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Medical students fear for health care as extra billing grows

Posted: April 28, 2017

(October 6, 2016)

By: Nick Parle and Sarah Hanafi, Hamilton Spectator

Medical students across Canada are concerned that a growing number of physicians are charging their patients fees for medically necessary care. We worry about the impact this trend will have on our future patients and our publicly funded, universal health-care system.

The practice, known as “extra-billing,” happens when doctors ask patients to pay extra fees — up to many thousands of dollars — to receive services covered under public health insurance, such as consultation appointments, diagnostic tests or necessary surgeries. Physicians are already compensated by the government for these insured services, and should not be asking patients for even more money. Patients pay these fees because they believe doing so will give them faster access to tests and treatments with long wait times.

The prevalence of extra-billing practice is on the rise across Canada. In Ontario, a 2014 report by the Ontario Health Coalition found that multiple Ontario health facilities have been charging extra fees for services that are covered by OHIP, including medical consultations, colonoscopies and cataract surgeries. In British Columbia, for-profit health facilities such as the Cambie Surgery Centre have been charging extra fees to patients for services already covered by tax dollars. And in Saskatchewan, the provincial government recently voted to give patients the ability to pay a fee to “jump the queue” and receive an MRI scan weeks ahead of others that were patiently waiting for their scan.

This trend is worrisome for a number of reasons. For one, it’s unfair that some patients should be able to pay a fee to skip the queue and receive surgery or MRI scans faster than others who cannot pay. In Canada, we value a health-care system in which we all receive care based on need, not ability to pay.

These extra-billing fees will likely have unintended harms. Evidence from the United States, Europe, Australia and New Zealand shows that extra-billing reduces access to health-care services for patients who cannot pay, discourages patients from seeking care, increases the amount of bureaucracy in the system, and inflates total health-care costs.

The federal government is supposed to discourage extra-billing, as per the 1984 Canada Health Act (CHA). Each year, the federal government transfers billions to the provinces to fund health care. When provinces do not follow the guidelines of the CHA, for example by allowing extra-billing practices to continue without recourse, the provinces are supposed to be penalized by having their transfer payments reduced. This provides the provinces with a very strong financial incentive to follow federal guidelines.

Unfortunately, the federal government has not adequately identified instances of extra billing or enforced penalties. Ontario was not penalized at all for failing to prevent extra-billing practices. Other provinces, such as British Columbia, where health facilities like the Cambie Surgery Centre have been openly charging patients extra fees for many years, have only seen weak fiscal clawbacks. This simply is not enough to incentivize provincial action on this issue.

We believe that Federal Health Minister Jane Philpott is committed to serving all patients in Canada, promoting equitable access to care, and improving the efficiency of our health-care system. Given the importance of enforcing the CHA, we believe that her office must take action by answering some important questions:

1.What is her office doing to identify violations of both the letter and the spirit of the CHA?

2.What will she be doing to enforce the CHA and put a stop to extra billing and user fees?

3.How can we as future doctors help her in this important work?

On Sept. 29, medical students from across Canada came together to organize “Defend the Act” — an advocacy campaign aimed at promoting unimpeded patient access to publicly insured medical services and encouraging the federal government to adequately enforce the CHA. We hope that our calls to action were heard, and we look forward to hearing how our three questions will be addressed.
Nick Parle is a second-year medical student at McMaster University, writing on behalf of the Canadian Federation of Medical Students, a national organization that represents more than 8,000 medical students from across Canada. Sarah Hanafi is a third year medical student at the University of Alberta, and sits on the board of directors for Canadian Doctors for Medicare.

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