Ontario's reform experiments

Since the early 1990s, Ontario has implemented several systematic reforms to reduce health care costs. Similar reforms have been implemented in other provinces.
User premiums
Currently in Ontario, people who earn salaries above $20,000 must pay an annual health care premium ranging from $300–$900. Funding for medicare in Ontario also comes in part from a dedicated Employer Health Tax (EHT) that ranges from 0.98%-1.95% of employer payroll. Eligible employers are exempted from EHT on the first $400,000 of payroll. British Columbia and Quebec charge similar premiums. Alberta charged $44 a month or $88 per family until it abolished premiums in 2009.
Medical clinics
Ontario has increased the number of 24-hour drop-in medical clinic networks to reduce costs associated with treating off-hours emergencies in hospital emergency rooms.
Many family doctor practices have created their own clinics, offering 24-hour service for their patients if needed. Each doctor in the practice takes a turn at being "on call" on a rotating basis. Patients who have family doctors belonging to these practices are able to have a doctor come to their home in extreme situations. There is no additional charge for these services as they are billed to the Province, the same as an office visit.
Hospitals in some major Canadian cities, such as London, Ontario, have restructured their emergency services to share emergency treatment among several hospitals. One hospital may provide full emergency room care, while another sees patients who have broken limbs, minor injuries and yet another sees patients suffering cold, flu, etc.
Recently, the first nurse practitioner-led office to relieve waiting times caused by a shortage of primary practitioners was opened in Sudbury, Ontario.
Alternatives to fee-for-visit or service
Ontario has also attempted to move the system away from bill for service or visit and toward preventive and community-based approaches to healthcare. The Ontario government in the early 1990s helped develop many community health care centres, often in low-income areas, which provide both medical and social support which combines health care with programs such as collective kitchens, Internet access, anti-poverty groups and groups to help people quit smoking.
While funding has decreased for these centres, and they have had to cut back, they have had a lower cost than the traditional fee-for-service approach. Many of these centres are filled to capacity in terms of general doctors, and there are often fairly long waiting lists and the centres also utilize nurse practitioners, who reduce the workload on the doctors and increase efficiency.
Midwives and hospital birthing reforms
Ontario and Quebec have recently licensed midwives, providing another option for childbirth which can reduce costs for uncomplicated births. Midwives remain close to hospital facilities in case the need for emergency care emerges. These births often cost much less than the traditional hospital delivery. Hospitals have also reformed their approach to birthing by adding private birthing areas, often with a hot tub (which is good for relieving pain without medication).
Privatization
Currently, privately owned and operated hospitals that allow patients to pay out-of-pocket for services cannot obtain public funding in Canada, as they contravene the "equal accessibility" tenets of the Canada Health Act. Some politicians and medical professionals have proposed allowing public funding for these hospitals. Workers' Compensation Boards, the Canadian Military, the RCMP, federally incarcerated prisoners, and medical care for which an insurance company has liability (e.g., motor vehicle accidents) all pay for health care outside of the public systems in all provinces.
In Quebec, a recent legal change has allowed this reform to occur. In June 2005, the Supreme Court of Canada overturned a Quebec law preventing people from buying private health insurance to pay for medical services available through the publicly funded system and this ruling does not apply outside the province. See: Chaoulli v. Quebec (Attorney General).
In November 2005, the Quebec government announced that it would allow residents to purchase private medical insurance to comply with this ruling.
Private insurance from companies such as Blue Cross, Green Shield and Manulife have been available for many years to cover services not covered by Medicare, such as dental care and eye care. Private insurance is provided by many employers as a benefit.
The Canadian Medical Association (CMA) released a report in July 2007 endorsing private healthcare as a means to improve an ailing healthcare system. Dr. Brian Day, who acted as President of the CMA in 2007/2008, is the owner of the largest private healthcare hospital in Canada and a proponent of mixed public and private healthcare in Canada.
Canadian Health Practitioner standards
It is generally accepted that physicians arriving in Canada from other countries must meet Canadian Health Practitioner standards. So there is concern that doctors from other countries are not trained or educated to meet Canadian standards. Consequently, doctors who want to practice in Canada must meet the same educational and medical qualifications as Canadian-trained practitioners, others suggest that the current regulatory bodies, the Canadian Medical Association, the Ontario Medical Association, and the College of Physicians and Surgeons has created too much red tape to allow qualified doctors to practise in Canada. It should be noted that Canada's Health system is ranked 30th in the world, suggesting the logic of the doctor shortage defies the statistics. In fact according to a report by Keith Leslie of the Canadian Press in the Chronicle Journal, Nov 21, 2005, over 10,000 trained doctors are working in the United States, a country ranked 37th in the world. It would suggest money or the perception of better working conditions, or both, are resulting in an exodus of Canadian doctors (and nurses) to the USA.
It is important to recognize that many consider the doctor shortage in Canada to be a very severe problem affecting all sectors of health care. It may relate in part to the details of how doctors are paid; a detail often misunderstood. In Canada, almost all doctors receive a fee per-visit, not per-service. It has been suggested that this type of "fee-for-visit" payment system can encourage complexity, volume visits, repeat visits, referrals, and testing.
One consequence of the shortage in Canada is that a great many patients are left without family doctors, and trained specialists, making early intervention very difficult. As the article in the Toronto Star specially isolates, it is not so much a problem of a doctor shortage but of a shortage of 'licensed doctors'. Michael Urbanski states that Canada already has a hidden reserve of foreign-trained MDs eager to begin medical practice. "However, what's crucial to understanding the issue of doctor shortage in Ontario is that while the Liberal government is planning to go "poaching" for other countries' doctors, there are an estimated 4,000 internationally trained doctors right here in Ontario working at low-wage jobs."
A CBC report [6](August 21, 2006) on the health care system reports the following:
Dr. Albert Schumacher,[49] former president of the Canadian Medical Association estimates that 75 per cent of health-care services are delivered privately, but funded publicly. "Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics …The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization.
In a report by Keith Leslie of the Canadian Press in the Chronicle Journal, Nov 21, 2005, commenting on an Ontario Medical Association Report, prepared by the human resources committee states "The year 2005 finds the province in the midst of a deepening physician resources crisis". The report continues to report, "the government should make it easier for doctors from other provinces to work in Ontario and .... ". Here we have signs of inter-provincial competition affecting the doctor shortage in one province over another. Essentially, privatized healthcare is not a choice of interest for lower income Canadians, it is most likely to be unaffordable and unfair to those who suffer on a social standard.
Provincial insurance plans
Though the Canada Health Act provides national guidelines for healthcare, the provinces have exclusive jurisdiction over health under the constitution and are free to ignore these guidelines, although if they ignore the guidelines, the federal government may deny federal funding for healthcare. All provinces currently abide by the Canada Health Act in order to receive this funding; however the Alberta legislature has considered proposals to ignore the Act to allow them to implement reforms not allowed under the Act.
The federal government has no direct role in the delivery of medicine in the provinces and territories so each province and territory has its own independent public health insurance program. Under the Canada Health Act, each province and territory must provide services to members of plans in other provinces and territories.