Private medical providers are rapidly expanding their services across the country, but even the industry’s own advocacy group lacks definitive numbers on the size and scope of the private health care sector, The new world of for-profit medical service has been crying out for a consumer guide to what’s available, what it costs, who’s offering it, and how to pay for it. Here it is: a Canadian first.



Private medical providers are rapidly expanding their services across the country, but even the industry’s own advocacy group lacks definitive numbers on the size and scope of the private health care sector, The new world of for-profit medical service has been crying out for a consumer guide to what’s available, what it costs, who’s offering it, and how to pay for it. Here it is: a Canadian first.





Private medical providers are rapidly expanding their services across the country, but even the industry’s own advocacy group lacks definitive numbers on the size and scope of the private health care sector, The new world of for-profit medical service has been crying out for a consumer guide to what’s available, what it costs, who’s offering it, and how to pay for it. Here it is: a Canadian first.





33 Emergency •

34 Family physicians •

35 Financing

36 Specialists

37 Orthopaedics

38 A private hospital

40 Medical consultants

41 Executive health

42 Medical travel agents

43 Cataracts

43 Cancer

46 American clinics •

46 Health advocates



you might expect. The leaders are B.C. and Quebec, not Alberta.

PET scans

Considered the gold standard in cancer diagnosis. Two of the four private PET scanners in Canada are in Montreal.

CT scans

There is a huge demand for both CT and MRI scans. The national median wait time for CT scans is 5.5 weeks.

MRI scans

The national median wait time for MRI scans is 12.3 weeks. B.C. and Quebec have the highest numbers of private MRI scans.

Cataract surgery

Aging boomers are fuelling a huge market in private cataract clinics. Untreated, cataracts can cause blindness.

0 Doctors who have opted out

An astonishing number of doctors (lOl) have left the public health system in the province of Quebec.

Surgical clinics

Private surgeries in Canada do everything from vascular surgery to full hip and knee replacements.

If all goes according to plan, this summer will see another watershed moment in the relentless march of private health care across the nation. The Copeman Healthcare Centre, which already operates a private clinic in Vancouver, is planning to open three more—in Ottawa, Toronto and London, Ont.—as part of its push to have centres open in every major Canadian city by next year. These are not facilities offering specialty surgeries, or redcarpet care for the jet-setting elite. Instead, they will let Canadians pay for quicker, better access to the central players in the health care system—family doctors. For an initial annual fee of $3,500 per person (their children 22 years and younger are free), and $2,300 per annum for subsequent years, patients will be able to buy a health care package including unlimited visits with a family doctor, and counselling from a range of health professionals. Patients can phone up in the middle of the night and talk to a nurse, and if necessary, they’ll be transferred to a doctor. In Ontario, Don Copeman sees a huge potential market in the estimated 1.4 million people who don’t have a family doctor.

“The public system will never be able to afford the provision of comprehensive, preventive health services that we offer,” he says. “Governments don’t have the funding to provide these services and politically it’s unfathomable. They would literally have to find billions of new health care dollars and the public is no longer willing to accept an ever-

increasing tax burden.”

Paying for access to family doctors would mark a monumental shift in Canadian health care, says Colleen Flood, the Canada Research Chair in Health Law and Policy. For many Canadians, they are the first and only point of access to the system. They expedite a patient’s access to specialists in both private and public medicine, and act as the gatekeeper to cutting-edge care. They also have a lot of influence over how long a patient waits for treatment. “They can try and help their patients get faster service with specialists by making phone calls depending on their connections and depending on the patient’s need,” says Flood. Doctors who have fewer patients have more time to be a patient’s advocate, and Copeman’s clinics promise four times more doctors per patient than in the public system.

Private medicine is rapidly altering the options available to patients in Canada. What once provided only cosmetic procedures and after-hours MRIs is now a dynamic, multifaceted industry serving thousands of Canadians and providing a host of treatment options. Cataract MD, for example, hopes to open its first Ottawa office this summer and one in Vancouver in the fall. The clinics will offer cataract surgery—a procedure that was formerly available only in the public system in the province. Patients will be able to jump the public’s median wait-list time of 34 weeks, for a cost of $l,500-$3,000 per eye. In Montreal, the country’s first private emergency


Broken ankle? In pain? No waiting

Fed up with having to cut corners and squeeze patients in, Dr. Luc Bessette and two other emergency room doctors opted out of the public system in Quebec and started the country’s first private emergency medical clinic in Montreal. The centre does not have the full facilities of a hospital, but it has treated patients experiencing heart attacks, broken ankles, and a headline-making case of flesheating disease.

Donna (who requested her last name not be published) almost died, she said, while waiting in a local clinic. After 2V2 hours, she left the waiting room and went to Clinique

médicale MD-Plus. Bessette saw her right away. She was nauseous, feverish and flushed. Her breasts were inflamed and bright red. Bessette did not tell Donna at the time, but he suspected her symptoms were caused by streptococcus A—the bacterium that can cause flesh-eating disease. He arranged for her immediate transfer to the infectious disease department at Montreal’s Royal Victoria Hospital. Today, she is in good health and credits Bessette with saving her life.

About 30 per cent of the clinic’s patients need immediate treatment for minor emergencies such as cuts, bruises and burns. If patients buy a coverage plan they get an apppointment with a doctor within half a working day. Because the clinic does not have the capabilities of a hospital, it cannot stay open 24/7, and sees patients only during normal business hours and Saturday until 4 p.m. The facility is not equipped to treat people with major emergencies. When these patients arrive, the centre does what it can, and transfers them to the public system. “Please don’t come here if you have a major

clinic—Clinique médicale MD-Plus—opened in October 2004This month, the Westmount Square Surgical Center added total knee replacements to their menu of services, a complex procedure offered by only one other private facility in Canada. The Vancouver-based Cambie Surgery Centre plans to follow suit as soon as negotiations with the provincial government are completed.

It’s difficult to estimate the full size or scale of private health care in Canada. Most provinces track only the services available in the public system, and though the private system has an advocacy group, the Canadian Independent Medical Clinics Association,


it doesn’t track the number of practitioners, patients or procedures. But the Maclean’s complete guide to private health care reveals a growing industry: 23 private surgical centres offering medical services nationwide; 17 private cataract clinics; and in Quebec, 101 doctors have already opted out of the public sector entirely to work privately.

The Canadian Institute for Health Information estimates private-sector health care spending will reach $43.2 billion this year, up from $32 billion five years ago (with more than half of those dollars going toward drugs and dentistry). Those numbers have grown fast, and are only going to get bigger, says Brett Skinner, director of health policy

research with the Fraser Institute. “There are more and more people being affected by the problems in the Canadian health care system, and that is driving acceptance of private for-profit care,” he says. “The genie is out of the bottle, and there’s no going back.” Dr. Jeffrey Brock, who runs MedExtra, a medical consultancy firm based in Montreal, agrees. “Patients aren’t getting what they need in the public system, and are looking for alternatives,” he says.

In part, it’s a simple matter of supply and demand. At the moment, 875,000 Canadians are on waiting lists for medical treatment, and many expect those lists to grow as the pop-

ulation ages. In 2004, the Conference Board of Canada reported that health care already consumes close to a third of all provincial revenues, and by 2020 that will rise to 44 per cent, just to maintain current levels of service. With medical expenses already projected to rise by $5 billion a year without doing anything to reduce wait times or improve care, it seems unlikely that governments will be able to increase spending enough to meet all the demand for service. “Health care, as it is currently funded, is unsustainable,” said Glen Roberts, director of health programs for the Conference Board.

Not surprisingly, those with the means are looking for alternative, more expedient op-

tions. According to a Decima Research poll conducted in June, negative ratings of the country’s health care system have now

eclipsed positive ratings, increasing the pressure for change.

And the qualms many Canadians had about “two-tier health care” are fading. The Decima poll found that a majority of Canadians now approve of private health care51 per cent said they thought private family doctors were a good or very good idea. In Quebec and British Columbia, those figures were 58 per cent and 53 per cent respectively.

It seems the spreading dissatisfaction with Canada’s publicly funded system has begun to break down Canadians’ traditional hostility toward forprofit health. Maclean’s recently polled 3,759 readers and found 64 per cent said they, or a family member, have waited what they consider to be an unreasonable amount of time for medical treatment or tests. And

emergency,” Bessette says. “Wait until we open our private hospital.”

HOURS: Monday-Friday: 8:30 a.m.—5 p.m.; Saturday: 9 a.m.—4 p.m.

PRICES: $300 an hour (there is a 20-minute minimum of $100). Lab tests, blood work and vaccines are all done privately and charged separately. Patients can buy year-long coverage plans. A complete checkup plus one other visit costs $895. A complete checkup plus six visits costs $1,495A.S.


More face time with your doctor

When businessman Don Copeman opened his clinic in Vancouver last November, the media had a field day. “$2,300 for a ticket to ‘Club Medicare,’ ” proclaimed the Toronto Star; “U.S.-style private health clinics,” admonished the CBC. “It’s preferential access to care,” warned then NDP health critic David Cubberley.

Why the big fuss? Copeman was offering a service that had hitherto been very difficult to purchase in Canada: more face time with doctors. For $3,500 a year, his clients can call a nurse 24/7, and, if need be, talk to a doctor. The clinic also offers unlimited access

to “expert general practitioners.” These are family doctors who have chosen to focus on one of the following fields: oncology, gynecology, urology, cardiology, pain management, neurology, women’s health, sports injury, or orthopaedics. The range of services at Copeman is tailored to mid-lifers, the target audience.

Copeman’s intent is to set members on the path toward optimum health. This journey begins as soon as patients sign up. At their first visit, they are evaluated by a team of health professionals. The team performs a multitude of screens and tests, and interviews the new member at length. Nutrition, diet, stress management and family medical history are all assessed. With this information, the team compiles a profile of the patient, including his or her susceptibility to certain diseases.

To prevent those particular health risks from becoming a reality, every member is then assigned another team that includes lifestyle coaches, clinical dietitians, kinesiologists, exercise physiologists, internists,

while many advocates of public health care have long decried the threat of a so-called “twotier” medical service, many Canadians no longer see that as such a bad option. Respondents were closely split on the wisdom of establishing a parallel private/public system: 42 per cent in favour, 44 per cent opposed, and 14 per cent on the fence.

A recent Supreme Court of Canada decision has given the notion of private health care new legitimacy, says Peter Hogg, scholar-inresidence at the Toronto law firm Blake, Cassels & Graydon, and an expert in constitutional law. In June 2005, the Supreme Court ruled in favour of George Zeliotis and his family physician Jacques Chaoulli, striking down a

Quebec law that said patients were not allowed to buy private insurance for health care procedures covered by medicare. Though the decision concerned private insurance, and ruled on a Quebec law only, the court did say that, in essence, if governments could not provide timely access to health care, they cannot prevent citizens from obtaining it on

nurses, doctors and psychologists. Frequent counselling sessions, screenings and coaching interventions are designed to help the member ward off illness and catch diseases in their early stages.

For extra help, there are programs such as sustainable exercise strategies, smoking cessation and stress management designed to ensure members stay fit and healthy throughout the year.

For more serious problems, members are transferred back into the public system, or given the option of private treatment in Canadian

or international facilities. The centre promises its doctors will do their best to expedite care in the public system, if medically necessary for the patient.

Companies signing up their employees for membership are given a few extra perks, including employee health screening and immunization programs. There is also a 24hour travel hotline that offers medical advice and access to a member’s medical files in case he or she falls ill while on holiday. The hotline is available to both individual and corporate members.

At present, the only Copeman Healthcare Centre is in Vancouver. However, new clinics are scheduled to open in Toronto, Ottawa and London by late summer. By the end of 2007, Copeman plans to have 12 clinics openone in every major city in Canada.

PRICES: $3,500 a year or $300 a month per person for the first year. For subsequent years, the cost is $2,300 a year or $200 a month. If one parent is signed up, children 22 and under are free. Ä.S.



How to get a loan for that new hip

If the sums for private procedures are beyond your budget, financing options are available. Several companies cater to this growing market, including Medicard Finance and CareCredit. Thousands of Canadians rely on these services—private clinics rarely have payment plans and usually ask for full payment up front, before proceeding with treatment.

The largest Canadian company offering medical financing is Medicard Finance. Founded by Toronto businesswoman Ann Kaplan in 1996 (she was then living in British Columbia), Medicard has provided loans to

their own. “In some serious cases, patients die as a result of waiting lists for public health care,” the decision said. “The prohibition on obtaining private health insurance ... is not constitutional where the public system fails to deliver reasonable services. Life, liberty and security of the person must prevail.” This decision has created a fundamental shift in the legal landscape of public health care, Hogg says. “Governments are now on notice that they have to deal with their waiting lists. It’s no accident that since the case there’s been a tremendous amount of interest in the health care system and getting rid of waiting lists. None of that action occurred before Chaoulli. Governments were perfectly happy to just leave it all under the rug.”

The decision served to embolden private health care providers, causing some to expand their menu of services. The ruling encouraged orthopaedic surgeon Brian Day to offer more complex surgeries at his Cambie Surgery Centre. The decision also encouraged management at Winnipeg’s Maples Surgical Centre to expand their services. They are currently in negotiations with Manitoba Health.

Private health care in Canada is about more than increased choice for the very rich. It’s about providing options to people on wait lists who are suffering in pain and have had to put their lives on hold. For some, it’s about gaining access to life-saving drugs or cutting-edge treatments

that aren’t funded by the public system. In this, the first-ever guide to the burgeoning industry of for-profit medical care, Maclean’s details what is available, what it costs and

where to get the services that are increasingly in demand. We also explore private sector firms that offer ways to access public care in a more timely fashion.

more than 100,000 Canadians across the country. (According to Kaplan, Medicard’s share of the medical financing market in Canada is 90 per cent.)

Kaplan, whose husband is the renowned Toronto plastic surgeon Steven Mulholland (there is no connection between Medicard and Dr. Mulholland’s practice), was one of the first to recognize the need for financing for the

growing trend of cosmetic surgery. She started out offering loans for these kinds of procedures. In addition, she simplified the application procedure, so it could be done while waiting in the doctor’s office or even from home.

Kaplan now offers financing for all sorts of private surgical procedures, both medical and cosmetic. Interest rates are about three per cent higher than they are for a conventional loan, she says, because of the lack of collateral. (Larger breasts or a more shapely nose may be very valuable to those who purchase them, but are not considered assets, at least when applying for a loan.)

Most Medicard loans are for less than $15,000. Applications can be made by phone, fax, or email and can be processed in about 20 minutes. Loans for larger amounts require more detailed applications. A.S.


An appointment in days, not weeks

The Specialist Referral Clinic is located across the street from the Cambie Surgery Centre, a private hospital in downtown Vancouver. Both were founded by Dr. Brian Day, a renowned orthopaedic surgeon who will be president of the Canadian Medical Association in August 2007

The clinic offers a simple service: patients phone the centre and tell the secretary what type of specialist they would like to see. Appointments with any type of specialist—neurosurgeons to cardiologists—can be arranged. (Day says all his specialists work in the public system while providing these independent

The very term “private health care” often causes confusion. Some Canadians consider all for-profit facilities to be part of the private system, even when they bill the gov-

ernment for all services, and patients pay nothing from their own pockets. These sorts of facilities—like the Gimbel Eye Centres in Alberta, and the Shouldice Hospital north of Toronto—are now well-entrenched in the public system: so much so, in fact, that when NDP Leader Jack Layton had hernia surgery at Shouldice in the 1990s, he didn’t realize it wasn’t a purely public facility. In any case, the government paid the bill, and that makes it a public facility. “It’s just part of the system,” Layton said this year when questioned about the procedure. “The doctor says, ‘Go there.’ You pay with your [Ontario health] card. It never occurred to me [it was] anything other


than medicare, which it is.”

For the purposes of this guide, private systems are defined, in essence, by who pays. If the patient pays, either for purely private care, or for faster care in the public systempaying a consultant, for example, to jump the queue and gain quicker access to a certain specialist—then the service he’s paying for is considered private.

The amount available across the country varies widely from province to province (see map, page 32). Some, such as New Brunswick and P.E.I., have no private health care providers. Others, namely Quebec and British Columbia, have seen an explosion in growth.

The discrepancy encourages those who

want timely care to travel for it. Out-ofprovince patients have become an important market, and private providers usually cater their services accordingly. The Cambie Surgery Centre in B.C. tells its clientele when they’ll be fit enough to travel home, given that so many of its patients come from out of province. Medical tourism, in other words, is not just about heading to India or the U.S., but is an industry we can call our own.

Quebec has the most comprehensive and advanced private health care in in the country. More doctors have opted out of public medicine in Quebec (lOl) than the rest of the provinces put together (6). There are more

private cataract clinics in the province than anywhere else in Canada. Only in Quebec are there private PET/CT scanners, which are widely considered the gold standard in cancer diagnostic (page 46).

The centre of all this activity is Montreal, which local media have dubbed “the private health care capital of Canada.” The city is home to the country’s first private emergency clinic (page 33), and the only private surgeon in Canada doing full hip replacements (at the Duval Orthopaedic Clinic, page 37). In this city, there are more private cataract clinics (5) and radiology clinics than anywhere else in Canada (16). Only in Montreal can you pay to have your vaccines done at home, or

assessments.) A doctor’s referral is not necessary, nor is waiting: the medical receptionist gets the patient an appointment usually within a week. If the patient does not know what type of specialist he needs, he can talk to a doctor. Most patients already know what kind of specialist they want to see, Day says, because they have already seen doctors in the public system and are looking for a second opinion or exploring their private options.

Currently, all of the specialists patients are referred to are in B.C., and most of them are in Vancouver. However,

Day’s group plans to offer the service in Ontario within 18 months. At the moment, they are searching for Ontario-based partners.

PRICE: $400-$700 for the appointment with the specialist, depending on the type of specialist you want to see. Includes arranging the transfer of the patient’s

medical file, if need be.

PUBLIC WAIT : The time it takes to see a specialist varies greatly between province and type of specialist. For example, in Alberta, there is a median wait of 26 weeks to see an orthopaedic surgeon, but just two weeks to see a cardiovascular surgeon. The median wait time to see a specialist in Canada is 8.3 weeks.*

PRIVATE WAIT: Within two weeks, though usually a week. It may be longer if a specific doctor is requested.

* Wait time information is from Waiting Your Turn: Hospital Waiting Lists in Canada, by Nadeem Esmail and Michael Walker, published by the Fraser Institute in 2005. The median is calculated from the following specialities: cardiovascular surgery, general surgery, gynecology, internal medicine, medical oncology, neurosurgery, ophthalmology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology, urology. A. S.


Knees, hips and Montreal meals

Four years ago, Dr. Nicolas Duval was working at Notre-Dame and St-Luc hospitals in Montreal, utterly frustrated. Renowned for his skills as an orthopaedic surgeon, he spent more time doing paperwork and discussing policy than practising his specialty. “A surgeon’s hands are like a musician’s,” Duval says. “You need to use them, otherwise you get out of practice. In the public system, my operating time kept getting cut back until I was practising only one day a week. I was not allowed to do what I had been trained to do—orthopaedic surgery.”

After opting out of the public system, Duval

your blood work done from the office.

“Quebec tends to look at European models rather than the American system. In France, they have a mixture of public and private health care, and Quebecers know they have one of the best health care systems in the world,” says Zoltán Nagy, executive director of the Canadian Independent Medical Clinics Association. “They don’t really believe in ‘it’s the Canadian way or the American way and there’s no other option.’ They are leading the way because they are more open-minded.”

British Columbia is also far ahead of the rest of the country. There are 14 private clin-


ics in British Columbia doing operations complex enough to warrant a general anaesthetic. They offer a range of adult and pediatric procedures in orthopaedics, urology, gynecology, general, cosmetic, vascular and oral surgery.

And the largest and most technically advanced private hospital in Canada is located in downtown Vancouver (page 38). The Cambie Surgery Centre was founded by Dr. Brian Day, who will become president of the Canadian Medical Association in August 2007 Known as a private health care trailblazer, he also founded one of the country’s only private specialist referral clinics. This service allows Canadians from anywhere in the country to book an appointment with a medical

specialist within just a few days. Patients don’t even need a doctor’s referral. They just phone a toll free number, and arrange for an appointment with whatever type of doctor they need. Once the appointment is booked, the clinic arranges the transfer of the patient’s medical file to that specialist. The service is extremely popular, Day says, and sees thousands of appointments made every year, many for patients from out of province.

There are no private surgical clinics in Alberta, Saskatchewan, Ontario, or Adantic Canada. There are also no private family doctors in Alberta, Saskatchewan, Manitoba, Ontario or Atlantic Canada either. Premier Ralph Klein

might have a reputation for opening the doors to private health care in Alberta—letting for-profit companies become part of the public system—but in terms of services that patients actually pay for, the province is a closed shop. When a private Calgary clinic with 24/7 access to family doctors announced plans to open earlier this year, the province’s College of Physicians and Surgeons sent letters of objection and those plans were promptly shelved.

Those patients who don’t want to wait in line are often referred out of province. It’s very likely that purely private care hasn’t taken off in Alberta because the province has the highest per capita public health care funding in the country, which has lessened the de-

mand for private medicine.

In Ontario, the situation is very different. In June 2004, the Ontario government brought in the Commitment to the Future of Medicare Act. This law built on the existing provincial legislation that banned private clinics from charging for medically necessary services. It also made it illegal for patients to pay for medically necessary services, with a penalty of up to $10,000.

Corporations were liable to a fine of $25,000. Doctors who facilitate the offence can also be fined $10,000, and anyone who knows it’s going on and doesn’t report it can be fined $1,000.

Some private health services that aren’t considered “medically necessary,” such as expedited MRIs, or certain sports medicine or pain management services, do exist in Ontario, and that sector is growing. Because the law demands that, in essence, the government must pay for anything medically necessary, private operators are moving into those areas the province does not classify as such. The Provis Infusion Clinic, for instance, Ontario’s first private cancer clinic, offers drugs that aren’t funded by the public system (page 44).

took out a $2-million bank loan, bought a nursing home, and redeveloped it into a 17bed hospital. Today, the Duval Orthopaedic Clinic in Laval, Que., has treated more than 1,000 patients from across Canada. It is the only place in Canada that does full hip replacements. Patients do not need a doctor’s referral; they can call the centre directly.

PUBLIC WAIT: The national median wait in Canada for joint replacement surgery (hips, knees, ankles and shoulders) from GP to surgery is 49.7 weeks. In some provinces,

two-year waits are not unheard of.

PRIVATE WAIT: 1-4 weeks.

PRICES: Hip replacement: $11,600 Knee replacement: $12,000 Partial knee replacement: $11,000 to $12,000 ACL tear: $6,000 Hip resurfacing: $18,000 Cost includes up to 11 days of convalescence and physiotherapy. If patients develop a post-operative infection, they are transferred back into the public system at St-Luc hospital, where they are covered by their provincial medical plan.

Because Duval works with doctors who have not opted out of public medicine, a portion of the cost is eligible for reimbursement from patients’ provincial health plan. The amount patients have been reimbursed ranges from $1,000 to $2,000 depending on the province and medical situation.

EXTRAS: If patients wish to convalesce for a longer period than recommended, they can stay at the clinic for an extra charge of $200$250 a night. For a luxury room with Internet access, the cost is $400 a night. A.S.


Faster surgery on the West Coast

The Cambie Surgery Centre in British Columbia is the only private hospital in the country where patients can go and buy the operations they need. Located in downtown Vancouver, the centre is a 16,500-square-foot facility, equipped with six multi-specialty operating rooms. There, a variety of specialists perform general surgery, laparoscopic surgery (abdominal surgery with a fibre optic scope), gynecology, neurology, ophthalmology, urology, vascular surgery and dental surgery, as well as ear, nose and throat surgery.

The hospital was founded by Dr. Brian Day, the renowned orthopaedic surgeon who

The differing levels of private care from province to province are in part a function of how open provincial governments are to private medicine. Private clinics are not illegal under federal law. What does violate the Canada Health Act is charging patients for medically necessary services. However, what is considered medically necessary has changed and become more difficult to define, says Colleen Flood. “We used

to have a boundary between what is medically necessary and what is not, but it was between whole categories of services, such as in vitro fertilization, or dental or cosmetic surgery that was considered unnecessary, and hip operations and MRIs that were considered medically necessary. Why else would a patient need a hip replacement unless it was medically necessary? But today, private clinics have started using this grey area of the

law to muddle that distinction. Sometimes hip replacements are publicly funded and then they are considered ‘medically necessary,’ and sometimes they can be privately financed because they are not considered ‘medically necessary.’ These distinctions are more semantic than based in reality.”

In the past, there have been times when clinics have charged both patients and the government for the same medically nec-

will assume the presidency of the Canadian Medical Association in August 2007 In 1986, Day travelled to New Zealand on a factfinding trip to several cost-efficient hospitals. These facilities had streamlined the flow of patients through the building, so their turnaround time for surgery was much faster than it was in the Canadian public health care system. Impressed by what he’d observed, Day brought these plans back to Canada, where he began looking for private investors. In the end it took 10 years, but the Cambie Surgery Centre finally opened its doors in 1996.

Initially, its patients were mostly those covered by third-party insurance—injured workers, members of the Canadian Forces, officers from the RCMP, and prison inmates sent to z the centre by the federal government. Howx ever, Day soon realized that there was a much D wider market—it wasn’t only members of the i Canadian military who wanted faster treatw ment. Now, to keep up with patient demand, ¡ he has expanded the centre’s facilities to serve n more members of the public. Today, his hos-

pital treats thousands of patients a year from across Canada. It also has contracts with local government authorities.

PRICES: Patients at the Cambie centre are charged according to the complexity of their operation. Ankle replacement is $16,000$17,000; spinal surgery $12,000; partial knee replacement $11,500; hip arthroscopy $6,000; shoulder dislocation repair $3,000-$6,000; ACL tear $4,000-$5,000; gallbladder removal $3,800; hernia repair $2,500; hysterectomy $3,000; mastectomy $2,200; cataract $950 (per eye).

These costs do not include post-surgery physiotherapy. Residents of British Columbia pay slightly less because the surgeon’s fee is paid by the provincial health plan. Patients from other provinces can apply for reimbursement of the surgeon’s fee from their own provincial health plan.

PUBLIC WAIT: The national median wait from GP to surgery for joint replacement surgery (hips, knees, ankles and shoulders) is 49-7 weeks. In some provinces, two-year waits are not unheard of. For cataract surgery, the median wait is 28.8 weeks.

PRIVATE WAIT: All surgeries can be performed within two weeks. A. S.

essary service. This is known as “double billing” and violates the Health Act. But enforcement has been spotty. (Last year, the British Columbia government kept track of private clinics charging for medically necessary services by looking through old newspaper clippings.)

Some clinics charge “facility fees” to patients, while passing the doctors’ fees along to the government. Through the 1990s, Ottawa kept a lid on the practice by witholding federal transfer payments to provinces that allowed it. That effectively kept for-profit medical centres confined to elective procedures like laser eye surgery, MRI tests and plastic surgery. With the rise in patient demand, however, some private clinics have found innovative ways of billing patients. For example, Cataract MD combines laser eye surgery with cataract surgery as part of a package.

But in the wake of the Chaoulli decision, there may be no more need for creative ways to stay within the law. Many private heath providers are anticipating that any and all medical services can now be provided on a forprofit basis, and are ramping up plans to expand services and open outlets across the country. “In the wake of the Supreme Court decision, a fully open parallel private system is now allowed,” Brett Skinner says. “Previously, any province that said, ‘We’re going to allow a private payment option, forget what the Canada Health Act says,’ would be punished with the reduction of federal transfer payments. Now I think they could suc-

cessfully go before the courts and argue that that penalty is unconstitutional.”

There remain a number of other restrictions on private health care. For example, doctors are forbidden from providing medically necessary services in both the private and the public system, and

provinces have been reluctant to give hospital licences to private providers. The legal restrictions have meant that not every medical service is up for sale. The most complex operations must be done in a hospital, and private hospitals are few and far between.

Patients who can’t access the care they need in this country can travel outside of


They’ll spell out all your options

Confused by all the possibilities? You are not alone—which is partly why MedExtra came into existence. In 1997, the company’s founder, Dr. Jeffrey Brock, was working as an emergency room doctor in Montreal. A friend was having a hard time sorting out a medical problem in the public system—he was being passed from doctor to doctor and wasn’t getting the treatment he needed. As a personal favour, Brock took his case on, and agreed to work as an unofficial medical consultant.

Brock used his inside knowledge of the health care system to find out which doctors were best suited to treat his friend and to help

him book the appointments he needed. When other people had similar problems accessing health care, he helped them too. Demand for his expertise quickly spread, and in 2001, Brock stopped working full-time as a doctor to launch MedExtra. To date, he has assisted more than 5,000 Canadians.

One of the reasons patients on their own don’t get the care they need, he says, is because doctors don’t have the information they require at their fingertips: scans are often mislaid and pertinent information is not always transferred from one doctor to another. Nor, he adds, do doctors always have time to dig out synopses from five years ago, or decipher pages of illegible physician scrawl.

MedExtra takes care of these details: it gathers the relevant medical information, interviews the patient, and summarizes his case

history in a few pages of notes. Doctors are faxed a “care management overview” with every appointment, so even an overworked doctor can get a full picture of the patient’s health in just a few minutes.

The MedExtra team says it keeps abreast of the latest medical breakthroughs and knows which doctors are using the most advanced techniques. Clients are told about new drugs that are just hitting the market. The company has even imported medications for cancer patients that are not yet available in the public system.

MedExtra lets patients know what their public and private options are, in Canada and the U.S. Private care across the border is almost always more expensive than private medicine in this country, Brock says. “We do whatever we can in Canada, so it’s either covered under medicare, or it’s done pri-

Canada, and with wait lists growing, increasingly they’re doing just that. This has spawned the growth of another industry in Canadamedical brokers and medical travel agents. These middlemen help arrange travel and care at a private clinic, either in another province, or outside the country. Some medical travel agents, such as MedSolution, specialize in out-of-country care. MedSolution has business relationships with hospitals in France, . Turkey and India, and arranges cosmetic and medical procedures at these locations.

Other medical travel

agents, such as Vancouver-based Timely Medical Alternatives, deal only with private clinics in North America. The company offers package deals on hotels and operations at U.S. clinics not more than a two-hour drive from the border.

Patients who pay out of pocket for medically necessary care may be eligible for gov-

ernment reimbursement, says Brian J. Cohen, a health law lawyer based in Toronto. Cohen has represented clients seeking reimbursements for medical services not covered by their government health plans and has won several precedent-setting cases for patients seeking treatment funding, both in Canada and in the United States, for care not previously covered by their provincial plans. Last year, he persuaded the Ontario Health Insurance Plan to pay for a patient to be treated with the colon cancer drug Erbitux at a Buffalo hospital. At the time, the drug had not yet been approved by Health Canada, but Cohen still won the case for reim-


bursement. “If the service is truly medically necessary, then the provincial health plan has to cover the cost, be it in Canada or out,” Cohen says.

Cohen has helped other cancer patients win funding for hospital-based drug treatments available stateside but not in Canada. The U.S. leads Canada by several years in both cutting-edge treatment and drug availability for cancers, stresses William Hryniuk of the Cancer Advocacy Coalition. For this reason, there are several services in Canada that help patients with access to the most advanced cancer care stateside. The consulting firm MedExtra arranges appointments and treatment plans with

renowned oncologists in the United States. These treatment plans can either be followed once back in Canada, or if the treatment is unavailable, pursued at a clinic in the United States. The renowned American cancer clinic M.D. Anderson has a Toronto office, which co-ordinates the travel and treatment of patients seeking cancer care at their clinic in Houston (page 46).

Currently, Canadians still look abroad for the most advanced treatments, or to cut their own waiting times. Frustration with the public system has led U.S. firms to set up shop here in part to funnel patients south of the border. Canadian companies are now capi-

talizing on this same demand. For the hundreds of thousands of patients on wait lists and in pain, this is a welcome shift, Day says. “Canadians are looking to new treatments and technologies to keep them in optimum health, and are happy to pay for what cannot be provided in the public system. That leaves an important role for private health care. The public sector doesn’t have the resources to purchase and utilize these new technologies. This is an interesting and dynamic time in this country. There’s an enormous sense of frustration with the public system. There are close to a million on waiting lists, and these people are tired of putting their lives on hold.” M

vately in Montreal at a fraction of the U.S. cost.” Brock says Canadians pay higher prices in U.S. hospitals than Americans. (U.S. insurance companies buy medical care at a discounted rate and some of this is passed on to their clients.) “So,” he says, “the danger is that when you go down to a U.S. hospital and pay for everything yourself, you are going to end up with a very big bill. You might as well hand them a blank cheque.”

PRICES: Patients can pay by the hour, or they can purchase a membership.

Price per hour: $180.

5 Individual membership: $250 to $500 a year. i Corporate membership: $4 to $50 a month I per employee. “ Membership buys a consultant’s timéis more expensive plans allow more time with £ the consultant. Another membership perk “ is savings on the cost of private health care in Canada and the U.S. MedExtra has relao tionships with 4,000 health care facilities £ across North America, Brock says, and is able a to access discount rates for patients. Ä.S.


How to get a better physical

Executive health clubs, also known as “wellness centres,” offer a more exclusive and patient-centred approach to health care. Clients are mainly corporations, and the aim is to provide every possible service to keep employees fit, healthy and productive.

At the core of the service is an “executive physical.” This is a thorough checkup, including bone density screening, abdominal ultrasound, hearing test, cholesterol levels, fitness appraisals, stress electrocardiograms, blood counts for anemia, glucose count for diabetes risk, uric acid tests for gout or kidney stones.

And if they find a problem? The exact protocol depends on the provider, but many of these centres refer patients to doctors in both private and public medicine. The largest wellness providers, such as Medisys Health Group and Medcan Clinic, have relationships with family doctors and specialists in the public system. “Our doctors, who are practising with us—a lot of them are still practising in the public vein, and so what they may very well [do is take] that individual into their public practice so they are cared for right away,” says Shari Gottschalk, vice-president of sales for Medisys. “We have affiliated doctors in

every major city in Canada to help our 12,000 members. Our doctors are committed to giving the best care possible to Medisys members. We try to do whatever is needed, whenever it is needed.”

Medisys will also coordinate the care of patients who choose medical treatments stateside. The company has relationships with many U.S. health care facilities, so it can often offer savings on the price of treatments across the border. For U.S. procedures, a Medisys doctor will manage and oversee a client’s medical care so that the patient receives the right treatment and is not overcharged, Gottschalk says. The company also sends the treating physician an electronic copy of the patient’s medical file.

One of the ways in which Medisys guarantees timely treatment for its members is through a provision in the Canada Health Act that is often referred to as “third party pay.” Initially a provision that allowed workers’ compensation board cases, members of the armed forces, and the RCMP to receive immediate treatment, this provision is now interpreted more loosely. Patients who have a third party (such as an employer) paying the cost of their medical bills can often avoid waiting in line. Timely treatment is also facilitated through the use of Medisys facilities in Quebec. Members can avoid waiting for an MRI or CT scan in their own province in the public system by using the private company’s facilities in Montreal.


Annual executive assessment: $800-$l,200 Concierge service (“Medisys One”) includes

24-hour hotline, coordination of specialists’ appointments, 24/7 access to nurse or doctor. Concierge service for companies: $1,000-$1,500 per employee, depending on the number of employees who sign up.

Concierge service for individuals: $1,500. Corporations have access to a number of other services, such as disability management, which helps facilitate unwell or injured employees’ speedy return to work and which also manages the claims of those workers. (Medisys is partnered with the Sun Life Financial insurance company.)


Sun, sea, sand and a new set of knees

Until recently, sun, sea, sand and new knees were rarely sold together as part of a package. But the rise of medical travel agents (or medical brokers) is making these kinds of trips much more common and convenient.

It might seem like a tiny niche market, but eight Canadian companies (seven of them based in B.C.) offer such a service. The destinations are as wide-ranging as the surgeries on offer. Some medical travel agents place patients in private clinics in Canada and the U.S. Others look farther afield to clinics in India,

Thailand, Malaysia, Singapore, France and Turkey. Often the destination is tied to a particular specialty—the Krishna Heart & Super Specialty Institute in Ahmadabad, India, for instance, has a good reputation for cardiovascular treatments and, according to one agent’s website, excellent vegetarian cuisine.

To succeed in this business, a medical travel agent must gain the trust of the patient travelling: patient testimonials, resumés of doctors, and calls to their offices before the trip are often part of the service. What is rarely, if ever, included is any post-operative care back in Canada. Physiotherapy and followup are the patient’s responsibility and if done privately should be factored into the cost.

One of the medical travel agents operating in Canada, Timely Medical Alternatives, sends patients to private hospitals in Canada and the U.S. In Canada, the company uses three centres—False Creek Surgical Centre in Vancouver, Maples Surgical Centre in Winnipeg, and Westmount Square Surgical Center in Montreal. For treatment in the U.S., Timely Medical uses hospitals that are within two hours’ drive of the U.S. border.


Partial knee replacement:

C$14,000-$l6,000 Discectomy (spinal surgery for ruptured disc): C$5,000 Gallbladder removal: C$6,500 Hernia repair: C$3,000-$7,000 Cataract surgery: C$2,000 MRI with high resolution: C$755 CT scan: C$575

Total knee replacement: C$18,000 Shoulder replacement surgery: US$23,000 Total hip replacement: US$19,000 Removal of kidney stones: US$4,500 Tissue biopsy: US$1,800 Tissue biopsy analysis: US$220

Prices are in Canadian dollars when the operation is done in Canada and in U.S. dollars when the operation is done in the United States. Prices include hotel for an accompanying family member for up to four nights. Prices do not include travelling costs.

Another company, MedSolution, sends patients farther afield. It has relationships with hospitals in Ahmadabad, Istanbul, and three facilities in Paris. Prices vary according to the destination. Sample prices here are for surgery in the Krishna Heart & Super Specialty Institute in Ahmadabad:

Partial knee replacement: US$6,100 Total knee replacement: US$6,725 Coronary angioplasty (opening clogged arteries): US$3,700 Total hip replacement: US$5,800 Hip resurfacing: US$8,500 Gastric bypass: US$16,500 These prices do not include travel costs, visa and passport fees, or medical treatments for unanticipated illnesses occurring prior to the surgery. A.S.


Alternatives to going blind

Cataracts are the gradual clouding of the eye’s natural lens—an aging process that for at least 50 per cent of the population has started by the age of 80. Left untreated, cataracts cause fuzzy vision or even total blindness. Cataract clinics are one of the points at which the public system is colliding with patient needs and market forces. Many people, especially in provinces like Newfoundland, Saskatchewan, P.E.I., Nova Scotia, and Ontario, which have long wait lists, have found they don’t particularly like putting their lives on hold for months for such a simple surgery. They’d be happy to jump the queue even if it means paying.

To meet the demand, private cataract clinics are proliferating across the country. Montreal-based Cataract MD plans to open an Ottawa office this summer, and then another one in Vancouver in the fall. The company says it will throw in corrective laser eye surgery for free with cataract surgery.

CATARACT PROCEDURE: The damaged lens is replaced with an artificial one. The operation takes around 20 minutes for one eye and requires just a minor anaesthetic. PUBLIC WAIT: Median wait is 34 weeks from GP to surgery in Ontario, and 28.8 weeks from GP to surgery nationally. PRIVATE WAIT: One week.

PRICES: $l,500-$3,000 per eye depending on the type of lens requested. A.S.


Better screening, newest drugs

Should you develop cancer, where you live will help determine your chance of survival. British Columbians and Albertans have better survival rates for many types of cancers than Ontario residents. This isn’t a coincidence, or anything to do with a passion for jogging, or the quality of the mountain air. It’s a matter of money, and which province pays for what, says Bill Hryniuk, an oncologist and chairman of the Cancer Advocacy Coalition of Canada. The governments of Alberta and British Columbia give more money per capita to cancer care than does Ontario, so patients in these provinces have better access to drugs and cutting-edge treatments.

Patients who want to improve their chances have a number of options. Among them: PET

(positron emission tomography) scans, which are difficult to access in many provinces. This scan is a valuable tool in fighting cancer, says Dr. Jean-Luc Urbain, who specializes in nuclear medicine at St. Joseph’s Health Care in London, Ont. Unlike the more commonly used CT (computed tomography) scan, the PET scan pinpoints on a molecular level where the cancer has spread in the body. This means it can detect cancers CT scans would miss. It can also help stage the disease, so patients know whether the cancer has metastasized, and can choose the right form of treatment. (See private PET scan section, page 46.)

It’s vitally important that patients find out everything they can about their disease, says Dr. Jeffrey Brock, who runs a medical consulting firm, MedExtra (page 40). He says patients should do their own research because Canadian oncologists don’t always explain all the options. “In Canada, oncologists have adapted their care according to the scarcity of resources,” says Brock. “Often the mentality is, ‘Oh, we can’t use that [drug], it’s very expensive; it’s off label. Let’s save it for later.’ But saving it for later means the cancer has spread.”

For example, Avastin is a first line, or ini-

tial, drug therapy for advanced colorectal cancer in the United States. It works by stopping the growth of new blood vessels, which starves the tumours and prevents them from growing. Because it works so well, it is also being tested for advanced lung, pancreatic, ovarian and breast cancers. In Canada, the drug was approved by Health Canada for colorectal cancer last September, although only B.C. and Manitoba are funding it. “Avastin is a blockbuster drug,” Hryniuk says. “It prolongs the lives of patients with advanced colorectal cancer, which is the second leading cause of cancer deaths in Canada.”

The story is the same for many of the latest cancer drugs available in the United States. Even when a drug is given the go-ahead by Health Canada, it can take several years before a province decides to fund it. Certain drugs, such as Zevalin for non-Hodgkins lymphoma and Iressa for lung cancer, that have a proven record of success, are often available in British Columbia but are difficult to access in other parts of the country, Hryniuk says. Hryniuk practised oncology in B.C. for two decades and in the United States for 10 years before returning to Canada, to settle in Dundas, Ont. He believes the Canadian system is mired in bureaucracy, making it harder for Canadian oncologists to provide the best treatments for their patients. “There is no national cancer program in Canada. Nor is there any co-operation or sharing of information between the provinces,” Hryniuk says. “So although the quality of care people receive in B.C. is very good compared to the United States, in the rest of the country it lags several years behind.”

These discrepancies have created a market for private health care providers, who offer the following options:

1. Provis Infusion Clinic

This Toronto clinic lets patients buy cancer drugs either not covered by their provincial health plan, or not cleared for their specific type of cancer. On-site oncology nurses and doctors oversee treatments. Patients must be referred by their oncologist or a hematologist. Currently the clinic offers Alimta, Avastin, Gemzar, Rituxan, Velcade and Zometa. The price of these drugs is about half what Canadian patients would pay in the United States, says Graham Vincent, the clinic’s chief operating officer.


Colorectal cancer {Avastin): $4,500 to $6,500 per month. Patients receive two treatments a month.

Multiple myeloma (Velcade): $10,000 for one cycle, which is four treatments. Patients start a new cycle every three weeks.

Payment must be made in full prior to each cycle of treatment.

2. Ultrasound treatment for prostate cancer

The most cutting-edge treatment for prostate cancer is the high-intensity focused ultrasound, often abbreviated to HIFU. With the patient under anaesthetic, a rectal probe fires highly focused ultrasound waves at the prostate, burning off cancerous tissue without damaging surrounding organs. The operation takes less than three hours—compared to weeks of radiation—and hasn’t the risk of incontinence and impotence from a radical prostatectomy. Currently, there are two operational HIFUs in Canada, both privately operated—one in Windsor, Ont., and the other in Toronto.

Don Mills Surgical Unit, Toronto PRICE: $21,600.

HIFU is not available in the public system, although it has been approved for use by Health Canada.

MAXIMUM WAIT: Two weeks.

International Prostate Centre,

Windsor, Ont.

PRICE: $22,000.

MAXIMUM WAIT: Three weeks.

3. Treatment in the U.S.

There are a number of businesses in Canada that facilitate travel to the United States for cancer care. M.D. Anderson has an information office in Toronto to coordinate medical treatment at its Houston hospital (page 46). Some executive health centres, such as Medisys and Medcan Clinic, offer medical consulting services and will facilitate care in the U.S. if necessary. Medical travel agents (page 42) also provide this service.

PRICE: The pricing structure varies widely depending on the provider. Some companies, such as Medcan, charge a flat fee. Others bundle the service as part of a larger health package.

4. U.S. treatments In Canada

Patients who wish to explore their U.S. options can arrange an appointment with a U.S. oncologist through the medical consulting firm MedExtra (page 40). After that appointment, if a patient prefers to be treated in Canada, the U.S. doctor will compile a treatment plan to be followed once he or she is back in the country. “We

use world-class institutions,” says Dr. Jeffrey Brock, “such as the Dana-Farber Cancer Institute in Boston or Sloan-Kettering in New York. We arrange for a second opinion from these places about how cancers should be treated, and we pass on these recommendations to the patient’s oncologist in Canada. If the patient needs drugs that are not available in the public system, we can arrange them.”

Brock adds, “Of course, in these cases, the patient needs a prescription from their oncologist or treating physician, and the treating physician has to oblige. And for the most part, they’re good at obliging. Doctors want to help their patients, and we make their job much easier.”

PRICE: The cost of an independent second opinion depends on the choice of clinic. The approximate range is from $1,000 to $1,700.

PRIVATE PET SCAN: PET scans are considered the gold standard in cancer diagnosis in every G8 country. In Canada, access depends on the province. Quebec and B.C. fund the scans, but in Ontario they are still in clinical trials. There are four private PET scanners in Canada—two in Montreal, one in Vancouver and one in Mississauga, Ont. The two Montreal clinics offer the most upto-date technology, the PET/CT, which combines the PET scan with a CT scan.


Ville Marie PET/CT Centre, Montreal PET/CT scan: $2,500.

CT scan: $300.

Virtual colonoscopy: $850.

PRIVATE WAIT: 24 hours.

PUBLIC WAIT: Depends on the province. Widely restricted in many provinces, including Ontario. A.S.


Your U.S. options made easy

This spring, the Ohio-based Cleveland Clinic announced it would establish its first Canadian office. Cleveland Clinic Canada is scheduled to open in the heart of Toronto’s business district later this summer. The new facility will offer patients “health and wellness consulting” and will also provide information about health care options in its main U.S. clinic.

It is the second American hospital to branch into the Canadian market. In September 2003, the world-renowned M.D. Anderson Cancer Center opened a Toronto office. Patients may be referred by their oncologist or they can book an appointment themselves. The centre helps patients collect their medical information and refers them to an M.D. Anderson travel agent, who arranges their trip to the hospital in Houston, Texas.


M.D. Anderson

The cost of treatment is decided once a diagnosis has been made. Treatment prices depend on the type of cancer, and range from US$30,000 to US$1 million.

Cleveland Clinic Canada Treatment costs are decided after a diagnosis has been made. The clinic declined to comment on prices. A.S.


Getting medicare to pay the bill

In December 1995, Barry Stein was diagnosed with colorectal cancer. The Montreal lawyer was booked into the operating room three times, but each time, the surgery was rescheduled. Stein realized he would most likely die if he continued to wait, and so he went to the U.S. for private treatment.

The treatments (months of vaccines, operations and chemotherapy) were lengthy and expensive. Stein’s medical costs were approximately $250,000. Since the treatments were not available in Canada, Stein believed the Quebec government should foot the bill. He sued for full reimbursement, and won. Today, Stein, now the president of the Colorectal Cancer Association of Canada, receives about five calls a day from patients with questions about health care and government reimbursement. Some are in pain, and want more information about their private options. Many have cancer, and are having problems accessing the drugs they need.

Stein is licensed to practise in Quebec only. To access other lawyers specializing in health policy, patients should call their provincial law society. While they are not lawyers, “patient advocates” do specialize in the area of health policy. The Macleans directory on page 48 lists patient advocates and health-policy lawyers.


Lawyers charge $250-$750 an hour.

Patient advocates charge about $80 an hour. Payment plans are available. Pro bono work is assessed on a case-by-case basis. A.S.