Closing a health-care loophole

Since Health Canada issued its recent directive clarifying how the Canada Health Act will be enforced, the early reaction has focused on a familiar question: who should get paid, and how?

That debate is understandable. But it misses the point.

At its core, the federal directive reinforces a simple and long-standing principle of Canadian medicare: patients should not pay out of pocket for medically necessary care. Of course, this rule has been applied to hospitals and doctors for decades, but this new directive was needed because of how health care, and the professionals working in it, have evolved.

The federal directive closes a gap that has emerged in recent years. In some cases, other regulated health professions, such as nurse practitioners and pharmacists, are using a loophole to charge patients for medically necessary services that would be insured if provided by a physician. That creates a form of two-tier user-pay access to care in retail, private or for-profit settings and it runs counter to the spirit of universal care.

The federal government is now making it clear this loophole should be closed. Patients should not face a bill for essential care simply because of who provides it.

This is a rule about patient protection, not about provider payment.

What Health Canada has not done is direct provinces to pay non-physicians the same way they pay physicians. It does not mandate fee-for-service billing for other providers. And it does not expand what counts as medically necessary care. What it does is ensure consistency from a patient perspective that they should not be charged for care that is covered by medicare.

That is a principle worth supporting.

Some of the early debate has focused on how different providers should be compensated under this directive. Those are important discussions, but they should not overshadow the bigger issue. The real question is not whether to fund these services, but rather how to organize them in a way that best serves patients and best respects taxpayers.

Right now, Manitobans already experience a system that is fragmented and difficult to navigate, moving between clinics and providers that haven’t been given the tools to communicate well with one another. Referrals can be delayed or lost. Followups can fall through the cracks. Patients often carry the burden of co-ordinating their own care.

In other words, our health-care system already has too many silos for patients to move between, and too many gaps for them to fall through.

The goal should not be the creation of more parallel silos, each operating independently. That approach—even if publicly funded—creates more fragmentation, increased duplication, bigger gaps and higher costs.

This directive should be used as a catalyst to accelerate the shift toward team-based care. That means bringing physicians together with nurse practitioners, pharmacists, physician assistants, psychologists, social workers, nurses and other providers in co-ordinated settings where each professional contributes their expertise, supported by shared digital systems, clear roles and strong communication.

Team-based care models have been proven to work in both family medicine and specialty practices. Family physicians are able to take on more patients when they have other providers with expertise to care for specific issues or to support ongoing chronic diseases. A range of specialists can also benefit from teams – from psychiatrists with other mental health professionals, to sports medicine or orthopedic specialists with occupational or physical therapists, to geriatric specialists with pharmacists.

There truly are infinite diverse combinations in team-based care, but all with one thing in common — care is connected and co-ordinated, with the patient at the centre.

In a well-designed team, patients have timely access to the right provider for their needs, with a physician available when care becomes more complex or uncertain. Care is well co-ordinated, and patients are not left to navigate the system on their own.

A fragmented system is not just frustrating for patients. It is costly. When care is not well co-ordinated, it leads to delays, repeat visits and unnecessary administrative work. It also leads to unnecessary duplication, as assessments and testing are repeated. Expanding access without improving co-ordination will only make that worse.

By contrast, well-designed team-based models can streamline care and reduce duplication, allowing each provider to focus on the work they are best trained to do while ensuring appropriate medical oversight when needed.

Luckily, Manitoba has a solution to both meet the federal directive and improve well-co-ordinated access to care for patients. In the 2023 election, the provincial government promised $25 million to add 250 team-based providers to physician practices. This would be a significant boost to the existing 160 or so team-based providers in physician practices that have been funded for several years.

While the government’s third budget speech last month did not offer any details on when and how they will fulfil their team-based care promise, moving forward now will help to comply with the directive. It will also avoid fines under the Canada Health Act if user fees continue unchecked.

By moving forward on its commitment to team-based care, the province can close the loophole allowing two-tier user-pay care, reduce fragmentation and gaps and build a system that is more accessible, more efficient and that has patients at its heart.

That is where the focus should be — on patients — and physicians have been eager to expand team-based care, so Manitobans have better access to more co-ordinated and truly universal health care.

Dr. Nichelle Desilets is president of Doctors Manitoba and a family physician based in Neepawa.