Dr. Brian Day @DrBrianDay Twitter

  • Past President Canadian Medical Association
  • Past President Arthroscopy Association of North America
  • Honourary Associate Professor University of British Columbia
  • 2014 Doctors of BC Don Rix Leadership Award

Operating on the Fringes

Mar 01, 2004

MD Canada Magazine

Operating on the Fringes

As pressure mounts on all sides, medicare prepares to go to court

By Jennifer McLaughlin

All Canadians will one day again enjoy the right to buy any kind of medical care anytime they want or feel the need to do so. That, at least, is what Dr. Brian Day, an orthopedic surgeon in Vancouver, thinks will happen.

And he thinks that day could come in the very near future.

Dr. Day, president and CEO of the privately run Cambie Surgery Centre in Vancouver, is headed to the Supreme Court of Canada to fight for private medicine.

In January, a group of private clinics, doctors and patients led by Dr. Day was granted intervener status in a court case that could end the public system's monopoly on health care. The plaintiffs are Dr. Jacques Chaoulli and George Zeliotis, two Montrealers whose challenge to Quebec's version of the medicare legislation has been before the courts since 1999.

Another group granted intervener status consists of 10 senators led by Senator Michael Kirby -- he of the Kirby Report into medicare that preceded the much ballyhooed Romanow Report.

Other interveners include the Canadian Labour Congress, the Canadian Medical Association and the attorneys general for many of the provinces. Without a doubt, they will support the Canada Health Act and its corresponding provincial legislation.

George Zeliotis is a 71-year-old retired businessman. In 1996, he needed hip replacement surgery to treat an extremely painful condition that rendered him both largely immobile and unable to enjoy the quality of life he felt he had the right to pursue. However, the waiting list for the surgery in Quebec was nearly a year.

Despite his complaints and appeals for help, there was nothing the health care system would or could do for him. He was told he would simply have to wait his turn.

Dr. Jacques Chaoulli is a family doctor, trained in France, who opted out of Quebec's medicare regime. A colourful character, Dr. Chaoulli is perhaps best known for the portable emergency room he parked in his driveway -- a white van with the words "Emergency Care 24 Hours" painted on its sides. It was equipped with a portable X-ray machine, IV equipment and most of the trappings of a small emergency department.

However, Dr. Chaoulli was told that he couldn't use his little rolling private hospital, that he couldn't admit patients to a public hospital after opting out of the Quebec medicare system.

George Zeliotis and Dr. Chaoulli teamed up to challenge sections of two Quebec laws that respectively forbid Dr. Chaoulli -- and all other opted-out physicians -- from providing medical care in the province's hospitals, and his prospective patients from buying private health care insurance to pay for the care he provided.

The plaintiffs say that not being able to pay privately for health care services -- and therefore being left to wait in long public lineups for elective surgeries and treatments -- violates the rights to life, liberty and security granted in Section 7 of the Canadian Charter of Rights and Freedoms.

After a four-week trial that heard from nearly two dozen expert witnesses, Justice Ginette Piché of the Quebec Superior Court disagreed. She stated what many Canadians already believe: that a parallel private system would threaten the viability of the publicly funded health care system. The rights of the individual need to be balanced with the needs and values of the whole society, she added.

And that, it should be noted, is the crux of the prevailing pro-medicare argument: not that Canadians don't have a right to private care, but that the greater public good requires that the law abridge those rights.

The appeals court in Quebec agreed.

But, to the considerable surprise of many observers, the Supreme Court has given the doctor and the patient leave to appeal. Arguments are to be heard on June 8, 2004.

Despite the overwhelming challenge of confronting the entire medicare establishment, Dr. Day is unfazed. He believes the plaintiffs will win and that health care will be forever changed for all Canadians. And that, he says, is because he has the evidence that hasn't been used at the lower court levels: Canadian-made examples of how private health care works.


FOR MANY CANADIANS, the notion of private health care conjures up a frightening image in which health care becomes unaffordable for the middle class and unavailable to the poor.

But there are two facts that most Canadians don't know. The first is that Canada is one of only two nations on the globe with a universal public system that forbids a parallel private system; the other is North Korea. (Both China and Cuba have adopted parallel private systems in recent years.)

The second is that all of the European countries -- including France and Sweden, which regularly top the international quality-of-health-care surveys -- have long had a mix of public and private care. "It's a race to see which country, Canada or North Korea, will hold out the longest with its universal plan," says Dr. Day.

But there is another thing most Canadians don't know. It is that Canada already has a grassroots private health care system. "Right now, private health care exists on the fringes," says Dr. Edwin Coffey, a retired ob/gyn and a past president of the Quebec Medical Association who is an expert witness for Dr. Chaoulli and George Zeliotis. "It is evolving in a grey zone."

It's in that grey zone that Dr. Day lives and works. In 1996, he opened the Cambie Surgery Centre because, he says, he had concerns about the diminishing availability of surgery time in public hospitals in B.C. He says that in the early 1980s, he was allotted 17 hours per week of OR time. And, at that time, waiting lists for surgery were short. But by 1995, his OR time had been reduced to five hours a week and he had over 400 patients waiting for surgery. He blames increasing costs of technology and the rationing of health care for the lack of OR time and, as a result, the long waiting times.

Waiting times for surgeries vary by province and by procedure. But according to Waiting Your Turn: Hospital Waiting Lists in Canada, an annual study produced by Vancouver's Fraser Institute, a conservative think tank that has never been friendly to the concept of socialized medicine, mean waiting times (from general practitioner to treatment) for cornea transplant, hip replacement and knee replacement surgery are 50, 52 and 52 weeks respectively. This is modest compared with Dr. Day's estimates for waiting to see a orthopedic surgeon in the public system, which he says is one year to 18 months.

Today, the Cambie Surgery Centre is approximately 17,000 square feet and has six operating rooms. (There are only five at the University of British Columbia Hospital -- the nearby public facility.) About 150 doctors, along with 50 nurses, treat about 3,000 patients per year at the centre. All doctors must be fully accredited by the facility and licensed by the College of Physicians and Surgeons of B.C. to work at the centres. Most of the medical staff also hold faculty positions at the University of British Columbia.

Cambie carries out a wide range of surgical procedures. But despite the fact that these facilities exist, the majority of British Columbians can't access them for medically necessary surgeries. As private medical centres, they can only treat those who aren't covered by the Canada Health Act and B.C.'s provincial legislation. Those who fall outside the legislation include foreigners, RCMP and Armed Forces members, people from First Nations, veterans, motor vehicle accident patients covered by collision insurance, some federal employees and -- believe it or not -- even federal prisoners.

In 1999, Dr. Day was able to negotiate a private "parallel" system for another specific group of Canadians that falls outside the legislation -- injured workers. He approached the Workers' Compensation Board (WCB) of B.C. and created the first contract between it and a private clinic to expedite access to surgery for injured workers. Today, Dr. Day says the WCB pays for about 50% of the surgeries carried out at Cambie. "People have the perception that the majority of people we see are those who can afford private health care," he says. "When, demographically, it's really the working class."

The contracts between the WCB and private clinics started because of the waiting lists in the province, says Gord van der Eerden, senior manager of health care provider services at the WCB. "Here in B.C., our surgeons just can't get enough operating time to handle their case loads," he says. He adds that the WCB first tries the public hospitals before looking at private clinics for surgeries. This way, the worker remains close to home, can easily access rehabilitation therapy and has the support of family nearby. But as waiting lists in the public system began to lengthen, it became harder to get OR time in the hospitals. In the past, surgeons had been able to accommodate the WCB's needs during off-hours, such as Sunday mornings. "We didn't want to displace public patients," he explains.

Last year, the WCB sent 1,900 injured workers to private clinics for surgery. (It has contracts with 14 such clinics in B.C.) "We do believe we are providing a better standard of care," Gord van der Eerden says. "Surgeries are done about 22 weeks faster than the public queue." It's a fact of workers' compensation that the longer a worker is off work, the less likely he or she is to ever return. Cutting the waiting time dramatically affects the number of workers who make it back into the work force. And, at an average wage loss of $500 a week, the WCB is substantially reducing its costs.

The WCB, however, pays more for the surgeries. "We're paying the doctors two-and-a-half times what they would receive in the public system," Gord van der Eerden explains. But he adds that it's hard to measure how much the WCB might be saving by using the private clinics. "Injured workers who require surgery only represent about six percent of the total," he explains. "It's not a dramatic effect when you are talking about hundreds of thousands of injuries."

Private clinics in B.C. aren't taking surgeons out of the public system. In fact, they are required to work in the public system, but they just can't get the operating time they need for their public patients. "Last year, I was allotted four hours a week in the public system," says Dr. Day. (This year, Dr. Day is on sabbatical from the public system while he serves as the president of the Arthroscopy Association of North America.)


IT'S THE RATIONING of health care that caused Dr. Mark Godley to look outside of the public system. Dr. Godley graduated from medical school in 1997 as an anesthesiologist. At the time, rationed health care had already begun controlling the way health care dollars were spent, he says. "Many operating rooms had been shut, and with the shutting down of operating rooms, there was a relatively large number of anesthesiologists for the amount of that work in Vancouver," he says. He wanted to stay in the city and decided to open a surgical facility, False Creek Surgery Centre. (It is also listed as an intervener in Dr. Day's group that is going to the Supreme Court.)

At the start, Dr. Godley teamed up with plastic surgeons and focused on uninsured cosmetic surgeries. As the facility grew, and he was able to purchase more and better equipment, he wanted to expand the facility's procedures. He too, approached B.C.'s WCB and now has a contract with it.

Dr. Godley's surgeons also participate in the public system. "Most of the work they do is in the public system," he says. "If they could access more time to provide service for patients in the public system, they would. But obviously, they can't."

The experience in Alberta is similar. Dr. Stephen Miller is the CEO of the Health Resource Centre in Calgary. In addition to WCB patients, the centre sees a lot of patients whose employers are privately insured (rather than through the WCB). "In those cases, the company makes the initial referral to us for the employee," Dr. Miller explains. He adds that the centre is shortening the public health care lineup in his province. "Alberta residents are waiting an average of eight months for surgery," he says. "We take about 50 to 100 people out of the public waiting list [per month]. It moves Albertans up a few spaces per month."

He adds that he requires surgeons who work at the Health Resource Centre to maintain their public system privileges. "They are fully in the public sector," he says. "I don't want [surgeons] to leave the public sector because private surgeries pay more."


WHAT IRKS DR. DAY is how much tolerance Canadians seem to have for waiting and how much complacency they have for the Canada Health Act -- it's what he calls the country's "sacred cow".

It's the speed of service to those patients from the WCB and the value that the private sector could bring to health care that Dr. Day wants to explain to the Supreme Court.

Waiting has a tremendous effect on the patient, Dr. Day says. "The effects include emotional distress, increased pain and suffering, medical complications and negative economic consequences," he adds.

Dr. Day says that on an almost-daily basis, British Columbians come to the Cambie Centre looking to pay for the elective surgeries they are waiting for in the public system. Cambie turns them down. Most are frustrated with the long waiting time in the public system; many are enraged when they find out the surgery could be done at Cambie -- except for the fact that the legislation prohibits it. "We send many desperate patients offshore, to the United States, Europe and elsewhere," Dr. Day says.

"Canadians have to realize the private sector is going to help the public sector," says Dr. Day. For example, of the 150 surgeons who work at Cambie, 35 would not have stayed in Canada were it not for the work they receive from private clinics. "It's job retention for doctors," he says.

Like any for-profit business, private clinics aim to control costs -- often with less administration -- and funnel some of the profits back into the business to purchase and update equipment. "In the public system, there are no funds to upgrade equipment," says Dr. Day.


DR. COFFEY, the former Quebec Medical Association head, has been acting as the expert witness for Dr. Chaoulli and George Zeliotis in their legal proceedings. "There were about seven or eight witness for the defendants, [the attorney general of Quebec and the attorney general of Canada,]" says Dr. Coffey, who is also a research associate at the Montreal Economic Institute. "Each said that if you allow Canadians, individually, to buy private health insurance, it will threaten the integrity of Canada's medicare system, and in fact, could even destroy it."

Dr. Coffey says he believes some of the interveners, including Dr. Day's group, may have arguments that go beyond the scope of Dr. Chaoulli's. For example, Dr. Chaoulli is asking that non-medicare doctors be allowed to admit patients to public hospitals. But it's a theoretical argument, since there are very few physicians who have opted-out, Dr. Coffey acknowledges.

Dr. Chaoulli's argument doesn't address participating doctors, but whether a doctor and patient could create a contract outside of medicare. Dr. Coffey concedes, however, that any right given to non-participating doctors would likely have to be afforded to doctors who are in the system as well.

To date in the courts, Dr. Coffey has tried to use the European experience to show that it's possible to have a universal system along with a private system. There, citizens have access to universal health care coverage, but they are free to buy additional private health care -- and insurance to pay for it -- for the same services the public health care system covers. "And if at the time when they need a breast biopsy done, they can't get one in a public hospital, they go to a private hospital," explains Dr. Coffey.

One key concept of the European systems that often gets overlooked is that people can't opt out of paying for the public system. They continue to support it with their tax dollars even if they choose to buy other, more or faster service at the same time.

Some European systems also involve user fees for citizens who have a certain income level. "User fees give people a little more discipline when using the services," says Dr. Coffey, adding that they also bring in a little more funding from the private sector. "When you look at the systems in Europe and you see how well they run when they have exactly what you are fighting for, it makes you assume if the court does its research and reads the material that is sent into it, it's hard to believe that it won't see that we have over-legislated when it comes to the health care sector," says Dr. Coffey. "We have unjustifiably restricted the freedom of individuals in this country."


ONE OBSTACLE that a private health care system faces is what is called "the fairness argument". Is it fair that some people could use their own financial resources to buy a service that might get them health care a little bit faster than their neighbour, who doesn't have or may not want to use their own money to pay for the service?

Dr. Coffey says this moral argument only belongs in the public lineup. "Suppose you go to a public hospital for a hip operation and you try to pay your way through," he says. "You offer the doctor some money or you pay the administrator to get in faster. That's illegal and immoral because you are actually trying to buy your way ahead of a line that is designed for everyone in the medicare plan."

But the patient who never enters the public lineup and goes directly to a private clinic does not take anyone's place in the public line. In fact, he allows that line to proceed more quickly by staying out of it. And the fairness of the alternate arrangement is further bolstered if the private patient continues to fund the public system through his or her taxes.

Dr. Miller, of the Health Resource Centre in Calgary, offers the following example for the fairness argument: an electrician hurts himself on the job and ends up with a torn ligament. "With one day's notice he can get an appointment at my clinic [through the WCB]," Dr. Miller says. "He would have surgery within three weeks and after that he could expect rehabilitation and physiotherapy for 12 to 24 weeks." Now, let's say his spouse, a homemaker who is subject to the provincial acts and the waiting lines, happens to fall at home and incurs the exact same injury. "The spouse would wait eight to 10 months to see the orthopedic surgeon [in Alberta] and 12 to 18 months for surgery. No rehabilitation. No physiotherapy," he explains. "It's grossly out of whack."

The same holds true for three skiers who collide in Whistler, says Dr. Day. "Let's says a Frenchman, an Austrian and a British Columbian collide and they all incur the same knee injury," he says. "The Frenchman and the Austrian could be treated right away and the guy from B.C. would have to go to the U.S. or wait in line."

"The biggest provider of private medicine in Canada is the U.S.," says Brian Lee Crowley, president of the Atlantic Institute for Market Studies (AIMS) in Halifax.

But Canadians do not necessarily have to leave the country. Out-of-province Canadians can also go to private clinics, even though they are waiting in the provincial public lineup. An Ontarian, for example, could travel to Vancouver for a surgical consultation and then schedule the surgery three or four weeks later. The tab for the surgery could be picked up by his provincial government (in this example, Ontario) or another third-party insurer. Or, he could pay the bill himself.


ANOTHER WAY AROUND THE PROBLEM of long waiting lists is with what is being called a "care guarantee", says Patrick Monahan, Dean of Osgoode Law School at York University. He and two other Toronto lawyers are acting on behalf of Senator Michael Kirby in his intervention in the Chaoulli/Zeliotis case.

"We are supporting Dr. Chaoulli in his argument that the existing system, which says you have to obtain medically necessary services through the publicly funded health care system while, at the same time, you are forced to wait, does violate the constitutional rights of Canadians," says Patrick Monahan. However, he adds, "We're saying that the court should suspend any declaration of invalidity for a couple of years to give government the time to either restructure the system or take appropriate action to deal with this constitutional violation."

And that restructuring, the Kirby group will argue, should include care guarantees.

A care guarantee would mean the provinces would set standards for how long a Canadian should have to wait in the public lineup before receiving treatment or surgery. If a patient couldn't access the services needed by that guaranteed time limit, he or she could obtain the service privately in Canada or elsewhere and bill the public system. "A care guarantee is one way the government could respond to the constitutional violation that we are arguing exists," Patrick Monahan says. "It would give an assurance to Canadians that they are going to get care in a timely way in their own country," he says.

In a way, the concept of the care guarantee already exists in Canada -- as became clear in one of the cases brought into evidence when the Chaoulli/Zeliotis case first went to trial. It is the case of Montreal lawyer Barry Stein. Suffering from colon cancer in 1996, he needed treatment, but was repeatedly bumped down the waiting list. Finally, in desperation, he went to the United States and had the necessary treatment, for which he was able to pay out of his own pocket.

However, Barry Stein then went to the Régie de l'assurance-maladie du Québec and asked them to reimburse him for his medical expenses. They flatly refused. Barry Stein took the case to the Quebec Superior Court in 1999 -- and won. His medical expenses were paid.

But Patrick Monahan admits that a care guarantee doesn't address whether the provinces can afford to pay for health care.

The Canadian Medical Association is also weighing in on the case. "Canadians have recognized that access to timely, quality health care is in jeopardy," says Dr. Sunil Patel, president of the CMA. "It is worsening day by day."

The CMA has teamed with the Canadian Orthopedic Association to intervene in the Supreme Court case. Though they do not support Dr. Chaoulli and George Zeliotis in their quest to have parts of the Quebec legislation and Canada Health Act struck down, they will ask the Supreme Court to address the undue delays in treatment. "The CMA believes in a strong, publicly funded, single-payer system that meets the needs of Canadians," Dr. Patel says.

But, right now, Canada is in a crisis position, Dr. Patel adds. "Accessibility has been eroded over decades. We need to shore up the publicly funded system to make sure it can provide care to patients." And, if the system can't provide the care, the governments -- and they alone -- are responsible for providing alternatives. "Governments will have to make hard decisions," says Dr. Patel. "We would hope that it would never have to happen, but if they are unable to provide the care, then they must be responsible to Canadians."


IF PRIVATE MEDICINE IS VETOED, how could the governments remain accountable to Canadians? One answer is more money. "The sustainability of the health care system in Canada is the greatest public policy challenge," says Brian Lee Crowley of AIMS. "There is this incredible mismatch in the [ability of the] public sector to pay for health care services and the demands of Canadians for those services."

And this year, that mismatch is being played out again. At the end of January, Prime Minister Paul Martin announced an extra $2 billion for health care. By the first week of February, the provinces were already saying it wasn't enough. "There are no incentives to improve productivity in the health care system as it is currently structured," says Brian Lee Crowley.

And even if more money were the answer, "Canadians have no appetite for higher taxes," says Dr. Day.

So while the provinces try to determine how they will manage public health care, private clinics continue to sprout up and thrive. "Governments are trying to turn a blind eye because they realize that they work and people are happy," Dr. Coffey says.

"The provinces used to do everything they could to obstruct private health care," adds Brian Lee Crowley. Today, the obstructions are at the level of rhetoric. "They know they are unable to stem the tide."

The Supreme Court case is a Catch-22 for the provinces, says Dr. Day. "They have to defend their bad law. Medicare has become the sacred cow, but it's not a viable system." In fact, he says, it's a formula for bankruptcy. Twenty years ago, health care represented 30% of federal spending. Today, health care represents 43%. And at the rate it is growing, he adds, "statistics show that by 2020 it will be 100%."

Says Dr. Day, "Clearly that can't happen. The best thing that could happen for the provinces is for them to lose [the Supreme Court case]."


IN FEBRUARY, Alberta Premier Ralph Klein flirted publicly with the idea that Alberta might be prepared to break free from the Canada Health Act in an effort to save public health care.

It was, if nothing else, a measure of how much pressure the system is under. The premier publicly mused that the province might be prepared to face the consequences of opting out of the national system and losing its $1.3 billion in annual federal health care funding.

Alberta, Ralph Klein says, will measure the cost savings it could achieve -- without medicare -- against the amount that would be lost.

Shortly before that announcement -- in a smaller, but no less public forum -- former Quebec health minister Claude Castonguay (more affectionately known as the father of the Quebec public health insurance plan) told a group of about 150 people at the Montreal Economic Institute that the time had come to modernize the Canada Health Act. "The combined effect of significant changes over the past 30 years means that our health system is no longer able to respond adequately to public needs," Claude Castonguay said.

In the past, forbidding a private system and the absence of freedom of choice were justified while the health system met the needs of Canadians adequately, he added. "Prohibiting private care by invoking the principle of accessibility is in direct conflict with an individual's fundamental right to health and deprives the individual of his or her freedom of choice. Nevertheless, it is not impossible to reconcile the right to health with the maintenance of a universally accessible public system."

User fees and a parallel private system are two ways to address the financing burden, Claude Castonguay suggested.

The public may be starting to see things the same way. A survey conducted by Leger Marketing for the Montreal Economic Institute suggests that Quebecers are ready to pay for their own health care. The poll indicates that 71.7% of Quebecers would support faster access to health care for those ready to pay for private services, while maintaining the public system. And, about 67% indicated that the federal government should leave all health care management and financing to the provinces.

Dr. Coffey says Quebec has always been a leader when it comes to change and he looks forward to the Supreme Court hearing.

June 8, 2004 could be a very interesting day in Canadian medical politics. Though ramifications of a decision in favour of Dr. Chaoulli and George Zeliotis are uncertain, a formal private parallel health care system could be the long-term result.

Of course, it will take the Supreme Court up to a year to render its decision.

"Chaoulli and Zeliotis will be held up as the heroes for health care freedom in Canada, if they win," Dr. Coffey says.

Jennifer McLaughlin is managing editor of MD Canada.



Medisys Health Group Inc. -- a $50-million publicly traded business -- focuses on its 4,000 corporate clients. Last year, it conducted over 10,000 "preventive health" examinations. These exams go far beyond the scope of an annual checkup, says Dr. Sheldon Elman, a family physician and CEO of Medisys. They can include full fitness examinations, coronary artery checks, stress management checks, nutritional counseling and psychological assessments. The Medisys team will then review the information and design a preventive medicine program for the client to reduce risk factors.

"It really is based on the preventive evaluation where the medical is really one part of an overall assessment," says Dr. Elman. "Clients aren't coming in because they are sick. They are coming in because they want to apply the ideals of preventive health care." Corporations offer Medisys services to their executives as part of their benefit packages and they pick up the tab. "It does not contravene any aspects of any act, including the Canada Health Act," Dr. Elman notes. When these clients (and Dr. Elman is quick to point out that he does not refer to his clients as "patients") get sick, and they don't have a family physician, they can come in and see their Medisys physician under the medicare plan. "We aren't in or out [of medicare]. We're in." That said, he doesn't consider Medisys's wellness services a parallel health care system. "We just provide excellent service," he says.



Family physicians are dipping into the realm of private medicine by charging patients for uninsured services -- either delisted services or those services that were never listed. "When patients go to their doctors, they expect that everything is free," says Alan Smithson, president and CEO of the Smithsonian Group Inc., a company Smithson formed last year to help doctors establish "block fees" for uninsured services.

Family physicians perpetuate the myth that medicare covers everything by absorbing the costs of uninsured services into their practices -- rather than bill patients directly, says Alan Smithson. "Although philanthropic, it can't be done from a business standpoint," he says. The loss is quite considerable. "Let's say a family physician writes one $11 sick note each day and works 200 days a year," he says. "That's $2,200 on sick notes alone." If the average family physician does five uninsured services a day and the average cost is $10, that's a $10,000 loss. A block fee, Alan Smithson contends, is one way a physician can recoup those losses.

Block fees can also help the doctor to be more diligent in his or her billings. "Let's say you offer a block fee and 50% of your practice signs up," Alan Smithson says. "The other 50% of patients have decided they will pay as they go." How can a family physician give away services for free to people who aren't willing to support the block fee? "What they end up doing is charging everybody the same amount," Alan Smithson explains.

Block fees can vary by practice, but generally are between $100 to $125 per patient annually. The block fees follow the provincial guidelines for uninsured services and each individual doctor can choose which uninsured services he or she plans to make available to patients and which of those services will be included in the fee. Patients have the option of paying for each uninsured service individually.

Dr. Leonard Warner, a family physician in Thornhill, Ontario, began using a block fee in November, 2003. So far, 10% of his clients have signed up. "It's not a lot, but it's something," says Dr. Warner. "We are also being more careful to bill for non-OHIP [Ontario Health Insurance Plan] services for those who didn't sign up." The block fee helps to cut down on the paperwork, he adds, as the number of smaller billings are reduced. "There have been very few complaints," he adds. "Most of the patients understand the rationale behind doing it."

Dr. Warner based his block fee on what he believed the average patient would use, while keeping the Ontario Medical Association recommendations for uninsured services in mind. "Most patients don't use of lot of the uninsured services, but some patients actually end up ahead [with the block fee]," he says.