Opinion

Boutique primary care clinics are making the family doctor shortage worse

In Canada, where universal health care is a cornerstone of our values, we are facing a primary care access crisis. The problem is multi-faceted and not just due to a decline in the number of licensed family doctors for the first time since the mid-1990s. The role of private primary care “boutique clinics” – and their effects on  access and equity in the public system – must be considered.

Recently, a recruiter approached me with an enticing job offer: an income of $390,000 to $450,000 annually, plus a $50,000 signing bonus, to care for just 400 patients (a typical full-time panel is more than 1,200). The catch? This role was at a boutique clinic, operated by “one of Canada’s most recognized brands” and has clinics in B.C., Alberta, Ontario, Quebec and Newfoundland. The recruiter told me that the clinic offers a combination of “insured” services –regular family doctor visits covered by the public system – and “uninsured” services paid for by the patient via extra fees. These uninsured services, I was told, included “comprehensive health assessments” that focus on “prevention and wellness.”

This description immediately raised red flags. Preventive care and wellness guidance are the bread and butter of family medicine. Every family doctor is trained to evaluate overall health, identify chronic disease risks, and provide lifestyle recommendations – all within the publicly funded system. The tests and imaging needed for evidence-based prevention and wellness are paid for in the public system.

So, what was I being asked to do in this boutique model? The recruiter elaborated: These uninsured services would include “executive health exams, annual wellness check-ups, and fitness-for-work assessments,” covered by the extra fees paid by the patients. Translation: patients would pay out-of-pocket fees and I would be asked to order tests that have questionable medical value. Though these extra, “personalized” tests are marketed as a pathway to better health, research tells us otherwise. The uninsured tests are unnecessary and not supported by clinical guidelines and can lead to overdiagnosis. Overdiagnosis refers to turning healthy people into patients by identifying problems that were never going to cause harm and may lead to potentially harmful, unnecessary interventions. These tests also strain our overstretched public imaging and laboratory services, as equipment needed for public patients is redirected to patients from boutique clinics getting extra testing.

Boutique primary care clinics do not expand access; they constrict it.

Boutique primary care clinics do not expand access; they constrict it. We already have a shortage of family doctors; by removing a physician, like me, from the usual public system to work in boutique clinics, the shortage worsens. Each doctor who transitions into a boutique practice leaves hundreds (maybe thousands) of patients without access to publicly funded care.

The boutique clinic model benefits a select few. Doctors in these roles can command large incomes while managing significantly smaller patient loads. Patients who can afford the fees get access and may feel they are receiving superior care (though the reality is they may be paying for unnecessary services and experiencing avoidable harm from too much medical care). And of course, corporations profit handsomely.

But let’s be clear: these boutique models harm everyone else. They siphon off limited health-care resources, exacerbate inequities in access, and erode public trust in our health-care system.

The Canada Health Act ensures access to necessary medical services based on need rather than the ability to pay, and explicitly discourages extra billing and private charges. The divide between insured and uninsured services at boutique clinics seems too flimsy to not be called a two-tiered system. We have a convincing body of evidence that tells us a two-tier system worsens access overall, especially for those already experiencing other inequities.

I declined the recruiter’s offer to learn more. While the salary might be tempting, the ethical cost was too high. I do not want to participate in a model that contradicts the principles of universal health care. As a physician, my commitment is to provide equitable, evidence-based care – not to profit from a system that undermines it.

We must resist the normalization of boutique primary care in Canada and direct that energy to solutions that work for all. Policymakers need to attend to the spirit and letter of the Canada Health Act and close loopholes that allow boutique clinics to use preferential access to blur the lines between “insured” and “uninsured” services. And physicians must advocate for sustainable solutions that address the root causes of health-care shortages – like expanding community-centred, team-based care.

Boutique clinics are not the future of health care. They are a step backward and are making primary care access worse. Let’s work together to stop diversions of doctors and resources from the public system we all depend on.

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2 Comments
  • George Magee says:

    Show me the numbers! This article reeks of unsubstantiated critical language from either a government health care bureaucrat or a radicalized socialist. The term “Botique” is inappropriate and evokative. These clinics are innovations that spring up in a capitalist democracy to fill in the service gaps created by a government sponsored public system. The gaps, orphaned patients, docs, nurses, beds.CTscanners,MRIs/1000, ER closures, surgical wait times, are some of the well published numbers of Canadians who don’t have and can’t find a family physician.These innovative clinics set the bar for equity, efficiency, effectiveness that our public health care system shamefully resists. George Magee

  • Carl Christie says:

    Thank you for sharing your thoughts on this unfortunate and troubling development, and especially for your socially responsible decision to decline the ‘opportunity’!

Authors

Rita McCracken

Contributor

Dr. Rita McCracken, MD, PhD, CFPC (COE), FCFP, is a practicing family physician in Vancouver and an Assistant Professor in the Department of Family Practice at UBC.

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