Get ready to pay to see your doctor. It sounds far-fetched, even alarmist. But some critics worry there could come a time in the not-too-distant future when British Columbians-and possibly every Canadian-will have to decide whether it will be cash or charge before they're able to even walk, stagger, or limp through the front door of a medical office. Sure, when it comes to worrying about health care, Canadians can make themselves queasy. But in this case, the fears are real. In British Columbia, the Copeman Healthcare Centre in Vancouver has already started charging patients thousands of dollars before they can see a family doctor working in its office. It's a controversial move, but one that could set a precedent. If the provincial and federal governments allow the clinic to continue charging what can be compared to an exclusive club's membership fee, it won't be long before the practice spreads. That thought has many worried, including David Cubberley, the MLA for Saanich South. "It would create a recipe and a precedent for doctors charging patients to be on their rosters," says Cubberley, who is the NDP's critic for health. "It would afford doctors the opportunity to make additional amounts of money and perhaps reduce the number of people they have to see to make it." Not every doctor will introduce fees in the short run, Cubberley says, but some would. And as more do-and as their former patients who can't afford to follow them to a private clinic go looking for new doctors-it would put increasing pressure on the ones who might have tried not to charge. Soon, he says, even the doctors who are reluctant will be tempted to charge as a way to keep their caseloads manageable. "It would put virtually everyone in the position of having to pay fees to have a family doctor." User pays According to the Copeman Centre's website, the clinic charges adults $3,500 for their first year of membership. For each year after that, the charge is $2,300. Those who sign up still have to pay their provincial Medical Services Plan premiums. The clinic has been open for nearly a year, beginning in the same building as the False Creek Surgical Centre on West 8th in Vancouver. It recently moved into new digs on Hornby Street, complete with a reception area featuring a "personal entertainment centre, refreshment bar and wireless Internet access." The clinic now has three doctors and is bringing in a fourth who specializes in sports medicine. Within 12 to 18 months, says its founder Don Copeman, the office should grow to eight doctors serving 4,000 patients. He won't say how many patients now use the clinic. "We don't like to talk about patient numbers too much." And it's not limited to Vancouver. Copeman says he plans to expand to Toronto, Ottawa and London, Ontario, this summer and to have 40 clinics running across the country-including Victoria-within the next five years. The clinic justifies the fees by saying members get access to a number of services that the province won't pay for, including annual health screening, personal coaching, counseling, diet advice and fitness consultation. "The fees for these enhanced medical services are bundled by the centre and made available to each client for a simple, annual fee," says the website. People aren't paying to see a doctor, the argument goes. They are simply paying for the additional services. There are numerous treatments Canadians already pay for outside the public health system, including visits to massage therapists, physiotherapists or chiropractors. We take for granted that even medically necessary things like drugs or dentistry aren't included in our healthcare system. Rather than have clinic patients pay separately for each of the extras he offers, as they would normally, Copeman is charging them at the front end, before they even see one of the doctors. When I ask Don Copeman whether non-fee payers could see the clinic's doctors, too, he says, "If they are accepting new patients, they would accept those people." It has not, however, been an issue. "We've never had that situation come up. We've never even had anyone ask the question." Copeman insists he doesn't pull doctors out of the public system. Three out of four of the doctors he hires aren't doing comprehensive family care before they come to work for him, he says, so the community has a net gain of family doctors when he opens a clinic. "They come from desk jobs. They come from other countries . . . There's lots of people out there. Some of our critics are doctors who write books." Copeman, by the way, is not himself a doctor. He took pre-med courses at McGill and Queens and graduated with a degree in science. Fast track access By charging patients before they can be on the clinic's roster, says health critic Cubberley, Copeman is essentially billing them for access to their doctor. That would be fine, except that the doctors in the clinic are also billing for much of what they do under the Medical Services Plan. "It's selling expedited access to doctors who are billing under MSP for the service," Cubberley says. "In actual fact, what he's doing is selling preferential access to those doctors. You get to see the doctor right away and that doctor gets to spend longer with you . . . you're using the Medical Services Plan to subsidize preferential treatment for those who have more money." In Canada, that kind of preferential treatment is against the law, which insists health care must be universally accessible. Access to publicly funded care can't depend on ability to pay. And therein lies the controversy over the clinic. "Mr. Copeman is in flagrant contradiction of the Canada Health Act," says Cubberley. "It's a clever scheme, but it's not compliant with the act." The issue is perhaps the biggest question facing the beleaguered Canadian healthcare system right now. For one thing, the clinic could be viewed as a symptom of an overworked system where it is already hard for people to find a family doctor. But far from fixing the problems, critics say, fast-tracked patients will put more pressure on the public system, as people who've paid in advance for medical services are likely to make sure they use them. But far from being the killer of public health care, Copeman says his clinic is pointing towards a cure. "I'm a great supporter of the public system, as hard as that is to swallow or believe. What can I say, people are too cynical," he says. "We're going to do health care the way we think it should be done. We're going to show people how you do primary health care." That model, he adds, is essential to improving the public system. "It will collapse unless we fix primary health care, in my view." The way things are now, people have a hard time getting good, basic care. When patients don't get help early, their problems fester and the public system ends up spending money on clogged emergency rooms, hospital stays and specialists. But instead of offering solutions, he says, the politicians run around putting out fires and responding to crises. "We are in a death spiral. If the government doesn't take steps to pull us out, it won't even be in their control anymore." Instead, he says, the courts will make decisions like the recent one in Quebec that extend the reach of private health care. "Private health care will arrive in a willy nilly fashion because politicians and bureaucrats didn't see right to start organizing for the inevitable." At the same time, many doctors are keen to work in an environment where they have time to practice high quality medicine, he says, and have access to resources. "This is what's going to create a profession young people will want to go into someday," he adds. "If we don't fix the profession, we'll never be able to fix the shortages. It's as simple as that." Clinical observations The question of preserving public health care-or encouraging a private system-is the kind of thing one would expect the politicians to be decisive about. So what does George Abbott, the B.C. minister of health, think about the issue? He did not respond to a request for an interview. The way Cubberley tells it, Abbott spent 10 months dithering on the question and paying staff to research it. Then in March, Abbott announced he was turning over the decision to the Medical Services Commission, a little-known body that makes rulings on doctors' billing practices. Given the importance of the decision Abbott is asking the MSC to make, it's worth taking a closer look at how the body works. The MSC has nine members, three each from the government, the B.C. Medical Association and the public. The government and the BCMA agree on who the three public members will be through a process where each nominates one, then together negotiate on the third. That structure has advantages when it comes to making tough decisions on things like the Copeman clinic. "Neither the government nor the BCMA are in a position to carry the day on this if they were to choose to do that," says Tom Vincent, who chairs the Medical Services Commission. Vincent is an assistant deputy minister in the advanced education ministry and one of the government appointees to the MSC. If he were a doctor, he'd have a great bedside manner-he's somewhat soft spoken, offering thoughtful, potentially alarming answers in calm, reassuring tones. The MSC isn't exactly independent, he says. "I think there's a danger in stressing the independence of the commission. The commission reports to the minister of health. This is the commission's decision [on the Copeman clinic], though." So, say that both the BCMA and the B.C. government want to see Copeman stay open. One might expect that possibility, which would be a reasonable explanation of Abbott's earlier inaction. Nor is the BCMA necessarily against this kind of clinic. The doctors' organization recently picked Brian Day, a partner in the False Creek Surgical Centre and an outspoken advocate for greater privatization in health care, when it came its turn to pick the next president of the Canadian Medical Association. (Day, by the way, recently told Maclean's magazine that B.C. is one of three provinces that is being "proactive" when it comes to increasing private health care.) It's entirely conceivable then that the BCMA and the government would agree to look the other way while the Copeman clinic carries on its business as usual. Not to worry, says Vincent. Whatever positions the BCMA and the government hold, it shouldn't affect the decision of the people on the commission. "Their allegiance to the organization that appoints them ceases when they are appointed," he says. Their job, he adds, is to administer the laws around billing practices. They will start with open minds, take a set of facts about the Copeman Centre, then decide whether or not what the clinic is doing falls inside or outside the province's Medicare Protection Act. "We're not splitting the atom here." Copeman expects approval Looking at the biographies of the commission members, it is clear they come to their job with a mix of perspectives. At least some of them will likely be business friendly. Gordon Denford, for example, is the president and CEO of Berwick Retirement Communities Ltd., a past nominee for an entrepreneur of the year award, a 40-year member of the members-only Union Club in Victoria and a longtime Chamber of Commerce member. Then there's Douglas McTaggart, a medical doctor who also holds a bachelor of commerce degree from the University of British Columbia. The commission also includes Marshall Dahl, a past president of the BCMA, who is "passionate about the importance of renewing B.C.'s ailing Medicare system and has been a public voice on the issue." In 2001, numerous newspapers quoted Dahl saying "We need to avoid getting tied up in rhetorical debate and accept that private-sector involvement already is well-established across the country and new opportunities need to be pursued." But he also stressed that he supports a single-payer public system, something that would preclude Copeman's clinic. Again, whatever the commission members' personal views, says Vincent, their job is to administer the act. "These are very capable, diligent people in my experience. The lion's share of them are members of the commission as an act of community." On April 18, the commission sent a letter to Copeman outlining its concerns and asking him for information. In early May, he responded. "Mr. Copeman has been very co-operative," Vincent says. "What remains for us is to dig through the information he's provided and decide what other information we might need and whether we need to talk to some of the physicians who work for him." Vincent couldn't say how long the process will take. "I'd hate to sacrifice quality for speed on this one," he says, "but it shouldn't linger too long. I'd be very disappointed if we're not finished well within a year." Asked whether the MSC's letter and Copeman's response are available to the public, he says "I'm not sure just what is and isn't public here." The documents refer to physicians by name, he says, and the commission needs to balance the public's right to know with the confidentiality of the people who are named. "We're going to be trying to walk that line as appropriately as possible," he says. "I'm staying very close to the commission's legal counsel on that one . . . I know there's a lot of public interest." Vincent says the commission hasn't decided yet whether there will be opportunities for input from the public or other parties. Meanwhile, Abbott seems to be distancing himself from the whole process. "He has no intention of making any recommendation himself to the commission," says Cubberley. "He's abdicating any responsibility for stewardship . . . I don't think this government is passionate about health care." For his part, Copeman says Cubberley is the one government representative who has thus far visited his clinic and talked to him. He's surprised Cubberley is opposed to what he's doing and says he's not worried about the MSC investigation. "I think they'll be very hard pressed to find anything incorrect or anything we've done against the legislation," he says. He figures there's a 90 percent chance the MSC will decide that everything is okay at the clinic. "We have a very good legal team. We have counsel who have written legislation in some provinces." The clinic has worked with the province since before it started, he says, and has made changes to its business plan to make sure it is working within the law. "We know what we're doing. We understand the spirit of the law in the country and we're not breaking it. We're actually supporting it." Government representatives have suggested, he says, that the doctors at his clinic should de-enroll from the public system. There is nothing to prevent them from going fully private. It's not, however, something Copeman plans to do. Despite choosing the clinic, he says, the patients should still benefit from the public system. "Why should they not be entitled to get a benefit from a physician who's here when they've been paying into the system their entire lives? It's nonsense." National concerns While the Copeman clinic currently exists in B.C., it's planning to expand to other provinces. As such, it raises the question of the federal government's inclination to preserve the Canada Health Act, which assures free access to health care for all. It should be pointed out that Prime Minister Stephen Harper's Conservative government in Ottawa could pull out its scalpel at any time, as the federal government can fine provinces that don't live up to the Canada Health Act. For example, on March 31, Harper sent a letter to Alberta Premier Ralph Klein warning him there would be fines if he didn't drop a couple parts of his "third way" approach to health care. One of the two things the federal leader scuttled was Klein's proposal to allow doctors to work in both private and public healthcare, something that is not now allowed. It seems analogous to what Copeman is doing. There are those who would like to see Harper take similar action in B.C. The B.C. Health Coalition's Co-Chair Joyce Jones sent the prime minister an April 25 letter asking him to warn B.C. Premier Gordon Campbell about violations here, including at the Copeman clinic. In the letter, she writes "We commend you for acting in a timely fashion to the potential violations of the Canada Health Act which were anticipated if Alberta enacted legislation described by Premier Klein as 'The Third Way'. However, we wonder if this important federal law extends to this side of the Rocky Mountains." Occasionally, B.C. and other provinces have been fined, Jones says in an interview, but the fines amount to a "slap on the wrist." Despite rulings going back nearly a decade, she says, federal politicians have shown little leadership in this area. The Federal Minister of Health, Tony Clement, was unavailable for an interview. A spokesperson for Health Canada, Carole Saindon, writes "Here is the reply to your question about follow-up action by Health Canada on the Copeman clinic: Health Canada is currently discussing the matter with the B.C. government. Have a good week-end." 'Door's wide open' Which brings us back to the province, where members of the MSC might now be said to be pulling on the rubber gloves, parting the Copeman clinic's hospital gown and preparing to give it a deep examination. "You have to be either cynical or misinformed to think the path we're going down is a bad one," Copeman says. There is much to be learned from countries that mix private and public care, he adds, and running the clinic is not driven by politics or ideology. He often gets described as right wing, he says, but sees himself as leaning heavily to the left: he describes himself as a youth as a "card carrying Communist". "There's nothing to fear . . . There's going to be a lot of disinformation that goes on with this for a long time. We're just trying to be truthful about it." Either way, it appears change is coming. How it comes about, however, is yet to be seen. "The act is there to protect single-payer health care," says the NDP's Cubberley. In making their decision, the members of the MSC should follow the act. "I'm going to start from the premise that that's their job and they'll do it." He adds "I'm not pessimistic at this point, but I'm concerned that this issue gets a really open and fair hearing . . . My job is to involve myself and make sure the process comes to the right outcome because there's an awful lot riding on it." What's riding on it, in short, is the accessibility of the Canadian health care system and free access to medical care. Says Cubberley "If you say 'yes' to Copeman, the door's wide open." Andrew MacLeod writes for Monday Magazine in Victoria, where a version of this story also appears today.