Transcript
Speaker: Hello and welcome to today's episode of Red Eye. I'm Jane Williams.
Speaker: On the podcast today, Dr. Daniel Raza speaks with Lorraine Chisholm about the release of the long -awaited Canada Health Act interpretation letter regarding coverage of basic healthcare by non -physician providers. On the healthcare front in Canada, very good news.
Speaker: A new interpretive letter on the Canada Health Act is a win for access to public healthcare across the country. The letter says primary healthcare services provided by qualified non -physician practitioners must be covered by provincial and territorial plans. But the letter left the whole area of virtual care unresolved.
Speaker: The new rules were sent to provinces and territories by the federal minister of health, Mark Holland, last week. Danielle Raza is a family physician with Unity Health Toronto St. Michael's Hospital and an assistant professor with the University of Toronto. He's also the inaugural primary care and health policy scholar at St. Michael's Department of Family and Community Medicine. And he joins me today. Hello, Danielle. Hi, Lorraine. Thanks for having me on.
Speaker: Oh, I'm really pleased to be talking with you again. Before we dive into the details, can you explain what an interpretation letter is in relation to the Canada Health Act? Yeah. Well, you know, the Canada Health Act is a piece of legislation that's about 40 years old, you know, people will recall it was passed in 19 eighty four And it's you know quite a robust piece of legislation, but there's lots of things that the authors of the Canada Health Act, you know just like many people in 1984, didn't foresee in terms of what the world would look like.
Speaker: 40 years later. So what an interpretation letter is, not just for the Canada Health Act, but for legislation in general, is it basically a clarification or and ah or reinterpretation of legislation that puts it into the modern context. So basically looks at this legislation that was written in the past, but applies it to conditions that the authors didn't necessarily foresee today.
Speaker: So, can you explain the the good news for the funding of nurse practitioners or non -physician services that stops out of pocket expenses for the patient? Yeah, before I do, I'm just going to back up a bit and talk a little bit about why we're seeing the rise of ah private paying nurse practitioner clinics. You know, it's no surprise to anyone that we're in a bit of a squeeze, a bit of a crisis when it comes to primary care.
Speaker: There are are millions of people across the country he who can't access a primary care provider, whether that's a family doctor or a nurse practitioner. And so what that's meant is that there are people who are, you know, quite desperate for care and, you know, looking for care in any way they can get it.
Speaker: One of the ways that that that type of care has manifested is these private pay clinics that are providing private pay NP services. And this is an issue, of course, because if you were to get that same service from, for example, a family doctor, you're not paying out of pocket because it's covered under Medicare. However, when the Canada Health Act, you know, was passed in 1984, and it set the terms for our universal healthcare system, really, you know, Medicare is only universal for two things.
Speaker: for hospitals and for for doctors. But of course, you know, nurse practitioners who are working out in the community don't fall under either category, even though there are some things a nurse practitioner can do that a family doctor might also do when ah when you see them. So of course, this was, I think, a bit of a loophole, you know, in Medicare that many people correctly recognize that if you could go see a family doctor, and that was covered under Medicare for things like a regular checkup, a pap smear, ah for a cough or cold, why were you paying out of pocket when you were seeing some of these private pay NP clinics. And that was a discrepancy that this interpretation letter ah was seeking to address. So then the letter actually now prevents out of pocket expenses or charges for visiting a nurse practitioner when you're covering um primary health care.
Speaker: Yeah, so it uses this interesting term called physician equivalent services. So what it's starting to do now is not just think about the type of healthcare worker delivering or doing the care, but actually the services that we're interested in. So if there's something that is covered under Medicare that a doctor is doing, but also another type of healthcare professionals able to do, well, that is not something that you can bill someone privately for because that service is already covered under Medicare. So that means if you're going to go see um a nurse practitioner for, for example, a Pap smear, that can't be billed to you out of pocket because it's a, you know, quote, physician equivalent service that's already covered under Medicare. So are there other practitioners in addition to nurse practitioners who would be now covered?
Speaker: So there's two answers to that question. So number one, there are certainly many other types of healthcare care workers whose scopes of practices have expanded and who now overlap with doctors. I mean, you know, two healthcare workers have the same scopes of practice, right? That's why we have nurses, nurse practitioners, pharmacists, and doctors, and of course, many other folks like psychologists, social workers, physiotherapists, the list is long.
Speaker: But the kind of edges where our expertise begin and end, they're beginning to get a little bit blurry. So for example, across the country, pharmacists have also being granted. Larger scopes of practices where they can even do some diagnosis and treatment for minor ailments, things like you know UTIs, for example. So that would be deemed a physician equivalent service. So you know presumably through this interpretation letter, a pharmacist couldn't also bill you out of pocket or privately for that service because it's publicly covered as traditionally ah a physician service or now a physician equivalent service. But
Speaker: The extent to which this applies, I think remains to be seen because we need to get a better sense of what exactly these physician equivalent services are and how broadly they can apply. And depending on how, you know, this policy is implemented, it could potentially apply quite broadly. But there's a second piece to your question that I think is important as well. And that's, does this interpretation letter compel provincial governments and of course the federal government to begin to fund these services, right? Or does it just mean that these physician equivalent services can't be billed out of pocket? It's a subtle but important difference, right? One says you can't bill these services privately and the other one says you can't bill these services privately and thus you must also publicly fund these healthcare care services.
Speaker: So it's a subtle difference, but we also are not entirely clear. Does the prohibition on private pay for these medically necessary physician equivalent services also compel the provinces to fund them, or is it just a prohibition on private pay for this for this type of care? Subtle, but absolutely critical. Yeah, absolutely, because I think this is also a huge opportunity for us to build the type of primary care system we want. you know We know from across the world The highest quality primary care systems are ones that are built on team -based care. But the funding mechanism for Medicare for primary care really just is universal for physicians. Now, depending on where you live in, we have other models of primary care that fund more than just doctors, like community health centers or you know family health teams. There are many different types of models all across the country that vary province by province, but they're all determined
Speaker: at the provincial level and based on the whims or the priorities of the provincial government of the day. We don't have a uniform policy towards funding team -based primary care in the way that we do hospitals and doctors. So there is potential in this letter, I think, to create these funding agreements and mechanisms through the Canada Health Act for team -based care, but by no means is it a sure thing. The implementation is going to be really important.
Speaker: The Ottawa citizen described this as a sea change in the delivery of primary care across Canada. Is that a given? How do you rate its significance? So I think there's what we're going to see in the short term and ah then what we could see in the medium to long term. And it's the medium to long term potential that is the most promising. So if we so first start with the short term,
Speaker: The provinces have until April 2026 to essentially end the practice of private pay billing for physician equivalent services that are already covered under Medicare. So that includes some of these private pay or all of these private pay NP clinics. And that's a good thing because if we continue to see the rise of private pay care for medically necessary services, it's also a big drain on publicly funded care. ah We have a shortage of all sorts of healthcare care workers.
Speaker: And the more opportunities we create for private pay care, the larger that sucking sound we're going to hear of healthcare workers leaving publicly funded care to privately funded care. And of course, we know that's problematic because then it begins to distribute in ration care based on not on medical need, but ability to pay. And we also know that folks who are most able to afford private pay care also or tend to be the healthiest and the least in need of that sort of care. So this, the interpretation letter in the short term will put an end to this type of redistribution of but healthcare care workers. But of course, opposition is not enough, right? We also need proposition. We need a good offense with a good defense.
Speaker: And so I think it's that propositional piece, that potential that is the most promising, in particular, if this letter can be used to unlock team -based funding in primary care for the so -called physician equivalent services. And so that Medicare extends to beyond just what doctors do, but also what we can do in teams.
Speaker: and Now, Daniel mentioned in my introduction that there's also maybe a problematic part here with virtual care, which has become a lot more prevalent. What did the interpretation letter say there? Yeah, well, let me also back up here for a second and first say that virtual care is unequivocally, it's a good thing as a tool. I use virtual care as a part of my team -based family medicine practice. It's allowed me to deliver more care than I would before. That's also more convenient for many of the people I take care of. And I use it as a tool as to compliment the in -person primary care that I provide. But one of the consequences of it's very rapid and necessary adoption that we saw, you know, of course, during the COVID -19 pandemic.
Speaker: is that we've seen the rise of these for -profit virtual care walking clinics that are also charging patients out of pocket for the you know same sorts of medically necessary care that you might reasonably expect to be covered.
Speaker: And, you know, these companies are doing it in two ways. The first is through essentially like a direct to consumer model where you, you know, go into Google, you type in whatever virtual care for weight loss, or something similar, and then you interact with someone at the company and they will issue a prescription or something similar to that. But then you also have the rise of, you know, the lingo is enterprise care.
Speaker: And that's, I would argue, actually potentially even more problematic. And what what that actually looks like is when these virtual care companies, in collaboration with private insurance companies, contract out their service to large employers. And it creates this it creates access that's based on your ability to get good benefits through your job. So you better have a decent enough job with decent enough benefits to access this so -called enterprise care.
Speaker: And the reason this is problematic is because it scales much faster and much larger than this direct to consumer model. And again, just like the issue that around private pay NP care, it takes healthcare workers of all types, physicians and nurse practitioners and locks them behind paywalls or now, you know, through enterprise virtual care, these work walls. And the reason why all of this is important is because many of us were expecting that the interpretation letter would also address this sort of private pay virtual care. In fact, a version of the interpretation letter was leaked last summer, and in that version, it did. But the version that was released last month did not. It left virtual care out. It did act on this physician equivalent NP private pay piece, but this really huge level of ambiguity that's allowing these for -profit virtual care companies to charge patients out of pocket, that's going to continue as it is today.
Speaker: With so much happening on the political and electoral front in Canada, how can ordinary people act to protect and expand accessible public health care? but Number one, I think people need to understand that we can build a better system and we don't need to reinvent the wheel to do that. The principles upon which Medicare was founded their sound. and right And that's the principle that care should be based on medical need, not ability to pay. And we can learn a lot from what other countries do really well. I'm a family doctor. I work in primary care. So that's in the area that I'm particularly laser focused on. And we know that countries that do this really well have team -based care. They think about ah your right to accessing primary care the way we think about school boards and the public education system where
Speaker: You have access to a clinic that's in your neighborhood. And when you move, just like, you know, your, you know, your child will have a school in the new neighborhood. You and your family will have a primary care team in that new neighborhood. That's a really fundamentally a different way of thinking about how we plan for healthcare services. ah We know we can do better in terms of integrating technology into care. And we can learn from folks all around the world.
Speaker: ah So I think we need to first expect better, ah know that we can do better and then demand better. It's no secret we're going to have a federal election in the next few months. Many provinces will have just had a provincial election or will be having a provincial election this year as well. So there's all sorts of opportunities to make noise about this when candidates come knocking on your door, when you're going to all candidates debates, when you have the opportunity to talk to ah legislators of all sorts, whether they're provincial or federal. So good to talk with you this morning and to catch up on this important shift here. No problem. And you know, the other thing I'll say is there are lots of great organizations who are working on this issue that you can sign up and work with too.
Speaker: I'm ah privileged to be the past board chair of Canadian Doctors for Medicare. They're doing some amazing work here. There's other groups like the Council of Canadians that's, for example, working on pharmacare. There's the Canadian Health Coalition in BC. There's the great folks at the BC Health Coalition. There's all sorts of other folks who care about this, just like you, ah organizations that you can connect with and be part of taking action, not just on your own, but as part of these broader strategic and really targeted efforts.
Speaker: Fantastic. Thanks so much, Daniel. My pleasure. I've been speaking with Daniel Raza. Daniel is a family physician with the Unity Health Toronto's St. Michael's Hospital and an assistant professor with the University of Toronto. He is also the inaugural primary care and health policy scholar at St. Michael's Department of Family and Community Medicine.
Speaker: The Red Eye Collective is based in Vancouver. You can check us out at coopradio dot .org slash redeye.
