The best defence is a good offence: Ensuring equitable access to primary care in Canada

Introduction

There are significant changes in primary care taking place across Canada. Reforms in most provinces centre on integrating team-based models of primary care; however, the make-up of teams, as well as the governance and remuneration models, vary from province to province.^1,2 Some provinces have chosen to implement major payment reforms for family physicians, offering more alternatives that move away from traditional fee-for-service models.^3,4 In addition, the federal government recently made sweeping commitments to primary care, and provinces and territories agreed for the first time to report on a set of indicators that include the percentage of the population who have a regular primary care provider and the number of net new family physicians entering the workforce each year. ⁵

This focus on primary care is not surprising. Maintaining access to high-quality primary care is a persistent problem across most jurisdictions and many Canadians report challenges with finding a primary care provider or otherwise receiving care in a timely fashion.^6-13 The COVID-19 pandemic made this problem worse and, as of 2023, more than 6.5 million Canadians—nearly one in five—do not have a family doctor or nurse practitioner they are able to see regularly. ¹⁴ At the same time, long-standing research indicates that the best-performing health systems are those that have a strong foundation of primary care.^15–17 The best-performing systems also have a predominance of public funding ¹⁸ and commitments to equity in access to and availability of health services. ¹⁶

Against this broad backdrop, there has been a rapid and substantial increase in private sector involvement in primary care in Canada, including by large, investor-owned corporations. This increase in corporate involvement represents both a symptom and a cause of public-sector primary care reforms. In this article, we provide a short history of the “public-private” conversation as it relates specifically to primary care, discuss how this led to the current state of primary care, and identify data and accountability needed to ensure that reforms remain consistent with the principles that are the foundation of health systems in Canada.

Current framing for the “public-private” debate in Canada

The development of publicly funded physician services in Canada can be traced back to the early 20^th century, but the modern era began in 1968.^19–21 By 1971, all the provinces and territories had agreed to cost-sharing between the provinces and federal government that reflected a commitment to enabling universal access to healthcare services and treatments without respect to a person’s ability to pay. These values were further upheld in law with the passage of the Canada Health Act (CHA) in 1984, which enshrined the five principles of universality, accessibility, comprehensiveness, portability, and public administration and prohibited direct billing (or extra-billing) of patients for services covered under the Act. ²²

This foundation of healthcare financing—or how we raise money to pay for healthcare services—is central to the equity commitments of healthcare systems in Canada and also of pivotal importance to people in Canada.^23,24 Equally important are arrangements for healthcare delivery, as those affect who has access to what services, where and when. Separation is a critical feature of the arrangements and relationship between healthcare financing and delivery in Canada, at least for services covered under the Canada Health Act. That is, we pay through taxes, which provides general revenue for governments, and we use healthcare services when they are needed. Primary care systems in Canada have “first-dollar coverage” for care, with no deductibles or other user pay. Conversations about this arrangement ebb and flow in Canada, for example, with suggestions arising from time to time that people having to pay for services will make them think carefully about whether they are really necessary. This view, however, is not supported by research evidence; that evidence shows first-dollar coverage is a necessary, though not sufficient, requirement for ensuring equity in access to healthcare. ²⁵

Debates about healthcare financing and delivery in Canada are traditionally framed around a relatively simplistic “public-private” divide—that is, public versus private financing and public versus private delivery. Proponents of parallel private financing have long argued that allowing individuals to pay out-of-pocket alleviates burden on public systems, reducing wait times for services. However, there is a substantial body of evidence demonstrating that this is not the case. Rather, private payment may reduce waits for people who are able to pay, but worsens wait times in the public system. ²⁶ On the delivery side, proponents of privatization claim that private, for-profit ownership of delivery systems improves and incentivizes quality of care because investor-owned facilities are forced to compete for patient “business.” In reality, profit-driven delivery is associated with higher costs, poorer population health, and higher mortality rates.^27,28

Perhaps more importantly, the reality of public and private interfaces has always been more complex than this simple two-by-two framework might suggest. Most primary care physicians, for example, are small business owners and as such work as “private” providers, funded through public payments, and in that sense work “for profit.” This for-profit status, however, is quite distinct from that of investor-owned private corporations which are increasingly involved in healthcare delivery—such as the expansion of investors into primary care.

There is a subtle but important difference between “private” physicians and “investor-owned” entities. While physicians are small business owners, they are also a regulated profession, with standards set and enforced by Colleges that register and control licensure. They have professional as well as ethical responsibilities to their patients and are expected to provide advice and recommendations on behalf of, and in the best interests of, their patients. Corporate entities, and particularly investor-owned entities on the other hand, have a fiduciary duty to their shareholders.

Corporate arrangements do not always mean that healthcare professionals in their employ cannot or do not provide good care, but there is significant scope for conflict of interest. Investor-owned entities, for example, might offer “special” upgraded services that have no additional therapeutic value, other than generating more income to the provider, company, and/or shareholders. ²⁹ Importantly, this is distinct from patient-centred care, where patient preferences are valued and accounted for, and patients are treated as equal partners in decision-making. Rather, these are cases where corporations can take advantage of asymmetry of information to push patients towards services that cost additional money but do not produce additional value.

Changes in “private” delivery and the interrelationships between financing and delivery

As noted above, while most physicians are small business owners delivering publicly funded services, there have been significant changes in how they can access and use corporate status. For example, many physicians incorporated starting in the early 2000s and began benefiting from related tax advantages that in Ontario were explicitly acknowledged as being “in lieu of fee increases.”^30,31 This became a talking point in 2017 when the rules changed, limiting some of the tax-saving approaches physicians were using. Despite the moves to team-based models of care and changes to physician remuneration models, primary care remains very much dominated by physician-owned private practices. However, in recent years, there has been growth in private, for-profit, investor-owned clinics, some of which operate solely through public financing. In BC, for example, nearly one in five of the 516 walk-in clinics in the province is owned by a non-physician corporation (across 97 different companies). ³²

More challenging to classify are the variations of privatization at the intersection of private financing of care and for-profit investor-ownership of the delivery system. One example of this intersection is virtual “walk-in” clinics. A recent study of 18 virtual care clinics shows that more than half bill the public system, and 39% charge patients directly for services that are not covered through public systems. ³³

Additionally, while “executive clinics” have existed for some time, large corporations recently have been purchasing networks of bricks and mortar clinics and not only billing the public system for services rendered, but also charging patients for non-insured bundled services and/or annual subscription fees. Telus, for example, paid $100 million for 30 walk-in clinics in 2018.^34,35 Well Health, another example, owns 20 clinics in BC, one in Ontario, and six in Quebec. ³⁶ There are myriad others. These clinic networks bill public provincial health insurance systems, but also charge patients for non-insured services such as preventive care offered by allied health professionals, cosmetic dermatology, sleep supports, alternative medicine, and others. ³⁷ One of the lures used to attract patients is convenience: laboratory, physiotherapy, and other complementary services available at one site. The acquisition of physical clinics and operation of virtual platform introduces not just privatization of the care delivery system, but also corporatisation and investor-ownership of healthcare infrastructure. More importantly, these acquisitions provide a direct example of potential changes in the interests of providers and thus the agency relationship between providers and patients.

As we noted in our introduction, most Canadian provinces and territories are grappling with a complex series of problems in primary care. There are long-standing shortages of accessible and timely primary care services. ¹⁴ Well before the pandemic, patients were asking for the ability to see their family physician virtually ³⁸ (as was already available and commonplace in other OECD countries).^39-42 Family physicians have the highest rates of burnout of any medical speciality,^43,44 and rates doubled during the pandemic. ⁴⁵ Nearly half of family physicians would prefer to be an employee of a clinic with access to sick time, parental leave, and other benefits rather than the owner of a small business, a practice model that is still not widely available in any Canadian jurisdiction. ⁴⁶

This situation creates fertile ground for the financial viability of investor-owned clinics funded via a mix of public and out-of-pocket payments (for uninsured services or membership fees), and is exacerbated by these clinics drawing providers away from the publicly funded system. Such practices have always existed in a legal grey area,^47,48 constrained by, but also challenging, the edges and spirit of the Canada Health Act. However, their prevalence has increased dramatically in the past few years.

Implications of changes in sources of financing and types of delivery

There are both monitoring and more substantive implications associated with not having a solid understanding of the evolution of ownership and profit orientation of the care delivery system, or the payment arrangements for care delivered in those facilities, particularly in those that are investor-owned. These implications necessitate policy change, requiring specific action from health leadership at all levels.

Conclusions and the way forward

Fundamentally, the ongoing debates that confuse private delivery and private financing are obscuring the degree and rapidity of change happening within the system. All the examples of privatization and corporatization we provide here, and their implications for the distribution of, payment for, and receipt of healthcare services, represent undermining some of the most fundamental values upon which healthcare in Canada is built. They are real and present threats to access to and quality of primary care. This is not to deny that reform in public sector primary care is anything less than urgent. It does, however, point to a need to update how we approach both documenting and understanding the role of private finance and for-profit investor-ownership of healthcare delivery. Privacy experts and heath policy-makers should craft stronger protective legislation around data sharing and use, making public sector and private sector safeguards equivalent. Health leaders should mandate the collection of comprehensive data on ownership and payment arrangements for all primary care providers that supports clinical care, patient and family self-management, and research, as well as enforcement of the CHA. Finally, and in parallel, health leaders and policy-makers should require evidence-based and evidence-generating reforms to primary care and robust evaluation of those reforms. Ultimately, a robust, efficient, effective, and equitable public system is ultimately the best defence against the erosion of our commitments to health equity for everyone in Canada.