives on whether and how to charge patients for uninsured services

Abstract

Objective

To explore family physicians’ decision-making process regarding charging patients for uninsured services in Ontario.

Design

A secondary analysis of 55 interviews from a constructivist grounded theory study on before-tax income differences among Ontario family physicians.

Setting

Ontario.

Participants

Independently practising family physicians.

Methods

Interview transcripts were analyzed using inductive content analysis. Key patterns pertaining to charging decisions and processes were identified through iterative coding. Categorization matrices were developed, enabling comparison of key dimensions related to practice features and physicians’ charging decisions.

Main findings

Participants varied in their approaches to charging for uninsured services, describing decisions as shaped by value-laden negotiations between professional commitments and system-level inadequacies. Across remuneration models, rising financial costs and administrative burden influenced charging decisions. Some physicians viewed charging as necessary to support the costs of practice and manage administrative workload, while others described fees as misaligned with their commitment to delivering accessible, equitable care or as adding a new administrative burden. When deciding whether and how to enforce fees, physicians often made exceptions based on perceptions of patient financial circumstances.

Conclusion

The findings suggest that while addressing financial shortfalls and reducing volume of unpaid administrative work are key motivators for charging for uninsured services, fees may simultaneously introduce new ethical and operational challenges. Addressing family physician remuneration for administrative and uninsured services is essential for reducing these tensions and sustaining core family medicine values.

In Canada, uninsured physician services are medical or administrative tasks not covered by provincial insurance plans because the Canada Health Act only requires medically necessary services be covered by public plans.¹ Examples of uninsured services include writing sick notes, renewing prescriptions outside of appointments, or completing forms for employment or education.^2-4 While these services facilitate patient access to essential resources, they create additional work for physicians. Recognizing this, most provincial regulatory colleges allow physicians to charge patients directly for this work, under particular conditions.^2,5-8 Charges may be collected per service or as a “block fee” covering multiple services for a set period. These fees provide a substantial, albeit controversial, revenue stream that can affect the financial viability of practices.⁴

In Ontario, the College of Physicians and Surgeons of Ontario (CPSO) permits, and the Ontario Medical Association (OMA) supports, charging patients directly for uninsured services if fees align with OMA guidelines, are clearly communicated, and do not restrict access to insured care.^2,9,10 Both organizations encourage fee waivers or reductions for patients facing financial difficulties.^5,7-10 Table 1, using information from the 2026 OMA guide, outlines examples of uninsured services and recommended fees.¹⁰ Average annual block fees were $106 in 2019, although no published data exist on typical physician income from these fees.⁴ Fee guidelines remain consistent regardless of the primary care payment models. Ontario family physicians may be paid through a patient enrollment model (fixed per-patient payment for rostered patients, supplemented by fee-for-service billings and potential bonuses or premiums), a service-based model (primarily fee-for-service billings), or salaried models (salary or sessional payment independent of patient volume or services provided).¹¹

Table 1.

Examples of uninsured services and fees suggested by the Ontario Medical Association as of January 2026

UNINSURED SERVICE	OMA SUGGESTED FEE
Copying or printing medical records	$30 for the first 20 pages, plus $0.25 per additional page
Electronic transfer of medical records	$30.00
Physician review of medical records	$45 per 15 minutes, after the first 15 minutes
Documentation or forms for physical examinations for educational purposes (eg, schools, camps, preschool, daycare, university)	$37.25
Documentation or forms for physical examinations for employment purposes (eg, pre-employment certification of fitness for employees of fitness clubs, hospitals, or nursing homes)	$49.00
Return to work, sick, or daycare notes	$26.00
Canada Revenue Agency Disability Tax Credit form (T2201)	Physician’s hourly rate, suggested $150.00 minimum
Motor vehicle accident insurance disability certificate (OCF-3)	$262.00
Motor vehicle accident insurance treatment plan documentation (OCF-18)	$278.00
Motor vehicle accident insurance treatment confirmation documentation (OCF-23)	$262.00
Attending physician’s statement	Physician’s hourly rate, suggested $160.00 minimum
Insurance medical examination and report	Physician’s hourly rate

OMA—Ontario Medical Association.

Data from the OMA.¹⁰

Family physicians, as primary access points and information coordinators in the health system, encounter higher volumes of administrative requests than other specialties.^12-14 Although patients see these requests for insured and uninsured services as a routine part of publicly insured care, they add substantial administrative burden for family physicians.^15-20 This leaves physicians balancing the expectation of “free” health care with charging for uninsured services that may threaten access. However, practice needs, concerns regarding unpaid or undercompensated work, and provider well-being^21-23 also factor into charging decisions.

Research and recent media reports suggest more family physicians are charging for uninsured services,^4,24 but little is known about how these fee decisions are made or managed in practice. We aimed to extend previous work⁴ by examining how Ontario family physicians decide to charge for uninsured services; how they navigate the practical, administrative, and ethical tensions of charging; and how practice features influence these decisions.

METHODS

Study design

Previously, we conducted a constructivist grounded theory study investigating how Ontario family physicians perceive their social identities to impact before-tax income.²⁵ The current study is a secondary analysis of the same data to examine how Ontario family physicians navigate charging decisions for uninsured services.

Participants

All participants were English-speaking family physicians practising independently in Ontario.

Sampling and recruitment

Participants were purposively sampled from willing respondents to an OMA survey on income and practice decision making²⁶ and via recruitment notices shared through personal and professional networks and on social media. Interested individuals were invited to complete a brief demographic survey, allowing us to further sample for variation in remuneration models, geographic regions, and years in practice.

Data collection

Data collection occurred through semistructured interviews with physicians from February to July 2024. Interviews were conducted by nonphysician women interviewers (K.S., A.C.) who are all trained in qualitative research and were not known to the participants. Interviews were conducted virtually, lasting between 28 and 77 minutes (average of 48 minutes), and were audiorecorded and transcribed verbatim. The interview guide was developed based on a literature review and refined with the input of representatives from the OMA, the Section of Generalist and Family Physicians, and family physician team members. The guide was piloted and refined with feedback from 2 family physicians. The interview guide inquired about billing practices, including explicit questions about practice-level and individual decisions about charging for uninsured services.

Data analysis

We extracted all data related to uninsured services and analyzed them using an inductive approach to content analysis.²⁷ This approach allowed us to stay close to participants’ descriptions of their experiences while allowing for some interpretation through abstraction to understand how they navigated fee-related decisions. A.E. and A.K.S. led the analysis, reviewing extracts and writing analytic memos to identify recurring ideas, patterns, and themes. Regular analytic meetings were held with the principal investigator (M.V.) to discuss insights and collaboratively develop a coding framework. The framework was iteratively refined and applied to all relevant transcripts. Data analysis was managed via NVivo 14.

Constant comparative analysis was facilitated by categorization matrices constructed on a shared digital platform.²⁸ Each participant was listed vertically, with the horizontal axis capturing key dimensions: whether a participant charges fees; fee structure (none, block fees, fees per service, combination); level of adherence to practice fee policies (high, medium, low); remuneration model (capitation, service-based, salaried); and perceived affordability for patient population (many, some, few patients would struggle to pay). Analysts independently reviewed and labelled data across these dimensions before comparing interpretations. Discrepancies were resolved through discussion, and if consensus could not be reached, the principal investigator resolved disagreements.

Research team

A.E., A.K.S., K.S., A.C., and M.V. are graduate-trained qualitative researchers, all of whom conduct research in primary care, medical education, and physician practice patterns and organization. D.O. is a practising family physician in Ontario, while B.K. and A.S. specialize in physician remuneration and health economics.

Ethics approval

This study received ethics approval from the Hamilton Integrated Research Ethics Board (project number 16222). All participants provided written informed consent.

Funding

This research was funded by the Canadian Institutes of Health Research (funding reference number 186174). The funders were not involved in the design or conduct of the study, or in the decision to publish this research.

FINDINGS

Fifty-five Ontario family physicians participated; 53 discussed uninsured service fees. Thirty-three worked in family health organizations, a capitated model of team-based care,^29,30 while others practised in various models. Demographic information is available in Table 2¹¹ and illustrative data (ie, quotes) are excerpted in Table 3.

Table 2.

Participant demographic characteristics: Categories with n<5 were suppressed for blinding purposes. N=53.

CHARACTERISTIC	PARTICIPANTS, n (%)
	BLENDED CAPITATION*	SERVICE-BASED PAYMENT†	SALARIED MODELS‡	TOTAL
Population size	37 (70)	7 (13)	9 (17)	53 (100)
Gender
Woman	25 (68)	<5	8 (89)	38 (72)
Man	12 (32)	<5	<5	15 (28)
Self-reported race or ethnicity
White	15 (41)	<5	<5	20 (38)
East Asian	8 (22)	<5	<5	12 (23)
South Asian	6 (16)	<5	<5	10 (19)
Black	<5	<5	<5	2 (4)
Indo-Caribbean	<5	<5	<5	2 (4)
Jewish	<5	<5	<5	2 (4)
Multiple races	<5	<5	<5	2 (4)
West Asian	<5	<5	<5	2 (4)
Arab	<5	<5	<5	1 (2)
Location of MD training
Canada	30 (81)	<5	8 (89)	41 (77)
International	7 (19)	<5	<5	12 (23)
Age, y
≤29	<5	<5	<5	2 (4)
30-39	16 (43)	<5	6 (67)	26 (49)
40-49	15 (41)	<5	<5	17 (32)
50-59	<5	<5	<5	6 (11)
≥60	<5	<5	<5	2 (4)
Typical length of intermediate assessment (A007 billing code)
≤14 min	12 (32)	<5	<5	16 (30)
15-24 min	21 (57)	<5	<5	24 (45)
≥25 min	<5	<5	7 (78)	13 (25)

FFS—fee for service, MD—medical degree.

^*Blended capitation: Physicians receive a fixed per-patient payment for rostered patients, supplemented by FFS billings and potentially bonuses or premiums. Includes capitation, family health organizations, and family health teams.

^†Service-based payment: Physicians are primarily remunerated through FFS billings, with payment amounts varying by the type of services provided. Some models may also include bonuses or premiums based on patient enrollment. Includes FFS practices and family health groups.

^‡Salaried models: Physicians receive a salary or sessional payment that is independent of patient volume or types of services provided. This remuneration model is common in community-based or institutional settings. Includes community health centres, alternative payment plans, and salaried, sessional, and locum positions.

Data from the Ontario Ministry of Health.¹¹

Table 3.

Illustrative quotations from interviews with Ontario family physicians

SECTION	QUOTE NO.	QUOTE
Navigating a series of decisions about charging fees
Whether and when to charge fees, and how to enforce them	1	We charge them, but we mostly tell everyone, you can opt to do it [block fees], but if you don’t, you’ll be responsible for paying for each thing that’s not covered by OHIP, and we detail everything out (P35, FHO)
	2	We all have to be on the same page.… Like patients talk, or you don’t want to hear like “Oh, I got it waived because I’m really low income, and how come this person didn’t,” and that kind of thing (P28, FHO)
Financial pressures in family medicine	3	We would do these forms and get paid nothing for them. And then, our current manager said, “Oh my god. I mean … OHIP’s not kept up with our ability to pay these physicians. We need to be getting money for all these additional services.” So, we’re actually back to billing for these additional services again (P06, sessional fee)
	4	I mean, most of my days spent, those after-hours things are spent dealing with, “I need a massage note.” “Oh, can you send these labs over to me?” “Can you do this?” “Can you do that?” So, we charge for those now. And that actually at least gives me a level of “At least I’m not doing it for nothing” (P35, FHO)
Mitigating administrative burden	5	The number of messages we would get per day were ridiculous. And so, we had to hire an entire human being whose job the entire day—so she was a secretary—but she was assigned to do the portal. And she would spend 7 hours per day on this frickin’ thing. And half the messages are stupid. “When’s my dermatology appointment?” Well, did you call your dermatologist’s office?… So, because it was being abused, we started a discussion about having a small fee for the portal (P28, FHO)
	6	We have now started telling our patients that we will charge for faxing prescriptions. When you come for your visit take all your prescriptions with you. We’re not going to entertain faxes from the pharmacy. So, there will be a fee for that (P15, FHO)
Consideration of patient preference and ability to pay	7	It’s kind of like a social thing. Not everyone can afford it. So yeah, none of the practices that I’ve been part of have charged a block fee (P36, CHC)
	8	Patient population? No. I don’t think so, no. It’s because we can’t discriminate, so it’s basically all a flat fee depending on whatever they’re requesting. Depending on some extenuating circumstances, if the patient comes from a lower socioeconomic part of the demographic range, then yeah, we can waive fees.… Everything is all within reason (P11, FFS)
	9	In my practice most of my patients can afford to pay for these things, so I do charge them (P10, FHO)
	10	I would say that I have patients from literally all walks of life and all socioeconomic statuses, and so I would say that financially if it’s not affordable, I would never pressure any patients specifically, whether they have money or not, to get a block fee. It’s just whether it’s—if it’s worth it to them, based on their needs and the type of paperwork that they often get filled out. If they think that it’s something that they want to do, then we just say, okay, yeah, you can do that, that’s one of your choices, or you don’t have to. But obviously the ones that can afford it are going to be the ones that are more likely to do it, because they have the financial means (P49, FHO)
Values-based decisions	11	I mean our costs have gone up and fees have stayed the same and so we’re much more—we’re much more aggressive or better at charging fees for patients but it’s such a hard, awkward position to be in. I really hate it (P12, FHO)
	12	It’s very patient-by-patient dependent. So, we have a lot of new immigrants to Canada who don’t have a lot of money, so we’ll waive fees very frequently. So, it varies. We have our set fees listed outside, but I would say about 30% of the time, I’m waiving fees for people just because they’re not able to afford them (P53, FFS)
	13	I think growing up, my parents were—like, we didn’t have a lot of money. I would say we were sort of lower middle class. And maybe that probably influences how comfortable I am having a conversation with patients. I’m maybe a little bit more sensitive to low-income patients and their finances. And so I guess that’s a scenario where my identity [intersects], and maybe that rolls into how comfortable I am selling block fees to my patients as well (P29, FHO)
	14	My mindset is that I’m not in money-making mode when I’m in my clinic. I’m in “do my job” mode and do it well and take the psychological meaning and purpose out of it.… It’s like missionary work, you do your best because it’s the right thing to do. And forget about if you make 5 extra dollars for this and 2 extra dollars for that (P17, FHO)
	15	I felt that it was kind of turning things more into a business by doing it that way and less patient care (P43, FHO)
	16	I hate to have patients like prop up a broken government system. Like I’d rather there be system change than kind of piecemeal. I don’t want to charge. The reason I left the United States is so that I don’t have to track down patients for money. Like when it comes down to it, a lot of the—I write off a lot of the bills that I charge for non-OHIP-covered services because I’m just not willing to like chase them for money (P14, FHO)
Remuneration model	17	We’re an academic family practice, and we felt that there are some ethical dilemmas about charging that block fee.… We have a large number of [patients in] lower [income] demographics … how would they be able to afford paying a block fee? So, we decided to go against it (P27, FHT)
	18	The other things are just part of the salaried position, but, again, I don’t find that I’m, I rarely, if ever, do work outside those scheduled hours, so I feel that that’s compensated appropriately in that model (P09, CHC)
Implications of charging decisions
Financial sustainability	19	I’d say a third of my practice have signed up for the portal. So that’s about $60 per person per year, in my opinion, totally worth it. You are messaging me.… He asked for a dermatology referral, not urgent, I did it within 4 hours of him messaging, because he has that.… So far, I’ve made like 12 or 13 grand from it. It’s significant. It’s only the people who really feel like, “Yes, this is worth my $60” (P28, FHO)
	20	And there’s some patients who, I kid you not, I probably make a thousand dollars through all the sick notes that I write for them, through all the APSs [attending physician statements] that I do for them, etc, and so I’d rather just do fee for service per service rather than offering patients this block fee. Because financially I feel like it wouldn’t benefit me in any way, it would actually be more harmful (P52, FHO)
	21	Even if I was to charge $15 [for prescription renewals], it would be an extra $300 a day that I’d be making. Yeah, so that is one thing that definitely is an income opportunity that is thrown aside for the patient’s sake (P25, FHO)
	22	In terms of collecting, so there’s—I don’t even want to imagine how many, probably thousands of dollars like sitting due to me, logged as the patient got this service like a massage note, but it was sent by email, and they weren’t physically here. And they’re owing it to me but haven’t actually paid it (P07, FHO)
New administrative burden	23	I was getting so many fax renewals that I had to be following up on that, it was taking me like an extra hour or 2 per week, and I finally got fed up. And so, in July of 2022, I reinstituted prescription renewal fees, and surprisingly, my patients now ask me about their prescriptions in their appointments. So that’s been way better (P26, FHO)
	24	I have at various times in my practice become more—try to become more diligent about like sending out a 1-month warning, a 2-month warning, but now it’s just way too much work for anyone to do spending that money on tracking down late fees, late payments. It’s just too exhausting (P14, FHO)
	25	And the collecting of those outstanding bills. And then eventually they’re like 5 years old, 3 years old. I’ll say, oh, this is ridiculous, I’m never going to be get paid for this. And then they just get written off. So that’s lost income (P07, FHO)
Professional impacts	26	They just bug me. I think I tried it for like a year or 2. It was just hard to figure out who I was charging for prescription refills and who I wasn’t and like half the time I found the people who paid didn’t really use it and I felt like I was ripping them off (P37, FHO)
	27	I would charge fee-for-service for uninsured services, but I felt that it was part of their care. I already spent so much time working per week that I didn’t really want to waste time having those discussions about block fees. Even though those are kind of front-loaded (P42, FHO)

CHC—community health centre, FFS—fee for service, FHO—family health organization, FHT—family health team, P—participant, OHIP—Ontario Health Insurance Plan.

Family physicians described implementing uninsured service fees as a response to escalating financial pressures and administrative burden. These factors shaped decisions about whether, when, and how to charge fees. Charging fees often introduced new tensions between professional identities as healers and businesspersons, equity and financial sustainability, and administrative relief and burdens.

Navigating a series of decisions

Whether and when to charge, and how to enforce. Family physicians described having to make a series of decisions about whether to charge fees for uninsured services, how much to charge, and how strictly to enforce those fees. This process was perceived as requiring continuous negotiation between the tensions of professional identities as healer and businessperson, and between equity and financial sustainability.

Participants reported following CPSO and OMA guidelines when charging for services such as prescription renewals outside of visits; form completion (eg, sick notes); and elective paramedical referrals often required for private insurance reimbursement. In line with these guidelines, many offered patients a choice between block fees and fee per service to avoid perceived coercion (quote 1 [all quotations are from Table 3]).

When deciding whether to charge, participants described practicewide discussions that led to 1 of 3 approaches: all physicians agree to charge fees; no physicians in the practice charge fees; or decisions are left to individual physicians. Regardless of the group decision, participants emphasized the importance of consistency with practice colleagues (quote 2).

Even when practice-level policies existed, decisions about application and enforcement ultimately occurred during individual patient interactions. Physicians reported varying adherence: some followed policies consistently (high adherence), while others frequently made exceptions (low adherence). Both practice-level and individual enforcement decisions were described as shaped by interrelated factors including how physicians negotiated tensions between financial sustainability, administrative resources, patient circumstances, and professional identity.

Financial pressures in family medicine. Many participants cited rising overhead costs and static remuneration as key motivators to charge fees. For some, fees were perceived as an essential mechanism for financial sustainability (quote 3). Others viewed them as a way to recover costs for the time and resources spent delivering these services (quote 4).

Mitigating administrative burden. Family physicians identified uninsured services as exacerbating their administrative burden. Charging fees aimed to regulate the volume of requests (quote 5). Some also viewed these fees as an opportunity to incentivize patients to consolidate requests and bring up administrative needs during rather than outside of appointments (quote 6).

Considerations of patients’ preferences and ability to pay. For physicians working in lower-income communities, charging and enforcing fees was complicated by patient circumstances (quote 7). Some expressed discomfort with charging patients facing financial hardship and waived fees on a case-by-case basis (quote 8). As shown in Table 4, physicians were more likely to charge fees when they perceived their patients as being able to pay (quote 9). Regardless of how participants described their patient population, most still reported inconsistent application of individual or practice policies for uninsured services. Here, participants emphasized setting clear expectations by communicating the value of the service while remaining sensitive to patients’ circumstances (quote 10).

Table 4.

Participants’ decisions about whether to charge fees for uninsured services with respect to the number of patients they perceive cannot afford to pay: N=51 as 2 salaried participants were excluded due to insufficient data on fee-charging status. Participants’ decisions were grouped as yes versus no compared to how many patients they perceived could not afford to pay for uninsured fees.

PERCEPTION	DECISION TO CHARGE FEES
	NO (NO FEES OR VERY FEW FEES)	YES (FEE-FOR-SERVICE OR BLOCK FEES)
Few patients would struggle to pay	0	10
Some patients would struggle to pay	3	14
Many patients would struggle to pay	9	4
Not indicated	4	7

Values-based decisions. Professional identity and values influenced participant decisions regarding charging and enforcing fees. Although some saw fees as necessary to offset financial pressures, they described the process as awkward and not aligned with their professional values (quote 11). For some, this discomfort stemmed from philosophical opposition, personal experiences (quote 12), or aspects of their identity (quote 13). These physicians described believing that fee discussions clashed with their view of what Canadian family medicine should be (quote 14) and shifted the focus away from patient care and toward a business model (quote 15). Some argued that charging fees was asking patients to prop up a broken system (quote 16).

Remuneration model. These concerns were also reflected within the practice’s culture. Physicians in academic or community-oriented settings described holding shared commitments to universal access and equity, which shaped their charging decisions (quote 17). Those working in salaried models believed this work was already compensated (quote 18) and were least likely to report charging fees (Table 5).

Table 5.

Participants’ remuneration models compared to decisions about uninsured fees organized into yes or no: N=51 as 2 salaried participants were excluded due to insufficient data on fee-charging status.

REMUNERATION MODEL	DECISION TO CHARGE FEES
	NO (NO FEES OR VERY FEW FEES)	YES (FFS OR BLOCK FEES)
Fee based (FFS, FHG)	1	6
Population based (capitation, FHO, FHT)	9	28
Salaried (salary, APP, CHC, locum)	6	1

APP—alternative payment plan, CHC—community health centre, FFS—fee for service, FHG—family health group, FHO—family health organization, FHT—family health team.

Implications of charging decisions

Participants reported varying strategies for implementing and adhering to policies about fees for uninsured services, each with different financial and professional consequences. While some saw fees as essential for sustaining practice and managing workload, others faced new administrative burdens and questioned whether the benefits outweighed the costs or aligned with their professional values.

Financial sustainability. Some participants reported generating additional revenue from charging block fees (quote 19) and fees for each service (quote 20).

Physicians who did not charge or enforce fees reflected on lost revenue. Some described this as a trade-off to avoid burdening patients (quote 21), while others avoided charging consistently because of the administrative burden of tracking unpaid fees (quote 22). This ultimately led to writing off charges, which was characterized as forgone income.

New administrative burden. While some participants saw charging as a way to ease administrative burden, descriptions of the overall impact were mixed. Some perceived that charging fees reduced the volume of requests because it encouraged patients to bundle administrative requests during visits (quote 23).

However, others noted that implementing and enforcing fees created new administrative challenges, such as issuing invoices and tracking and managing fee payments (quote 24). Even when third-party billing systems were used to manage fee administration and optimize income, a few participants noted that pursuing late or unpaid fees required ongoing oversight and effort. This effort was perceived as overly time-consuming, which led some to write off unpaid fees rather than spend additional effort collecting them (quote 25).

Professional impacts. For some, the challenge of managing outstanding payments led to frustration and doubts that the benefit of charging was worth the effort. Some questioned their value (quote 26). Even those who recognized the financial benefits acknowledged that enforcing fee policies was time-consuming and often distracted them from providing patient care (quote 27).

DISCUSSION

This analysis of how 53 Ontario family physicians navigated the decision to charge patients for uninsured services identified that decisions are not merely operational or financial, but value-laden negotiations that expose tensions between professional identity and perceived system-level inadequacies. While fees may offer additional revenue or reduce volume of unpaid administrative work, they also create moral and administrative burden that can contradict the reasons some physicians choose family medicine. For participants, these decisions were closely tied to their professional identities regarding providing accessible, equitable, and relationship-based primary care within a publicly funded system.

Remuneration models reportedly influenced charging decisions. Physicians in fee-for-service or population-based models, especially those serving patients perceived as able to pay, were more likely to charge. This aligns with prior research showing that these models often serve higher-income, lower-complexity patients,^31,32 justifying the charging decisions for some. In contrast, physicians in community health centres, designed for lower-income or higher-need populations,^31,33 were less likely to charge. This may reflect both the values motivating physicians to work in this model and their salaried remuneration.^34,35 Charging decisions may also be shaped by differences in how revenue is retained or redistributed across remuneration models. However, this study did not examine fee disbursements and cannot confirm whether or how physicians retained revenue from uninsured services. This contrasts with an earlier cross-sectional survey of Ontario family practices that found no significant association between payment model and charging decisions.⁴

Despite policies permitting charges,^2,3,10 some participants expressed discomfort with appearing to prioritize financial gain over care provision. Patients have expressed similar concerns in media reports.²⁴ This discomfort may stem from the perception that private billing undermines Canada’s publicly funded health care system, which emphasizes equity, universality, and accessibility. Yet, opting not to charge leaves physicians bearing the cost of uncompensated work, adding to their stress and workload.^36,37 Indeed, research has documented the time family physicians spend on administrative tasks, including uninsured services such as form completion, sick notes, or renewing prescriptions outside of visits.^16,19,38,39 Here, charging may represent a way family physicians remunerate their labour for this work, or generate revenue to support delegation of administrative tasks to other team members.^19,40 However, requiring physicians to decide whether to charge, set fees, and set up systems to administer and collect fees shifts responsibility of securing compensation for this labour onto individual providers rather than having standardized payment processes. Fee administration requires physician effort to navigate uncomfortable trade-offs between financial sustainability, patient relationships, and upholding principles of equitable, publicly funded care. Converting such services to be publicly funded could, in theory, reduce effort required for individual pricing and private billing. However, the impact on service demand or burden associated with public billing remain uncertain.

Among those with charging policies, adherence and enforcement were inconsistent. When charging was intended to reduce administrative workload by discouraging nonessential requests, participants often did not pursue unpaid fees, citing the extra administrative effort associated with tracking and collecting unpaid payments. Even when physicians invested in third-party billing systems, these approaches did not always reduce the need for follow-up on fee collection after service delivery. This suggests that, despite such investments, practices may have limited capacity to implement and maintain management systems that meaningfully reduce inefficiencies amid competing other practice demands. In contrast, when charging was primarily for generating revenue, adherence to charging policies was more diligent. This inconsistency in adherence may generate inequity in patient experiences.

Charging for uninsured services may further increase physician workload, reducing capacity to provide direct care to additional patients.^17,41-46 Some uninsured services, like prescription renewals outside visits, are essential to primary care but are not publicly insured. Most provincial payment plans typically only compensate this work when provided during a visit, incentivizing unnecessary appointments and further reducing access. New payment policies introduced in British Columbia and Ontario allow physicians to bill for time spent on insured administrative work outside of office visits.^47-50 Ensuring that this funding is also available to delegate these tasks to other team members may yield efficiencies to increase access and alleviate administrative burdens related to insured services, although uninsured services remain outside of the work compensated by these models. Facilitating the redistribution of administrative work to other team members through team-based care models and clear delegation guidelines can facilitate the provision of these services in an efficient and effective way.^39,40,51-53

In sum, charging for uninsured services may be financially beneficial, but simultaneously strain physician time and capacity. Since the Canada Health Act mandates public coverage only for medically necessary physician services,¹ policy-makers should consider whether some currently uninsured, but essential, services be publicly funded, or support remuneration policies that compensate family physicians for a range of patient-centred administrative work. Doing so could alter where physicians spend effort; shifting time away from making charging-related decisions, or administrative work related to private billing, and toward performing the service, while alleviating dilemmas related to equity versus financial sustainability.

Strengths and limitations

This study offered rich insights from 53 family physicians on how they navigate charging decisions for uninsured services. These findings are specific to the sociohistorical and practice contexts of participating physicians and may not represent the views of all Ontario family physicians. Compared with the broader comprehensive family physician population in Ontario, where approximately 40% practise in capitation-dominant models,⁵⁴ study participants were more likely to practise in capitation-dominant models (70%). This likely reflects physicians’ self-selection into remuneration models based on practice and personal preferences, which may shape perspectives on charging for uninsured services, and should be considered when assessing the transferability of these findings to other physician groups.

Conclusion

Ontario family physicians navigated charging decisions for uninsured services in varied ways, influenced by financial and administrative pressures and patient behaviour. Fee application was inconsistent and shaped by practice features and patient circumstances. While fees aimed to offset system inadequacies pertaining to financial sustainability and escalating administrative work, they introduced unintended consequences, requiring physicians to navigate dilemmas that threaten the core values of family medicine: equity, relationships, and trust.