The federal government’s long-awaited Interpretation Letter of the Canada Health Act (CHA), released earlier this month, missed a significant opportunity to modernize medicare.
Passed in 1984, the CHA provides the legislative framework for the universal aspects of our health-care system. Though it is a remarkably resilient Act of Parliament, re-interpretations are nonetheless needed to reflect the changing landscape of health care. This most recent interpretation letter was just the fourth issued for the Act; a significant milestone.
The letter addresses the rise of private-pay care delivered by health-care providers like nurse practitioners, whose scopes of practice now overlap with some physician services, a necessary step as shared areas of “physician equivalent” services among health-care professionals grows.
Another important change that was expected to be addressed was the rise of virtual care. While its rapid growth largely has been a very positive development, some for-profit virtual care clinics are billing patients directly or contracting with private insurance companies to provide care most people would expect to be covered by medicare.
The Interpretation Letter was supposed to resolve the ambiguity that some private-pay virtual care operators are taking advantage of. Instead, the letter omitted the issue, even though recent research has shown both the right and wrong ways to implement this style of care. Just before the close of the year, a policy paper was published that synthesized that research. Though federal Minister of Health Mark Holland did not heed its advice, it’s not too late for him to act.
As it stands, virtual care can be delivered by health professionals who are part of organizations or clinics operated on a for-profit or not-for-profit basis. It can be delivered as a standalone “walk-in” style service or as part of comprehensive team-based care, alongside in-person care. Additionally, it can be privately or publicly funded. Private funding can happen through out-of-pocket spending, or increasingly through job-linked private insurance, often called “enterprise virtual care.”
Enterprise virtual care is just as problematic, if not more so, than direct private-pay virtual care. Because it is linked to employers, especially large ones, it can more quickly siphon away health-care professionals from publicly funded care; it is subsidized extensively by federal and provincial governments; and yet it is only available to those who already are more likely to be healthy, wealthy and have access to good jobs.
The authors of the virtual care policy paper, also one of the authors of this piece, examined the various combinations of delivery and funding that are possible. In particular, what types are most and least desirable.
They recommend one such combination above the rest: non-profit virtual care, in which virtual services are integrated into ongoing comprehensive primary care, instead of walk-in style care. This model has the greatest potential to not only improve health outcomes but to promote health system sustainability.
Of course, there are caveats. To get the most from these models, technology must be integrated and “interoperable,” not just between clinics or hospitals, but within provinces and across the country. Bill C-72, the Connected Care for Canadians Act, offered a step in that direction but the recent prorogation of Parliament ended that effort. It must be revived when Parliament’s next session begins.
Governments also should consider going a step further and support health technology more broadly, including through the creation of public or non-profit Electronic Medical Record platforms.
The evidence shows that privately funded commercial virtual care models should not be supported as they increase health-system cost, worsen inequities and prioritize care based not on need, but on ability to pay. While the federal government’s Interpretation Letter missed an opportunity to prevent the growth of these problematic models of care, provincial and territorial governments can still pursue their own regulatory and legislative efforts by enforcing existing CHA-related legislation whenever applicable and avoiding outsourcing publicly funded care to these companies.
The risks of inaction are clear; a primary care system in an ongoing crisis, growing opportunities for private-pay virtual care in a regulatory and legislative vacuum, and a negative feedback loop that increases costs and worsens quality. None of this is inevitable, especially when we know better is possible as long as our legislators find the courage to act.
