A retired doctor who has worked in for-profit clinics and is disturbed by their rapid rise in B.C. says the provincial government needs to act now to restrict corporate ownership if it wants to fix primary care.
“The core problem right now in primary care as I see it... is who’s owning primary care,” said Robert Brown, a 71-year-old retired doctor in Sidney, B.C. “I’ve [worked] in the States. I know what happens. I know the road we’re on and it’s un-Canadian and it’s not what Canadians want in their health-care system.”
As a solution he proposes rules for health clinics like ones that have long been in place for law firms, where practices must be owned by licensed lawyers.
“What’s the difference between that and a medical [clinic] where you get this potential conflict of interest?” he asks.
Health Minister Adrian Dix said the questions around ownership are “interesting,” but not a top priority for him or the provincial government.
“Our focus right now is on unattached patients and that’s where we’re putting our effort,” Dix said. “Those issues of ownership are of interest, but they’re not the question. The key question is, are [primary care services] sustainable and are they linked into the health-care system, and that’s what I’m working on now.”
From the start of public health care in Canada, most family doctors have operated as small private businesses paid out of the public insurance system.
Family doctors and the groups representing them have complained that payments have failed to keep up with the rising cost of overhead. Many have decided they can make a better living, without the added complications of running a business, in other positions.
That has led to roughly one million British Columbians now being unattached to a family doctor, a number that has grown steadily since at least 2003.
Into the vacuum have stepped publicly traded corporations, including Well Health Technology Corp. and telecommunications company Telus, that have been buying primary care clinics, growing their digital health records businesses and building their presence in B.C.’s health-care system.
In 2018 Telus bought clinics operating under the Copeman Healthcare, Horizon Occupational Health Solutions and Medisys brands as part of a $2.5-billion expansion into health care that it hoped would differentiate it from telecommunications competitors and grow revenues.
That was a turning point, Brown said. “When Telus bought them you could see the writing was on the wall as far as what’s going to happen in corporate primary care.”
Corporations will be looking for more ways to profit from the clinics they own, he said. That may include charging fees to access care, which will prevent some people from seeing doctors, but also bring more revenue for owners. The Health Ministry has referred questions about clinics charging fees to the Medical Services Commission. In the case of Telus, Dix has said the MSC is acting on what it found in an investigation, the results of which will be made public when that work is done.
Brown, who worked for several years in the U.S., said he’s seen the kind of “economic credentialing” where physicians are assessed based on financial performance rather than quality of care or competence.
It puts doctors in an awkward position that can be in conflict with their training and ethics, he said. “I’m working not for my patient’s benefit, but for the benefit of the company I’m contracted to.”
The goal of care should always be strengthening the doctor-patient relationship, he added, but the involvement of a third party owning the clinic fundamentally changes that relationship.
While still in its early stages, the consolidation of primary care clinics under corporate ownership in B.C. is similar to what has happened in recent decades in other industries, such as veterinary clinics and funeral businesses.
One sector that has so far been off limits to corporate ownership is legal services. Like in other Canadian provinces and territories, the Law Society of British Columbia has rules about what types of business arrangements lawyers may participate in. While non-lawyers may have an ownership stake, they have to agree not to interfere in the legal practice.
There has been discussion about opening up ownership rules for law firms, with some arguing that it would bring needed investment and innovation to the sector. But regulators have stuck to the principle that lawyers need to be personally accountable and free from any influence, such as they might get from non-lawyer partners or owners.
Brown said he’s suggested to health regulatory bodies and the provincial government that ownership of health clinics should be similarly restricted, but has been met with limited interest. “They’ve given me sideways answers, but no definitive response.”
Dix said he and the government are aware of the issues around ownership, but there are more pressing priorities. “It’s a question we look at, but it’s not on my list of priorities, which is a long one.”
On Friday Dix was at the opening of an urgent and primary care centre in Port Moody. It is the 21st centre to open in the province and its goals include attaching patients to doctors in family practice.
There are also some 2,000 primary care clinics in the province, most of which are owned by doctors working as independent contractors.
Last week Dix announced a new three-year Physician Master Agreement that increases pay, adds support to cover overhead, offers premiums for after-hours service and introduces payments for the number of patients they are caring for that will vary depending on how complex those patients’ needs are.
The new model shifts the province away from fee-for-service, where doctors are paid a flat rate for each service they provide, but maintains the relationship of physicians as independent contractors.
With only about half of the 6,400 family physicians in the province currently working in a full-service family practice, the hope is to attract more into that work.
Dix said the government is working on the issue of where physicians are located, noting that people serving patients in B.C. should be practising within the province.
This is particularly an issue with virtual care, which grew substantially from the start of the COVID-19 pandemic in early 2020, and people should expect to see action on it soon, he said.
BC Green Party MLAs have repeatedly raised questions in the legislature about corporate ownership of primary care clinics, particularly ones charging fees to patients.
“The corporatized health-care question obviously remains top of mind for us,” said BC Green Leader and Cowichan Valley MLA Sonia Furstenau. “There was a real gap from this government in how they were going to address the growing family doctor crisis.”
Last week’s announcement addressed concerns that doctors have been raising about support for primary care, she said, but it was largely reactionary and lacked clear goals.
“It doesn’t convey clearly what the long-term vision is and how we are going to measure success of this funding program,” she said. “I think it’s really important that this minister articulate clearly what he envisions for health care and primary health care.”
Meanwhile the government has allowed corporate clinics, including ones charging fees for access to doctors, to gain a foothold, Furstenau said. “The passive response of this government, to me, is an indication that either this is included in his vision for health care going forward or that he is unwilling to take the steps to rein this in because he’s concerned about the lack of access to health care generally.”
Brown too said the government and the minister need to take the threat more seriously. They are “very naive” to allow corporate ownership to grow and to claim it doesn’t matter, he said.
“They don’t realize the Pandora’s box they’re opening up.”