Question Period Note: Canada Health Act-Private Delivery of Insured Health Services

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• With growing pressures on the health care system, including longer wait times, some PTs are increasing the use of private facilities to deliver publicly funded services. This has raised concerns among some stakeholders that Canada’s publicly funded, one payor health system is in jeopardy.
KEY MESSAGES
• Provinces and territories have committed to respecting the principles of the Canada Health Act as part of their agreements in principle on the parameters for access to the close to $200 billion in federal funding to improve health care services for Canadians.
• The Government of Canada will work with provinces and territories to ensure that its historic ten-year, investments of close to $200 billion in health care are used in ways that respect the principles of the Canada Health Act.
• The Canada Health Act does not preclude private facilities from providing medically necessary services, so long as patients are not charged to access these services.
• This Government will continue to uphold the Act so that Canadians have equitable access to medically necessary services based on their health needs and not their ability or willingness to pay.
IF PRESSED ON PRIVATE CLINICS CHARGING OUT-OF-PROVINCE PATIENTS FOR ACCESS TO NON-EMERGENCY SERVICES…
• Health Canada is aware that, in some cases, private surgical clinics in a number of provinces are charging out-of-province patients for faster access to medically necessary services that would be publicly insured if accessed in their home jurisdiction.
• While this issue is being monitored, and discussed with provinces and territories, charging out-of-province patients for access to non-emergency services is not a contravention of the Canada Health Act.

Patient charges for medically necessary services delivered virtually and/or by non-physician health care providers

On March 9, 2023, Minister Duclos wrote to his PT counterparts to express concerns about reports of patient charges for medically necessary services delivered virtually and/or by non-physician health care providers that would be insured if delivered in-person by a physician. The letter also stated his intent to issue a new Canada Health Act Interpretation letter to address the issue, which will require engagement with the PTs.

Private delivery of insured health services

Recent announcements by provinces and territories (PTs) to use private clinics to reduce backlogs in the public system have raised concerns in the media that the private delivery of medically necessary hospital and physician services (“medically necessary services”) is contrary to the Canada Health Act (CHA). On May 8, 2023, Ontario passed the Your Health Act to support its plan to expand the use of community-based private facilities to deliver medically necessary services, with payment coming from the Ontario Health Insurance Plan. British Columbia, Alberta, Manitoba, New Brunswick, and other PTs have similarly partnered with private facilities to deliver medically necessary services, paid for by their respective public health care insurance plans. Concerns have been raised that some PTs may use their share of the Government of Canada’s recently announced ten-year, close to $200 billion investment in health care to expand the private delivery of medically necessary services.

The CHA requires PT public health care insurance plans to provide coverage for all medically necessary services to insured residents on uniform terms and conditions. Patient charges for medically necessary services are not permitted under the CHA because of the barrier to access they pose. PTs that allow them are subject to mandatory dollar-for-dollar deductions from their federal Canada Health Transfer (CHT) payments.

The CHA does not preclude PTs from using private facilities to deliver medically necessary services, so long as there are no patient charges to access services in these facilities. Private facilities are permitted to charge for uninsured services, such as non-medically necessary cosmetic surgery, or upgrades to medically necessary services. However, access to medically necessary services must not be conditional on payment for upgrades, nor should the purchase of upgrades lead to preferential access to services.

The Government of Canada will continue to uphold the CHA when there are instances of patient charges for medically necessary services in private facilities. On March 9, 2023, the Minister of Health wrote to his provincial and territorial colleagues emphasizing the shared responsibility to protect universal, publicly funded health care.

Since 2015, over $188 million has been deducted from CHT payments for non-compliance with the Canada Health Act (CHA). On March 10, 2023, deductions totalling over $82 million in respect of patient charges levied during 2020-2021 were announced, for medically necessary services that should be accessible to patients at no cost. This includes the first deductions taken under the Diagnostic Services Policy (DSP), totalling over $76 million for patient charges levied for medically necessary diagnostic imaging services (deductions to BC, AB, SK, MB, QC, NB, and NS). An additional $6 million was also deducted for other patient charges including those levied for insured services provided at private surgical clinics (BC) and for access to insured abortion services (ON, NB). Under the CHA's Reimbursement Policy, mandatory CHT deductions may be reimbursed provided the province or territory implicated carries out a Reimbursement Action Plan to eliminate the patient charges and the circumstances that led to them.

Additionally, private surgical clinics in a number of PTs are leveraging regulatory gaps to charge out-of-province patients for faster access to medically necessary services that would be insured if accessed in their home jurisdiction.

Under the CHA, an insured resident of a PT is covered by their public health care insurance plan for emergent or urgent care received while traveling temporarily in another PT (e.g., a broken leg during a ski holiday). However, to access an elective or non-emergent service in another jurisdiction (e.g., an ON resident receiving knee surgery in BC), the insured resident must receive prior approval (permission) from their home province before the public plan is obligated to provide coverage. Additionally, the PT in which the care is accessed is not required to provide coverage, as the patient is not an insured resident of that jurisdiction. This results in providers charging patients for quicker access to services outside of their home PT.

• Under the Canada Health Act, medically necessary hospital and physician services may be provided in private facilities, so long as patients are not charged to access care.
• Several provinces and territories have been expanding the use of private facilities to deliver medically necessary services to address the service backlogs caused by the COVID-19 pandemic.
• Provinces and territories have used private facilities to deliver medically necessary services since the 1990s and have various mechanisms in place to ensure patients are not charged for their care.
• In March 2023, the federal Minister of Health wrote to his provincial and territorial colleagues expressing concern about private virtual care clinics charging patients to access medically necessary services. He also noted his intent to issue a new Canada Health Act interpretation letter to ensure that when Canadians access medically necessary services, whether in-person or virtually, those services remain free of charge.