Murky rules for nurse practitioners give rise to private clinics in Ontario

When Kyle Truong needed medical attention for a res‐ piratory infection last year, he said there weren't many convenient options for ac‐ cessing timely care. Truong, who lives in Toron‐ to, hasn't had a family doc‐ tor for about four years.

But then he discovered a private clinic where he could quickly get an appointment with a nurse practitioner, though it would not be cov‐ ered by the Ontario Health Insurance Plan (OHIP).

"First I was a little disap‐ pointed," Truong, 29, said. "Because if I'm paying tax dollars and we're supposed to have great health-care coverage, it kind of sucks that I have to pay for accessibility in this case."

Even so, he said he had a "great" experience at the clin‐ ic, with next to no wait times, a comprehensive appoint‐ ment, and the prescription he needed to treat his infec‐ tion. He's since signed up for a one-year membership for access to unlimited appoint‐ ments. Lucky for him, he was able to have the $450 fee covered through private in‐ surance.

Truong is part of what ap‐ pears to be a growing num‐ ber of Ontario patients who are accessing private primary care from nurse practition‐ ers. There are clinics popping up throughout the province, charging patients typically $70 to $90 for a single ap‐ pointment, and in some cases hundreds of dollars for an annual membership.

The province, like much of Canada, is facing a worsening doctor shortage.

The situation highlights a lack of clear provincial regu‐ lations related to nurse prac‐ titioners. Critics say the province needs to act to pro‐ tect Ontario's single-tier health-care system. Mean‐ while the Nurse Practitioners' Association of Ontario says the trend is proof that more funding options are needed, so that nurse practitioners don't resort to charging pa‐ tients.

Can't bill OHIP

Nurse practitioners have more training than registered nurses, and can perform more tasks. In recent years their scope of practice has been expanded in Ontario in‐ cluding, since 2017, allowing them to prescribe controlled substances. They can now perform the same standard primary care tasks as family doctors, including diagnosing and treating common condi‐ tions, referring to specialists and prescribing medication.

But unlike physicians, nurse practitioners cannot bill OHIP for their services. Some nurse practitioners work in salaried positions at a limited number of publiclyfunded family health teams, and nurse practitioner-led clinics.

Since they cannot bill the province for services outside those settings, like physicians do, those who operate pri‐ vate clinics say billing patien‐ ts is legal.

"I know this is a very touchy subject," said Alon Birshtein, CEO of Care & Family Health, a private nurse practitioner clinic in Toronto that opened its doors in 2020, and has since opened a second location.

"But really the fact is that, you know, most Canadians aren't aware that we've had a so-called two-tier system for many years already. This isn't really something new, I think it's just more at the forefront, more people are kind of talk‐ ing about it."

Provincial legislation re‐ lated to OHIP does not specifically mention nurse practitioners, but Natalie Mehra, the executive director of the advocacy group the Ontario Health Coalition, ar‐ gues that charging patients for nurse practitioner ser‐ vices violates the Canada Health Act, which guarantees universal access to medically necessary insured services.

"When you change who provides a physician service, it doesn't mean that you can start to charge patients for it," Mehra said.

The murky rules are an is‐ sue not just in Ontario.

Health Canada spokesperson Anne Génier told CBC News in a statement the federal government is concerned that recent expansions in the scopes of practice for nurse practitioners has led to pa‐ tients being charged for ser‐ vices "that would be insured by provincial and territorial health insurance plans if provided by a physician."

Génier said the previous health minister sent a letter to his provincial and territori‐ al counterparts a year ago, outlining those concerns, and "clarifying" that Canadians must be able to access med‐ ically necessary care "without having to pay out of pocket."

WATCH | Private nurse practitioner clinics popping up throughout the province:

Province says it will in‐ vestigate

When asked about private clinics by CBC News, Ontario Health Minister Sylvia Jones said charging for OHIP-fun‐ ded services is "a hard stop."

Jones said the province "will make sure that any clinic that is charging for an OHIPfunded service is ended, and the patients will be reim‐ bursed."

Despite those strong words, the province's actual stance on private nurse prac‐ titioner clinics is not entirely clear. CBC News asked the Health Ministry for clarity on whether it considers nurse practitioner services to be "OHIP-funded," but the min‐ istry did not respond.

Last fall, Jones promised to investigate after a new pri‐ vate clinic set to open in Ot‐ tawa caused public uproar. Months later, the clinic is now up and running, and continues to advertise pri‐ vate nurse practitioner pri‐ mary care services.

Mehra, with the Ontario Health Coalition, says some simple provincial regulations explicitly addressing nurse practitioners could easily eliminate any legal ambigui‐ ty.

"The government could have moved months ago to clear that up," Mehra said.

Limited funding, grow‐ ing demand

Because these clinics don't draw on public funds, there is no central database, which makes counting them diffi‐ cult. But their number ap‐ pears to be growing. The Nurse Practitioners' Associa‐ tion of Ontario says it has no‐ ticed more private clinics opening up in the last couple years, and is now aware of about two dozen throughout the province.

CEO Michelle Acorn says those clinics are a sign of the demand, and "are a conse‐ quence of a lack of funding models for nurse practitioner practices."

Acorn said she applauds a recent $110 million provincial funding announcement for new and expanded primary care teams, but said she would like to see even more investments. She also wants nurse practitioners to be able to bill for services in a similar way as physicians.

That's a sentiment shared by Rizwan Shaik, who is working on plans to open a primary care clinic in Picker‐ ing, Ont., west of Toronto. Until early this year, his com‐ pany QUBE HUB operated a clinic in downtown Toronto. He said challenges with re‐ cruiting and retaining physi‐ cians led him to change mod‐ els this past fall, instead hir‐ ing nurse practitioners and billing patients for appoint‐ ments.

Shaik admits there was "mixed reaction" from patien‐ ts. He said he would prefer to

be able to bill OHIP for the services, but argues that in the meantime, private nurse practitioner clinics are helping to fill a need.

"There are people in this country who are suffering with long-term care issues, and they're not able to ac‐ cess family doctors. And if you have the capacity to pay, you should have the ability to do so and have the access," Shaik said.

But Mehra, with the On‐ tario Health Coalition, said privatization only creates greater inequities in access to care.

"This obviously is a slip‐ pery slope that would cause the undoing of public medicare in Ontario and Canada if we're allowed to continue."