For $30/month, Ontario doctors offer rapid access to nurse practitioners

Some doctors in Ontario are offering their patients the option of extra health care, at a price: seven-day a week rapid access to appointments with a nurse practitioner, for a fee of around $30 a month.

It's perfectly legal under both the federal and provincial medicare rules. But since it involves charging for health care, it adds fuel to a growing debate over two-tier health care in Canada. 

Kindercare Pediatrics in Toronto launched its nurse-practitioner program in response to overwhelming demand from parents during the surge in respiratory illnesses among kids last fall, said the practice owner, Dr. Dan Flanders. 

"We couldn't keep up," said Flanders in an interview. "Everybody was working their brains out and we were still turning away close to 100 patients a day."'

The program he developed is called Kindercare365 and it is pitched as "on-demand health care for kids."  It relies on nurse practitioners, who are authorized in Ontario to provide many of the same services as family physicians, including diagnosing illnesses and prescribing medications. 

The optional subscription costs $29 per month (plus HST) for one child or $59 per month for two to five children. It promises an immediate virtual appointment with a nurse practitioner from 8 a.m. to 9 p.m. any day of the week and, if necessary, an in-person appointment no later than the next day.

"This has opened up a door so that more young families can have access to healthcare," said Flanders. "It's not ideal that patients have to pay, but it's something that's going to help increase access." 

Why it's legal

The Canada Health Act prohibits charging patients for medically necessary services that are covered under provincial health plans. Since nurse practitioner services are not covered by the Ontario Health Insurance Plan (OHIP), it's legal for doctors to charge.  

But within Ontario's complex systems of compensating physicians, there's a disparity that means some patients can actually get health care from a nurse practitioner without paying anything: 

• Physicians who practice in the province's Family Health Team model receive annual funding that allows them to hire health professionals such as nurse practitioners, so they don't charge their patients for access. 
• Doctors who bill on the fee-for-service model, such as Flanders and his fellow pediatricians at Kindercare, don't get provincial funding for nurse practitioners. 

Flanders says if nurse practitioners in family health teams improve patients' access to health care, the province should extend that funding to other primary care providers. 

"For those people who say this should be publicly funded, I say I 100 per cent agree," he said. "If the government paid for this, it would be a very efficient use of health care dollars." 

Dr. Danielle Martin, chair of the University of Toronto's department of family and community medicine, says this disparity is inequitable and unfair, particularly since less affluent patients tend to be less likely to be enrolled in Family Health Teams. 

"Why aren't we funding team-based care for all Ontarians when we know that this is the most effective way to provide healthcare services?" Martin said in an interview with CBC News.  

While Martin acknowledges it's perfectly legal for Kindercare365 to charge for the option of rapid appointments with a nurse practitioner, she has concerns. 

"I do think that this is a form of two-tier health care, in that we're talking about giving better or faster access to some patients," said Martin. 

Patient feels pressured to join

Toronto resident Katie Winstanley also feels that charging for access to a nurse practitioner amounts to two-tier health care. Her family doctor has told her he will soon join a larger practice where there is a $30 a month charge for NP access and she says she felt pressured to sign up. 

"I'm outraged by it, the more that I've thought about it," said Winstanley. "I felt like he was saying, 'You don't really have a choice, if you want to have a family doctor, you have to pay this fee to stay on as a patient with me.'" 

CBC News is not naming Winstanley's doctor because he could not be reached for comment. 

Winstanley, Martin and Flanders all agree on one thing: they wish Ontario would cover the cost of nurse practitioner services in all circumstances. 

"If we're going to ask that people see nurse practitioners so that we can relieve some of the pressure on family doctors, then it has to be funded," said Winstanley. 

More teams needed, says doctor

Given the shortage of family physicians in Ontario, Martin said the provincial government should be looking to bolster primary care by funding nurse practitioners in interprofessional teams. 

She points to the clinic where she works as a family doctor, the Family Practice Health Centre at Women's College Hospital, on a team that includes nurses, a nurse practitioner and a pharmacist. 

"We have … incredible, amazing resources that allow me to take care of more people and allow us to give better quality care as a team, and all of that is funded by the government of Ontario," said Martin. 

"But in a doctor's office down the street, there's no funding for that service whatsoever. So I do think that it's inequitable, it's unfair."

CBC News asked Ontario Health Minister Sylvia Jones on Tuesday for the government's view of clinics charging monthly fees for access to nurse practitioners. Jones said she needed to know more specifics before she could comment.    

Improving family health services is one of the four priorities for the $46 billion health care deal struck between Prime Minister Justin Trudeau's government and the provinces and territories. 

Flanders says the health care system is in crisis with hundreds of thousands of families who can't access primary care. 

"We can continue to wait for the government to fix it," he said. "When's that going to happen? Or we can do something. I'm doing something."