Alberta Premier Danielle Smith’s plan to allow physicians to dabble both in the public and private systems at the same time would be a Canadian first, and has drawn mixed reaction from critics and supporters alike.
It has also prompted a number of questions.
Adriana LaGrange, minister of primary services and preventative health services, would not elaborate further on the legislation prior to it being tabled.
And the government did not respond as to when the bill might be tabled. The legislative calendar indicates the fall sitting will end next week.
LaGrange said in a statement the government is committed to “ensuring that under no circumstances will any Albertan ever have to pay out-of-pocket to see their family doctor or to get the medical treatment they need.”
In a statement, Alberta Medical Association President Dr. Brian Wirzba said the announcement lacked details on “how it will be done.”
He said he’s received assurances from LaGrange that the AMA will be involved in the development of these regulations.
So what implications could the bill have?
While the Canadian Medical Association (CMA) confirms this would be a first, in a statement it drew comparisons to the model in Quebec, noting how that province has cracked down to stem the bleed of physicians to the private sector.
This year, the Quebec government enacted a law requiring new med school grads to work in the public sector for five years before they are allowed to go private.
Quebec has more doctors working in the private system than all other provinces combined, according to the CMA.
Dr. Martin Potter worked in the public system for two decades before opening a private clinic, where he says he has more freedom to hire as he wants and see patients as he pleases.
“I see a lot of patients who already have a family doctor, but they can’t see them in a timely fashion, so they make an appointment with me, and I’m happy to help them out,” Potter said.
“People who don’t believe in private care won’t come and see me. But the people who do see me … the majority are very happy.”
Quebec cardiologist Dr. Christopher Labos said the desire to go private has become common water cooler chatter.
“What used to be a verboten topic of conversation has now become almost commonplace with doctors asking each other, ‘Hey, are you thinking of going private?’” said Labos.
The plan outlined by Smith and Matt Jones, minister of hospital and surgical health services, would require surgeons to perform a set number of procedures within the public system before choosing to take on additional private surgeries.
Smith said the legislation could potentially restrict private surgeries to weekends or after-hours.
Dr. Margot Burnell, president of the Canadian Medical Association, said physicians are already reporting in the organization’s national surveys that they are burnt out.
“I don’t want a surgeon operating on me at the end of their day or at night. I want them when they’re fresh and keen and well-rested,” said Burnell.
Red Deer orthopedic surgeon Dr. Keith Wolstenholme agrees burnout is a common complaint. He is not sure how many have the capacity to take on more work.
“Now, that’s not to say that surgeons aren’t gonna jump at the opportunity to do the same work for more money,” said Wolstenholme. “Absolutely, everybody’s gonna jump at that opportunity.”
The Alberta government has not yet said what the legislation could entail for nurses.
“Surgery doesn’t happen in isolation with just the patient and the surgeon — you need a team,” said Burnell.
She worries Alberta’s plan will drain the public system of those team members, like anesthetists and nurses.
“If you allow more and more private clinics to operate, they will start poaching personnel from the public system,” said Labos.
It’s a concern shared by the United Nurses of Alberta, the union that represents more than 30,000 registered nurses in the province.
“There’s a limited number of physicians and nurses and other health care providers in the system,” said Danielle Larivee, the union’s first vice-president. “There’s no magic wand we can wave to increase the number of of health care providers.”
She worries this could open the floodgates to more nurses moving from the public to the private system, something she said is already happening as nurses choose to work in chartered surgical facilities, for example.
Larivee said the union wants to see the government backtrack on the proposal.
“This is a movement in the wrong direction,” she said. “If they go ahead, it is a full-on declaration of war against the Canada Health Act.”
That leads us to our next avenue.
The Canada Health Act does not allow physicians to charge for services that are already publicly insured.
Lorian Hardcastle, an associate professor of law and medicine at the University of Calgary, says the act is essentially a funding model between the federal government and the provinces. Contravening it will typically result in Ottawa withholding health transfers.
“But the federal government is often quite slow to withhold money and tries to work with the provinces to not have to withhold money,” said Hardcastle.
Plus, she said the federal government “doesn’t have as much teeth” because its share of the funding is smaller than what the province covers.
“Given the relationship between Alberta and the federal government and some of the tension there, I don’t think that the federal government threatening to withhold funds is going to make the province budge,” she said.
Then, there’s the possibility the issue heads to court.
Burnell said while the Canadian Medical Association needs to see exactly what the legislation says, “judicial review may be the outcome.”
A legal challenge could be an “uphill battle,” said Hardcastle.
“The courts in Canada have tended to take an approach where [they don’t] let the government intrude on your rights, but [they also don’t] make them do things in furtherance of your rights, like provide you with a certain standard of health care,” said Hardcastle.
In her video promoting the idea, Smith suggested the added costs of privatized surgeries could be covered either out-of-pocket or through patients’ insurance.
Jason Sutherland, director of the University of British Columbia’s Centre for Health Services and Policy Research, wonders if this will lead to more private insurance companies entering the market, offering insurance that runs parallel to public health care.
Andrew Ostro, CEO and founder of insurance startup PolicyMe, calls the move a net positive for the insurance industry.
“The more that gets paid out-of-pocket by patients, the bigger the need for private insurance,” Ostro said.
“I know it’s all going to be on the execution and the rollout, but I am really optimistic about what this model could represent.”
He hopes other provinces follow suit, and it results in lower wait times and improved patient care.
Ostro said if this goes through, his company will adjust the plans offered to clients in Alberta.
He said benefit plans offered by employers may also change to cover more of these private procedures. That would come at a cost, but he said it could be a way for companies to attract or retain employees.
Alberta Blue Cross, the largest benefits provider in the province, said in a statement it “will assess any future implications for our benefit plans and our customers once more information becomes available.”
In an email to CBC News, the Canadian Life and Health Insurance Association said, “It’s going to take some time for insurers to fully understand the details and we look forward to reviewing the legislation when it is introduced.”
