Private for-profit medical clinics are proliferating across the country, according to a detailed report by pro-medicare groups.
The number of such clinics has increased significantly over the past 5 years and there's evidence “to suspect that 89 for-profit clinics in 5 provinces appear to be in breach of the Canada Health Act,” states the 169-page Eroding Public Medicare: Lessons and Consequences of For-Profit Health Care Across Canada report.
But federal and provincial officials “have fallen down in their responsibility to protect patients against extra billing and 2-tier care,” says report author Natalie Mehra, director of the Ontario Health Coalition.
A spokesperson for federal Health Minister Tony Clement argued that enforcement of the Act falls to the provinces. “It is the responsibility of the provinces to ensure that providers of insured health services operate in compliance with the requirements of the Canada Health Act,” said press secretary Laryssa Waler.
Lack of political will seems to explain the fact that the Act — which forbids extra billing for medically necessary care and requires that such care be provided to Canadians on uniform terms and conditions — is not being enforced, Mehra says.
“Certainly, it is not very difficult to establish what is going on,” she adds, noting that researchers called up clinics and asked basic questions.
The report provides details on private clinics that offer magnetic resonance imaging (MRI) and computed tomography scans, surgical procedures, laser eye and cataract surgery. It also examines services offered by comprehensive “boutique” medical clinics that cater to wealthy clients.
Researchers also found evidence of physicians practising in hospitals but referring patients to their private for-profit businesses, where medically necessary services would be provided more quickly, for an out-of-pocket fee.
Former federal Health Minister Ujjal Dosanjh addressed the trend of doctors practising on both a publicly insured and private basis in a 2005 “Canadian Public Health Care Protection Initiative” statement, in which the government vowed to take action against the practice “when it undermines access to publicly insured services.” But report researchers found no evidence of any enforcement.
In 1995, then-federal health minister Diane Marleau issued a policy interpretation letter calling on provinces to introduce “regulatory frameworks” to govern the operation of private clinics, and make illegal the “facility fees” charged by private clinics which provide publicly-insured services.
But report researchers found many examples of facility charges, including a $240 fee charged to patients having publicly-paid-for colonoscopies at a Vancouver clinic, and a $450 direct charge to patients having the same procedure in Montreal.
The report, was supported by several provincial health coalitions, the Council of Canadians, Canadian Doctors for Medicare and the Medical Reform Group. It concludes that increased numbers of private clinics allow for queue jumping, facilitate provision of unnecessary and sometime dangerous medical procedures, siphon health care professionals from the public system, promote “cream skimming” (private clinics tend to handle less complex medical cases) and do not reduce wait times in public hospitals and clinics. Among the highlights of the report:
Of the 42 private for-profit MRI/CT scan clinics in Canada, all but one were willing to sell medically necessary scans to patients for out-of-pocket fees, a violation of the Canada Health Act's prohibition on 2-tier medicine.
Increasingly, private for-profit clinics that perform laser eye surgery (not deemed medically necessary) are also offering cataract surgery, a medically necessary procedure, for an out-of-pocket fee. In some cases, clinics charge the provincial health insurance plan and then also bill patients directly for cataract surgery.
72 private for-profit surgical hospitals were operating in 7 provinces in 2007. Almost half (34) of the hospitals told researchers they could buy medically necessary procedures, such as knee surgery, for out-of-pocket payments, and 31 said they did not charge patients for services. Meanwhile, only 2 provinces have accreditation processes that track these surgical hospitals.
In 1993, Alberta became the first province to allow private for-profit MRIs but by 2001 the province was reversing the trend, and no new private MRI clinics were opened between 2003 and 2007. Instead, Alberta increased the capacity of the public system, and patients who had paid out-of-pocket for medically necessary scans were reimbursed by the province.
The report calls on provinces to set up monitoring and enforcement regimes for clinics that provide both medically necessary care (to ensure extra billing and queue jumping is not allowed), and medically unnecessary care (to ensure they don't stray into areas covered by the Canada Health Act). — Ann Silversides, CMAJ
Figure. Canada is experiencing a boom in private for-profit clinics, says report author Natalie Mehra. Image by: John Bonnar