Is Two-Tier Health Care Growing in BC?

At 84, Lieta Robinson had a tough choice to make after receiving a letter from her doctor.

She and her 88-year-old husband could start looking for another doctor, joining the roughly 760,000 British Columbians who aren’t attached to any primary care provider. Or they could each pay an annual fee to stay with him when he moved to a Vancouver clinic owned by the telecommunications company Telus.

“We are really upset,” said Robinson. “We’re seniors, and we’ve had good health care, but this has kind of upset us.”

She and her husband had been with Dr. Geoffrey Edwards for some 36 years, staying with him as he moved from clinic to clinic, from Burnaby to Kerrisdale. They are in “pretty good health,” but at an age where they need care from time to time.

According to the letter the couple received from Edwards, the fee for each of them would be $4,600 for the first year, then $3,600 for each year after that.

While Robinson and her husband could afford the fees, she said, the wider implications bothered them.

“This is most disturbing if doctors are going to give up their general practice and go into something like this,” she said. “If everybody did this, then what happens to our health care?”

Edwards didn’t return calls by publication time.

The clinic he is moving to operates using a model that has been described as being in “a legal grey area.” The model has long been contentious.

Under the Medicare Protection Act, doctors who receive payments under the public Medical Services Plan may not charge a patient directly for any service normally paid for through public insurance.

Telus has spent more than $2.5 billion expanding into health care, seeing it as a way to differentiate itself from its telecommunications competitors and grow revenues.

It bought clinics operating under the brands Medisys, Copeman Healthcare and Horizon Occupational Health Solutions in 2018.

Telus said the annual fees patients like Lieta Robinson face if they want to stay with their doctors are not for necessary services covered by the provincial Medical Services Plan.

They are for services that the public system doesn’t cover, Telus said in an email.

“Clients complete an annual preventative health assessment under the supervision and guidance of a physician and have ongoing access from various health and wellness providers within the clinic, including kinesiologists, physiotherapists, psychologists, mental health counsellors and dieticians,” the corporation said.

Telus said most of the doctors working in its clinics “continue to work in the public sector seeing patients for MSP-covered primary care services.”

In fact, the company argued, by focusing on wellness the clinics help “alleviate the burden on our overall health-care system” by keeping people healthy.

The Copeman clinic, now owned by Telus, made the same argument in 2006 when the Medical Services Commission began an 18-month investigation that eventually concluded the clinic was operating legally.

One person who didn’t buy the argument was Adrian Dix, then opposition health critic, now health minister. He said the private clinics were undermining the basic principles of public health care.

“People aren’t paying for those services, and everyone knows it,” he said at the time. “You’re paying for the right to see a family doctor.”

He saw the model as likely to expand and called it a real threat to public health care. “It will be harder to find a family doctor and there will be more extra billing,” he said.

Today Dix said he’s still concerned people are being forced to pay to access medically necessary services.

The annual fees charged by private clinics could be a barrier to services that should be covered by public health care, he said.

Dix said that he has received other complaints like Robinson’s and that in the last two weeks the Health Ministry had asked the Medical Services Commission to review the fees being charged.

But, he said, “the doctor in question has the right to close his or her practice and to take another job in health care.”

And if the doctor is telling patients they can stay with him for a fee?

“If that’s happening, it’s precisely the kind of question the commission needs to look at,” Dix said.

Dix said the issue was not with Telus, a B.C.-based company and strong supporter of the province’s pandemic response and immunization drive.

Other clinics are using the same business model and the rules have to be clear and consistent for everyone, he said.

“I think it’s a reasonable thing to review that and so that’s not a criticism of anybody, Telus or anybody else, it’s just saying ‘OK, these things are in place, we have to ensure that equal access to health care is maintained in our province,’” he said. “There’s a lot of companies offering various forms of supplementary services, and so what we have to make sure is that the law is being fairly applied and that people are protected.”

Dix noted that family doctors have always operated as independent businesses. Private ownership, he said, isn’t itself the issue.

He said the situation the Robinsons are facing reflects a bigger challenge with primary care, where many doctors, especially younger ones, want to work in teams with other professionals and would rather avoid the burden of running a full-service clinic funded through the traditional fee-for-service model.

“There are undoubtedly cases like this and there will be more if we’re not aggressively pursuing other alternative payment arrangements for doctors that work for them,” he said.

That means one of the solutions is strengthening the public system, maintaining the existing options for primary care that people like the Robinsons are used to, while adding new ones, he said.

It’s a transition that’s been underway since at least 2018, when Dix and Premier John Horgan announced a greater focus on team-based care, and a plan to train more family doctors and nurse practitioners, create primary care networks and open urgent primary care centres.

“We’ve got to aggressively recruit and promote team-based care, that’s the alternative, because it’s one thing to get into a debate about scarce resources, but we have to deliver a high level of service in the public system,” Dix said. “We’ve got to continue to be better in the public system.”

Green MLA Adam Olsen and Green Leader Sonia Furstenau have raised a series of questions in the legislature about extra billing and corporate involvement in the health-care system.

“There seems to be an entrenchment of at least one, maybe more than that, major corporate player on the primary care landscape,” said Olsen, MLA for Saanich North and the Islands, in an interview. “There’s a very real threat to the entire business model being turned upside down.”

He said he received many complaints when a clinic in his constituency asked patients to begin paying a $50 “continuity of care allowance” annual fee.

The danger is that allowing that kind of fee will lead to two-tier health care, Olsen said.

Some people will get basic, walk-in, episodic care, while others who pay a premium will get access to annual screenings and other services the providers describe as “extras” that really are part of a well-run primary care system.

“What I’m shocked at is seemingly this government... [has] been standing on the sidelines while this has been becoming more entrenched in the primary health-care system,” he said. “What has Minister Dix done to protect the primary health-care services from a corporation monopolizing it? Because the reality of it is there are... clinics closing down because doctors are getting put on contract.”

Family doctors are being attracted to work in urgent care centres and other facilities the government has created, Olsen said, but also to clinics owned by Telus, a corporation that has access to billions of dollars.

The family doctor shortage was the number one issue in Olsen’s community when he was first elected, he added, and since then, as the population has grown, the problem has gotten worse.

“I’m quite concerned there’s a disparity between what the minister was saying back in 2007 as critic, and what he’s standing by and watching happen right now while he’s the actual minister,” Olsen said.

As for Robinson, she and her husband won’t pay the fees to stay with their doctor at the Telus clinic.

“He’s abandoning us,” she said when asked how she feels about the choice he gave them. “We feel bad. We still feel bad about it.”

More people should know what’s happening because it’s a trend that threatens the system, Robinson said. “If he’s doing it, probably down the line there will be more doing it. If all the doctors went that way, what happens?”