A Toronto Star/Ryerson School of Journalism investigation documents a hybrid health-care regime that markets to a clientele who can access public health care while paying for services that reach beyond what is covered by OHIP, including 24/7 access to health-care professionals, fast-tracking of MRIs and a range of annual tests and lifestyle assessments.
“I think this does represent two tiers (of health care in Canada),” says Dr. Danielle Martin, a family physician in Toronto who was founding chair of Canadian Doctors for Medicare and in 2014 defended Canada’s public health-care system to the U.S. Congress as it deliberated on Obamacare.
“But it also undermines Medicare because it contributes to an ethos that the public system is not delivering the highest quality . . . We need to push back against this myth that having extra testing is harmless. The potential for harm is very great.”
Clinic spokespeople counteredthat they offer responsible, supplementary care that fills in gaps in OHIP coverage, including preventative care and testing that follows expert guidelines.
“The real issue we’re trying to deal with is what we think OHIP should be dealing with,” says HealthCare 365 CEO Skip Schwartz. “Every patient in Ontario should have managed care and not just event-based care . . . I fundamentally believe that we should have a one-tier system. The question is, how do you make that one-tier system work better?”
Reporters posing as patients visited six Toronto clinics — Cleveland Clinic, HealthCare 365, Medisys, Regal Health Services, Executive Health Centre and Medcan Clinic — and were shown health-care plans that included tests that Martin and others say not only cost the patients who pay for services but also public health care.
In her practice, Martin says she has seen patients arrive after visits to boutique clinics with test results who then get treated on the public dime.
“The first time a patient showed up with 50 pages of results from an executive physical, I was floored, both by the expense the individual had gone through for results thatwere potentially harmful, and because largely insignificant abnormalities that had shown up were sent back into the public system to deal with,” she says.
Martin says private clinics do not typically refer patients to specialists or order further tests because it is “outside their scope” of practice.
“It’s actually the part of me that is most offended by these practices — as soon as you get sick, nobody wants to take care of you anymore.”
In response to questions about the impact of boutique clinics, Ontario Health Minister Eric Hoskins said that there are medical billing practices that sit in a “legal grey area” that the ministry is “monitoring very closely as we accumulate information so that we can fully assess the situation.”
“Any deviation from the values and integrity of our Medicare system are concerning, and we will continue working hard to uphold our high standards to build a health-care system we can be proud of for future generations,” Hoskins said.
Unnecessary testing — often leading to more tests — can come with risks, says Toronto cardiologist Dr. Christopher Labos.
“Maybe that CT scan isn’t dangerous, although it is exposing you to radiation that you don’t need, but any little abnormal finding is going to lead potentially to biopsies and more procedures. And these biopsies and procedures carry risks. If you do enough unnecessary tests, eventually you will cause a complication from all the overtesting.”
An international public awareness campaign called Choosing Wisely (the Canadian campaign launched three years ago) urges consumers to question the routine use of more than 200 tests — from annual exams to blood tests, ECGs to stress cardiac imaging — and consider best practices.
Choosing Wisely Canada’s website features lists “developed by Canadian national societies representing a broad spectrum of clinicians” that contain commonly used tests and treatments that are “not supported by evidence, and/or could expose patients to unnecessary harm.”
When it comes to colonoscopies, for example, Choosing Wisely’s website says that screening should begin at age 50 for most people, should be repeated “in five to 10 years” in cases where “one or two small, low-risk (benign tumours) are removed,” and that routine checks “usually aren’t needed after age 75.”
And while the procedure is safe, patients are advised that, “occasionally it can cause heavy bleeding, tears in the colon, inflammation or infection of pouches in the colon . . . severe abdominal pain, and problems in people with heart or blood-vessel disease.”
Some of those complications can lead to blood transfusions, surgery, hospitalization, “or rarely, death,” according to Choosing Wisely Canada.
“Because people think more is better, and there’s no harm from these tests, they may incorrectly assume they should get these things annually,” says Dr. Wendy Levinson, a professor of medicine at the University of Toronto and chair of Choosing Wisely Canada. “A lot of research shows that people don’t need annual exams. There is evidence of harm.”
Regal Health Services in downtown Toronto charges a $3,700 annual fee for services, including “quarterly mini-physical examinations.”
Much of the fee, according to the company’s website, covers extensive testing, including a “personalized comprehensive health and lifestyle assessment,” MRIs “within days” and “personalized blood screening and imaging assessment (OHIP covers some).”
Regal, like many boutique clinics, boasts office appointments within one or two days and “24/7 emergency medical advice from your personal physician.”
When reporters asked if any OHIP-covered services could be accessed without paying the fee, a staff member said: “Each person has to become a patient here . . . Regular office visits are just covered by OHIP like they normally would be.”
Regal Health Services officials did not respond to calls and emails requesting comment.
Cleveland Clinic Canada occupies a stunning, 26,000-square-foot space on the 30th floor of a Bay Street tower with a panoramic view of Lake Ontario.
Billed as a “hybrid medical clinic which offers provincially funded and privately paid services to Canadians,” the clinic’s “executive health program” offers a “comprehensive medical and wellness assessment and a personalized health report” as well as OHIP-covered care for ailments such as a sore throat, ear infection or flu. The package costs about $3,000 a year.
A Cleveland Clinic spokesperson wrote in a statement to the Star that the clinic “regularly reviews our processes for ordering tests” and uses “expert guidelines, revisits protocols regularly, operates with a do-no-harm mandate and acts as a responsible member of our universal health system.”
Mike Kessel, president and CEO, said in an interview the mission is to “complement the system in a meaningful way.”
“The services we’re providing, some of them happen to be covered (by OHIP) . . . Some of them are not covered. We believe that both are necessary for good health.”
Legal and health-care policy experts interviewed say that boutique clinics sit in a legal — and philosophical — grey area.
“This is the challenge of allowing a fringe of private enterprise in what is supposed to be a comprehensive public service for medically necessary care,” says Bernard Dickens, professor emeritus of health law and policy at the University of Toronto.
Waiting lists in the public system — made longer by physicians moving into private clinics — push many Ontarians to bypass by paying, says Dickens.
The wealthy should not be allowed to buy their way to faster urgent care at private clinics where they can jump the queue, says Natalie Mehra, executive director of the Ontario Health Coalition. “That is a violation of the fundamental values of our society. It should be stopped.”
Colleen Flood, director of the Centre for Health Law, Policy and Ethics in Ottawa, says that while the boutique clinic model does not breach the law, it “definitely goes against the principles and the ethos of the Canada Health Act and the Ontario legislation and other provincial legislation.”
Lorian Hardcastle, a law professor at the University of Ottawa says, “Medicare-plus” offerings are at least partly about jumping the queue.
“These people paying the fee are not just getting something extra. They’re buying quicker access to insured services as well.”
With files from Melissa Myers
Medcan, one of Canada’s largest executive health-care clinics, charges an annual membership fee of about $3,300 for an assessment that features 15 diagnostic tests and a “wellness plan” that includes a mix of private services and OHIP-based care such as physician appointments, X-rays and prescription renewals.
Reporters were told that clients receive, “same-day or next-day bookings” for acute health-care concerns and access to a nurse on a 24/7 hotline.
Tests include blood work, an abdominal ultrasound, cardiogram stress test, hearing, vision and respiratory function tests, an immunization review, a body fat composition test, Pap smear, pelvic exam and, depending on age, a mammogram, a staff member said.
Medcan officials declined interview requests.
In a written statement, the clinic said those who haven’t paid the membership fee can access OHIP-covered services: “Clients who use our Wellness Clinic OHIP services do have the option of accessing a number of uninsured health services … for which they pay a fee.”
Addressing the impact of private clinics on the public health-care system, the company wrote: “Medcan’s Wellness Clinic adheres in every respect, as all of our services do, to the principles reflected in the Canada Health Act, and to the regulatory requirements set out by the Commitment to the Future of Medicare Act, the Health Insurance Act, and the College of Physicians and Surgeons of Ontario’s published guidelines around the charging of fees by medical clinics for the provision of uninsured services.”
Executive Health Centre
Patients of this York Mills clinic pay fees as high as $4,500 for a plan that includes tests for nutrients, neurotransmitters, pharmacogenetics, vitamin D and omega fatty acids as well as “coaching” and “strategy sessions.”
Reporters posing as prospective patients were told the clinic also charges a $1,000 fee for 24/7 access to a “primary care” physician. “You can get access to the doctor throughout the year, so this is your primary caregiver,” a receptionist said over the phone.
“So that would sort of be like my family doctor, then?”
“If I don’t pay, can I still go to your clinic?”
Dr. Elaine Chin, founder and director of the clinic, said the $1,000 covers strategy sessions with a naturopath, medical doctor and nutritionist.
Chin acknowledged that “primary care” misrepresents the service.
“You are correct that I shouldn’t put 24/7 on there because I don’t provide that type of 24/7 implicit care. The $1,000 fee should be appropriately renamed to ‘year-round coaching fee’ as it refers to ongoing strategy sessions that continue the work from the initial session,” she said.
The clinic refers patients for diagnostic imaging and testing such as colonoscopies and mammograms. “We will schedule these tests as requested by the patient and copy their primary care physician to ensure that all are in the loop and that the test has been completed.”
Chin added the clinic’s focus on coaching does not undermine the principles of Canada’s health-care system.
“I believe that my model of care is the future, where we engage Canadians to be proactive and preventative by deploying the science of personalized medicine,” she said in a written statement. “While this model of care is not covered by OHIP, I hope that such services that I presently provide will be paid for by the health-care system in the future.”
Medisys clinic at 333 Bay St. charges clients $2,250 a year for tests that are part of a three-and-a-half hour exam. The tests include blood work, hearing and visual exams, urine and stool analysis, nutritional tests and an abdominal ultrasound.
The clinic also offers “continued care,” which provides “unlimited consultations” for an additional $1,500 per year, a representative told a reporter posing as a prospective patient.
“We don’t use the term family doctor because it’s a paying service,” the representative said. “We differentiate ourselves from the family physician for the simple reason that it’s not a service provided by OHIP. It’s a service that you opt into that would allow you to use Medisys as you would use your family physician.”
Meghan MacDonald, director of product management for Medisys, says the preventative “wellness” approach provides an alternative to the restraints of the public system.
“In a system with limited resources, ministries have to make decisions on where they’re going to focus that money. To date it has historically been focused on the acute care system . . . It’s more difficult for systems to see the long-term return on investment of prevention and wellness.”
When asked what happens when these test results require further investigation, reporters were told: “As soon as we fall into diagnostic medicine or treating medicine, we’re obligated to refer back to an OHIP-accredited centre.”
MacDonald acknowledges some patients do make a trail from her clinic to their family physicians’ offices for further tests.
“There is definitely the possibility of that happening,” she says. “It does happen. I’ve heard it as well in the system that people feel that clients and physicians at executive clinics tend to kick things off. We consciously try not to do that at Medisys, but I know why that perception exists in the system.”
MacDonald, a self-described supporter of public health care, says executive clinics add to — rather than undermine — universal care.
“(The) principle of people being able to get the care that they need when they need it . . . is fundamental to our universal, publicly funded system.”
For a yearly fee of $3,300, or $275 per month, HealthCare 365, in midtown Toronto, co-ordinates appointments, obtains consult notes from specialists and offers 24-hour access to a nurse.
Unlike the other clinics surveyed, HealthCare 365 does not conduct the slew of “executive physical” tests.
“The problem in those cases often . . . is if there are findings, they just refer you back to the public system after you’ve paid a whole bunch of money,” a representative told a reporter by phone.
In an interview, CEO Skip Schwartz says his clinic is a response to a broken public health-care system.
“The health-care system in Canada is incredibly unco-ordinated in terms of the management of specifically chronic conditions, serious chronic conditions, people who have cancer, diabetes, high blood pressure.”
Schwartz is an advocate for a one-tier health-care system but the one we have is simply not working, he says.
“I’m opposed, by and large, to two-tier medicine. I think we all deserve the same ability to be treated. The challenge is that that doesn’t actually exist in the system,” he says. “At nine minutes on average for a family doctor visit in Ontario, a grandma who has five or six chronic conditions cannot be treated and seen . . . It’s impossible.”
Schwartz’s answer is health management through innovative technology. With the technology available at his clinic, two nurses are able to track and manage the health of 5,000 patients, he said.
Those who cannot afford the fees are not turned away, says Schwartz.
“We don’t kick anybody out,” he said. “We do take those people and we do not charge them.”
Author: Robert Cribb, Vjosa Isai, Maham Shakeel