Physicians overwhelmingly choose public service. But whether the current balance of public and private health care in Canada is the right balance is an increasingly urgent question as patients struggle with access and timeliness of care and the health workforce experiences record rates of burnout. To help inform discussions about the way forward, here’s a snapshot of how we got here, current rules around private medical practice and trends in different parts of the country.
Opting in: The beginning of a public health system
Health care in Canada was mostly privately delivered and funded until Tommy Douglas and the Saskatchewan government introduced the first universal hospital care plan. The provincial and federal legislation that followed led to the Medicare system we know today and the Canada Health Act of 1984, which mandated universal coverage for all medically necessary health services provided by hospitals and doctors.
Opting out: A balance of public and private health care
The vast majority of physicians today practice within the public system, but the Saskatoon Agreement of 1962 permitted doctors to opt out of Medicare. And with the exception of Ontario, physicians across the country can still do the same.
Some provinces do have barriers in place to limit private practice. For example, in Saskatchewan opting out is permitted only when it does not compromise patient access to insured services. In Quebec, provisions within the provincial health act allow the government to either suspend doctors’ right to withdraw from public service force doctors to charge Medicare rates for service so that patients can be reimbursed by the public plan. There are also differences in terminology among provinces and territories for opting out, such as "non-participation," "non-enrolment," "practicing outside the Act," and "not subject to the agreement.”
Spotlight: Private medical practice in Quebec
There are more physicians outside the public system in Quebec than all other provinces combined. Based on interviews with health officials as well as provincial data, The Globe and Mail counted more than 600 non-participating physicians in Quebec, compared with a dozen across the country: nine in BC and three in Alberta.
One reason for that is Quebec’s three categories of physicians, which is unique to the province:
Les engages or physicians within the public system
- Physicians are enrolled in the public health insurance plan and charge the government directly
Les désengagés or opted out physicians
- Physicians charge patients directly but follow the provincial fee schedule
- Patients can get reimbursed through public health insurance
Les non-participants or non-participating physicians
- Physicians bill patients directly and can set their own fees
- Patients are ineligible for Medicare reimbursement
According to a report in The Globe and Mail, the ranks of non-participating physicians in Quebec have doubled in the past decade.
Fee for services: Rules for private medical practice
The Canada Health Act prohibits extra billing and user fees for services included under public insurance plans. But in private medical practice, the rules can vary depending on where in Canada a patient accesses care. In most provinces, opted-out physicians are not bound to the fee schedule negotiated with the government and can bill any amount. That is not the case for Manitoba and Nova Scotia, however, where all fee-for-service physicians must abide by their province’s fee schedule.
Who pays for privately accessed care, if it co-exists with the public system, also varies between provinces. In New Brunswick, for example, patients who agree to private services with prior notification waive any rights to Medicare reimbursement for any charges. Similarly in Alberta, patients who receive services from opted-out physicians are not entitled to reimbursement from the public health plan. Meanwhile, in British Columbia, opted-out physicians who work in hospitals and community care facilities must adhere to public insurance rates to ensure their patients are eligible for Medicare reimbursement.