“Extra-billing” – the two definitions

Stethoscope prescribing treatment to patient for doctor with pen writing recipe on clipboard in hospital.

“Extra-billing” is a term that comes up frequently in health care discourse in Canada – especially in British Columbia.

So what does it mean?

Patients should note that the B.C. government and the Canada Health Act have two very different definitions.

This table demonstrates the difference:

Scenario
B.C. Government’s Position
Canada Health Act
A patient doesn’t want to wait a long period of time to get a hip operation, knee surgery, etc. from the public health care system in B.C. The patient then decides to pay for the procedure at a private clinic and the clinic does not bill the government for the procedure.
This is extra-billing
This is NOT extra-billing

As a bit of background to this post, earlier this year I kept seeing the term “extra-billing” and it seemed to have different meanings depending on who was using it.

I contacted the B.C. government to try to learn more about what they defined as “extra-billing” and which activities they were trying halt through their enforcement of the province’s Medical Protection Act.

During a phone conversation with a staff person at B.C.’s Medical Services Commission, I asked lots of questions about what does/does not count and took lots of notes from the conversation. I then sent the notes to the commission to make sure my notes were accurate (you can see my email with the commission if you click here).

Here’s what they confirmed:

Scenario 1: A patient is deemed by a physician to require an MRI. The patient chooses to go to a private clinic and pays $1,000 and the clinic does not bill the government. Currently the government does not consider this to be extra-billing. 

However, if section 18.1 of the Medicare Protection Act is allowed to be enforced, the above scenario would be considered extra-billing and not allowed.

Scenario 2: A patient is deemed by a specialist to require hip surgery. The patient chooses to go to a private clinic and pays $10,000 for hip surgery and the clinic does not bill the government. Currently the government considers this to be extra billing.

The government is currently trying to further prohibit (eg. through Bill 92 – fines, ability to refund patients, etc.) private clinics charging patients for hip surgery and other insurable benefits (e.g. orthopaedic procedures).

Scenario 3: A patient is deemed by a specialist to require hip surgery. The patient decides to pay $10,000 for hip surgery at a private clinic and the clinic also charges the government. The government considers this to be double billing.

If you look at the Canada Health Act, however, you’ll find a completely different definition of “extra-billing:”

“extra-billing means the billing for an insured health service rendered to an insured person by a medical practitioner or a dentist in an amount in addition to any amount paid or to be paid for that service by the health care insurance plan of a province; (surfacturation)”

The key difference of course is this wording in the Canada Health Act – “in addition to any amount paid or to be paid” by the provincial government.

Basically, the CHA does not allow a clinic to take money from a patient and the provincial government for the same procedure.

Conversely, the provincial government is aiming to take the situation one step further – prohibiting clinics from taking money from patients period. That means B.C. patients could face a 2-3 year wait for surgery (like Bruce was told) or they’ll just have to leave the province for health care (like 30,000+ patients did in 2017).

 
Colin Craig is the President of SecondStreet.org

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Prevention – reduce demand in the first place

If Canadians lived healthier lives, we could reduce demand for emergency services, orthopaedic surgeries, primary care and more. 

For instance, if you visit the Canadian Cancer Society’s website, you’ll read that “about four in ten” cancer cases are preventable. The Heart and Stroke Foundation notes that “almost 80 percent of premature heart disease and stroke can be prevented through healthy behaviours.” A similar number of Diabetes cases are also preventable. 

Many joint replacements and visits to ERs and walk-in clinics could also be avoided through healthy living. 

To be sure, not all health problems can be avoided through healthy living – everyday the system treats Canadians with genetic conditions, helps those injured in unavoidable accidents and more.  

But there is an opportunity to reduce pressure on the health care system through Canadians shifting to healthier lifestyles – better diets, more exercise, etc. 

To learn more, watch our Health Reform Now documentary (scroll up) or see this column. 

Partner with non-profits and for-profit clinics

European countries will partner with anyone who can help patients. 

It doesn’t matter if it’s a non-profit, a government entity or a private clinic. What matters is that patients receive quality treatment, in a timely manner and for a competitive price.  

In Canada, governments often delivery services using government-run hospitals instead of seeing if non-profit or private clinics could deliver the services more effectively. 

When governments have partnered with non-profit and private clinics, the results have often been quite good – Saskatchewan, Ontario and British Columbia are just a few examples of where partnerships have worked well. 

Canada should pursue more of these partnerships to reduce wait times and increase the volume of services provided to patients.  

To learn more, watch our Health Reform Now documentary (scroll up) or see the links above. 

Make cross border care more accessible

In Canada, citizens pay high taxes each year and we’re promised universal health care services in return. The problem is, wait times are often extremely long in our health system – sometimes patients have to wait years to see a specialist or receive surgery. 

If patients don’t want to wait long periods, they often have to reach into their own pocket and pay for treatment outside the province or country. 

Throughout the European Union, we also find universal health care systems. But a key difference is that EU patients have the right to go to other EU countries, pay for surgery and then be reimbursed by their home government. Reimbursements cover up to what the patient’s home government would have spent to provide the treatment locally. 

If Canada copied this approach, a patient waiting a year to get their hip operation could instead receive treatment next week in one of thousands of surgical clinics throughout the developed world. 

Governments benefit too as the patient is now back on their feet and avoiding complications that sometimes come with long wait times – meaning the government doesn’t have to treat those complications on top of the initial health problem. 

To learn more, watch our Health Reform Now documentary (scroll up) or this shorter video. 

Legalize access to non-government providers

Canada is the only country in the world that puts up barriers, or outright bans patients from paying for health services locally. 

For instance, a patient in Toronto cannot pay for a hip operation at a private clinic in Toronto. Their only option is to wait for the government to eventually provide treatment or leave the province and pay elsewhere. 

Countries with better-performing universal health care systems do not have such bans. They allow patients a choice – use the public system or pay privately for treatment. Sweden, France, Australia and more – they all allow choice. 

Why? One reason is that allowing choice means some patients will decide to pay privately. This takes pressure off the public system. For instance, in Sweden, 87% of patients use the public system, but 13% purchase private health insurance. 

Ultimately, more choice improves access for patients. 

To learn more, watch our Health Reform Now documentary (scroll up) or watch this short clip on this topic. 

Shift to funding services for patients, not bureaucracies

In Canada, most hospitals receive a cheque from the government each year and are then asked to do their best to help patients. This approach is known as “block funding”. 

Under this model, a patient walking in the door represents a drain on the hospital’s budget. Over the course of a year, hospital administrators have to make sure the budget stretches out so services are rationed. This is why you might have to wait until next year or the year after for a hip operation, knee operation, etc. 

In better-performing universal health systems, they take the opposite approach – hospitals receive money from the government each time they help a patient. If a hospital completes a knee operation, it might receive, say, $10,000. If it completes a knee operation on another patient, it receives another $10,000. 

This model incentivizes hospitals to help more patients – to help more patients with knee operations, cataract surgery, etc. This approach also incentivizes hospitals to spend money on expenses that help patients (e.g. more doctors, nurses, equipment, etc.) rather than using the money on expenses that don’t help patients (e.g. more admin staff). 

To learn more about this policy option, please watch our Health Reform Now documentary (scroll up) or see this post by MEI.