Murky rules for nurse practitioners give rise to private clinics in Ontario
Clinics are popping up across the province, says Nurse Practitioners’ Association of Ontario
When Kyle Truong needed medical attention for a respiratory infection last year, he said there weren't many convenient options for accessing timely care. Truong, who lives in Toronto, hasn't had a family doctor for about four years.
But then he discovered a private clinic where he could quickly get an appointment with a nurse practitioner, though it would not be covered by the Ontario Health Insurance Plan (OHIP).
"First I was a little disappointed," Truong, 29, said. "Because if I'm paying tax dollars and we're supposed to have great health-care coverage, it kind of sucks that I have to pay for accessibility in this case."
Even so, he said he had a "great" experience at the clinic, with next to no wait times, a comprehensive appointment, and the prescription he needed to treat his infection. He's since signed up for a one-year membership for access to unlimited appointments. Lucky for him, he was able to have the $450 fee covered through private insurance.
Truong is part of what appears to be a growing number of Ontario patients who are accessing private primary care from nurse practitioners. There are clinics popping up throughout the province, charging patients typically $70 to $90 for a single appointment, and in some cases hundreds of dollars for an annual membership.
The province, like much of Canada, is facing a worsening doctor shortage.
The situation highlights a lack of clear provincial regulations related to nurse practitioners. Critics say the province needs to act to protect Ontario's single-tier health-care system. Meanwhile the Nurse Practitioners' Association of Ontario says the trend is proof that more funding options are needed, so that nurse practitioners don't resort to charging patients.
Can't bill OHIP
Nurse practitioners have more training than registered nurses, and can perform more tasks. In recent years their scope of practice has been expanded in Ontario including, since 2017, allowing them to prescribe controlled substances. They can now perform the same standard primary care tasks as family doctors, including diagnosing and treating common conditions, referring to specialists and prescribing medication.
But unlike physicians, nurse practitioners cannot bill OHIP for their services. Some nurse practitioners work in salaried positions at a limited number of publicly-funded family health teams, and nurse practitioner-led clinics.
Since they cannot bill the province for services outside those settings, like physicians do, those who operate private clinics say billing patients is legal.
"I know this is a very touchy subject," said Alon Birshtein, CEO of Care & Family Health, a private nurse practitioner clinic in Toronto that opened its doors in 2020, and has since opened a second location.
"But really the fact is that, you know, most Canadians aren't aware that we've had a so-called two-tier system for many years already. This isn't really something new, I think it's just more at the forefront, more people are kind of talking about it."
Provincial legislation related to OHIP does not specifically mention nurse practitioners, but Natalie Mehra, the executive director of the advocacy group the Ontario Health Coalition, argues that charging patients for nurse practitioner services violates the Canada Health Act, which guarantees universal access to medically necessary insured services.
"When you change who provides a physician service, it doesn't mean that you can start to charge patients for it," Mehra said.
The murky rules are an issue not just in Ontario. Health Canada spokesperson Anne Génier told CBC News in a statement the federal government is concerned that recent expansions in the scopes of practice for nurse practitioners has led to patients being charged for services "that would be insured by provincial and territorial health insurance plans if provided by a physician."
Génier said the previous health minister sent a letter to his provincial and territorial counterparts a year ago, outlining those concerns, and "clarifying" that Canadians must be able to access medically necessary care "without having to pay out of pocket."
Province says it will investigate
When asked about private clinics by CBC News, Ontario Health Minister Sylvia Jones said charging for OHIP-funded services is "a hard stop."
Jones said the province "will make sure that any clinic that is charging for an OHIP-funded service is ended, and the patients will be reimbursed."
Despite those strong words, the province's actual stance on private nurse practitioner clinics is not entirely clear. CBC News asked the Health Ministry for clarity on whether it considers nurse practitioner services to be "OHIP-funded," but the ministry did not respond.
Last fall, Jones promised to investigate after a new private clinic set to open in Ottawa caused public uproar. Months later, the clinic is now up and running, and continues to advertise private nurse practitioner primary care services.
Mehra, with the Ontario Health Coalition, says some simple provincial regulations explicitly addressing nurse practitioners could easily eliminate any legal ambiguity.
"The government could have moved months ago to clear that up," Mehra said.
Limited funding, growing demand
Because these clinics don't draw on public funds, there is no central database, which makes counting them difficult. But their number appears to be growing. The Nurse Practitioners' Association of Ontario says it has noticed more private clinics opening up in the last couple years, and is now aware of about two dozen throughout the province.
CEO Michelle Acorn says those clinics are a sign of the demand, and "are a consequence of a lack of funding models for nurse practitioner practices."
Acorn said she applauds a recent $110 million provincial funding announcement for new and expanded primary care teams, but said she would like to see even more investments. She also wants nurse practitioners to be able to bill for services in a similar way as physicians.
That's a sentiment shared by Rizwan Shaik, who is working on plans to open a primary care clinic in Pickering, Ont., east of Toronto. Until early this year, his company QUBE HUB operated a clinic in downtown Toronto. He said challenges with recruiting and retaining physicians led him to change models this past fall, instead hiring nurse practitioners and billing patients for appointments.
Shaik admits there was "mixed reaction" from patients. He said he would prefer to be able to bill OHIP for the services, but argues that in the meantime, private nurse practitioner clinics are helping to fill a need.
"There are people in this country who are suffering with long-term care issues, and they're not able to access family doctors. And if you have the capacity to pay, you should have the ability to do so and have the access," Shaik said.
But Mehra, with the Ontario Health Coalition, said privatization only creates greater inequities in access to care.
"This obviously is a slippery slope that would cause the undoing of public medicare in Ontario and Canada if we're allowed to continue."
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