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As private-pay crackdown looms, 'executive health' clinics charge freely

Clinics operate by paywalling primary care physicians behind 'block fees' for non-OHIP-covered services
Ontario Health Minister Sylvia Jones makes an announcement on health care with Premier Doug Ford in the province in Toronto, Monday, Jan. 16, 2023

As millions of Ontarians struggle to find family doctors, private-pay clinics are having somewhat of a heyday. 

New nurse practitioner-led clinics have made headlines recently for openly charging yearly fees for primary care. They're either illegal or exist in a loophole, depending on who you ask. Health Minister Sylvia Jones is reportedly trying to bring NPs into Canada's public system, which would see the clinics bill the government, not patients.

But Jones has refused to comment on another, older model of private medical centre — known as an "executive health" clinic — that charges patients for access to family doctors.

Increasingly, advocates are raising the question: why are some private-pay clinics OK, and others aren't?

In February, the opposition NDP accused the government of moving toward a two-tiered health system, pointing to 1,600 Toronto patients who lost their family doctor to an exec health clinic.

The clinic, MDDirect, charges almost $5,000 a year for "comprehensive annual physicals," "24/7 access to their personal physician," and more.

There are several such clinics in Ontario, and some have been around for many years. Some stay firmly within the spirit of the federal Canada Health Act, which bans charging for medically necessary care — Toronto's Executive Health Centre, for instance, only offers non-OHIP services like diagnostics and nutrition advice. 

Others, like Medcan, offer care to those who will pay cash. It works like this: patients pay a "block fee" for services that aren't covered under OHIP, like physio and massage therapy. Those patients just happen to also get a family doctor.

"Medcan would be considered private — I'm using air quotes, but you can't see me — private health care," a Medcan coordinator told The Trillium, believing she was speaking to a prospective patient. "So our doctors do have an annual fee."

"Your doctor's visit itself is always still charged through OHIP," she said by way of explaining the clinic's legality. "What you're paying for is everything else that comes with it," including doctor's notes and "all those like extra little things that you sometimes have to pay for that are tedious and irritating being in the public system."

Medcan's $3,700/year program includes three personal training sessions, a physiotherapy session, a chiropody session and a massage, she said.

There is no way to see a doctor without paying the fee, the coordinator said. 

"I just think that the standard of care, personally, is much higher because doctors have such smaller rosters," said the coordinator, who said she is also a patient. She said the busiest Medcan physician had about 500 patients on their roster. Public family doctors often have thousands.

"Just trying to find a doctor is so hard. And then being stuck, if you've got to go to a walk-in — or the wait times in the emergency rooms are up to 24 hours right now, like, it's just not worth it. I'll just pay the money," she said.

At press time, waits in Toronto ERs ranged from one to six hours.

Medcan's family doctor replacement plan includes same or next-day doctor appointments and a suite of uninsured services. Medcan
Medcan's family doctor replacement plan costs $3,700/year. Medcan

A total of four exec health clinics called by The Trillium (Medcan, MDDirect, Ottawa's Exec Health, and the Cleveland Clinic in Toronto) said they were taking new primary care patients — but only those who pay.

The Cleveland Clinic's $12,000/year "concierge medicine" program includes a $2,625 physical, year-round care with a 24/7 "dedicated team" ($8,335) and a $1,500 sports rehabilitation and wellness services credit, according to an email the clinic sent to The Trillium outlining its services.

An MDDirect receptionist said there was no way to see a primary care doctor without paying the fee.

The clinic declined an interview, saying it complies with the law.

"MDDirect patients are not charged for OHIP-covered services and have access to OHIP-covered services without paying any annual fee," Director of Operations Joanne Sierzant said in a statement.

She did not respond to a question about what those OHIP-covered services are.

What might seem like a loophole is, in fact, illegal, according to longtime health-care advocate Natalie Mehra.

"It's unlawful, and illegal, to commingle services, to require a patient to pay for a medically unnecessary service in order to get a medically necessary service," the Ontario Health Coalition Executive Director said. 

"It's a violation of the Canada Health Act. You cannot charge a patient for access to medically necessary hospital or physician care. And then, under (Ontario's) Commitment to the Future of Medicare Act, it's an offence — so it's illegal — to charge a patient for access to an OHIP-insured service," she said.

"So I wouldn't say in any way it's a loophole," she said. "It's exactly what our Medicare laws were set up to prevent."

The Trillium's experiment is "deeply disturbing," Liberal health critic Adil Shamji said. "The Canada Health Act sets clear parameters: that uninsured services cannot be a barrier to insured services. And so, the way that's been framed sounds, frankly, in contravention of the Canada Health Act."

Exec health clinics are a "slippery slope," NDP Leader Marit Stiles said. "Because it allows people to pay for a different standard and access to health care. And that, to me, is completely contrary to what we believe as Canadians. "

Green Leader Mike Schreiner said they exist in a "loophole" that needs to be closed.

"We don't want to have two-tier health care in this province, and everyone deserves access to a family health-care team," he said.

Liberal Leader Bonnie Crombie said last week that exec health clinics should be stopped altogether. 

"Our policy ... is that everyone has equal access to health care, and it should not be paid by your credit card," she said.

In Monday's question period, Shamji excoriated the Ford government for what he sees as a failure to protect universal medicare.

"Every time the government ... brings another feature of public health care to its knees, there is always a private, for-profit model there to save the day," he said. "Whether it is exorbitant subscription fees to nurse practitioners or executive health clinics, whether it’s pricey Pap smears or costly cataract lenses, whether it’s staffing agencies gouging our hospitals and long-term-care homes, this government rolls out the red carpet for anyone praying to the almighty dollar."

"The Liberal member opposite can throw around all the quips he wants," Jones said. "The truth is that we are making investments in our publicly-funded health care system in Ontario," arguing the province leads Canada with the lowest surgery wait times and "the number of individuals who are matched with a primary care practitioner."

After question period, Jones wouldn't say whether she believed clinics charging patients for primary care is legal — but suggested changes could be coming.

"You'd need more information because I don't know what that means," she said in the halls of Queen's Park on Monday, when asked about executive health clinics charging patients for primary care. "What I know is that there are very specific things that are covered by OHIP-funded services."

Asked if she planned to make any changes to executive health care, however, the minister said, "We'll have more to say about that imminently."

That appears to be a change from last week, when Jones avoided questions about exec clinics, saying only that her government won't tolerate charging for OHIP-funded services.

Asked if she sees a difference between private-pay nurse practitioner clinics and executive clinics, Jones said, "The distinction for me is if it is an OHIP-funded service, it should not and it cannot be charged."

Asked if she planned to look into executive health clinics, Jones demurred.

"Okay, I feel like I'm repeating myself. OHIP-funded services should not be charging people," she said at the time.

—With files from Jessica Smith Cross and Sneh Duggal

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