It’s October 20th, Tommy Douglas Day in Saskatchewan. Yesterday, Dr. Jeffrey Wilkinson, a cardiologist in Moose Jaw announced he had chosen to opt out of Medicare. Patients at his South Saskatchewan Heart Clinic will now pay $350 out of pocket per consult (over double what Medicare pays his colleagues in the public system). It’s not clear from the reporting whether the clinic will also be charging additional fees for tests like ECGs and echocardiograms.
Wilkinson’s decision makes him the first Saskatchewan physician to do so since the introduction of universal health insurance in 1962. That historical note alone makes this a big deal, but just how big?
From the beginning of Medicare, doctors have always had the option to practice within the public health system, billing the government for insured medical services or billing patients directly. They just can’t do both. It’s notable that in Saskatchewan, where doctors objected to the introduction of Medicare to the point of going on strike, not one has made this choice until now. Even the strongest opponents of socialized medicine came around to appreciate the stability of guaranteed payment and the freedom to see patients based on who was sick, not who could pay. The 1980s saw a rise in the practice of “double-billing”, where some clinics were sending bills to the government and to patients. This led to the introduction of the Canada Health Act, with its principles of universality, comprehensiveness and accessibility, and to a crackdown on double-billing across Canada.
So how should we respond to the first doctor to opt out of Medicare in Saskatchewan? Is it time to panic about the future of publicly-funded health care? The answer is no. This is one doc and not the end of Medicare as we know it. Across Canada there are doctors who opt out, though it is quite rare.
Ontario, where double-billing was particularly widespread, has all but banned opting out by barring physicians from charging patients directly for services that are covered by the Ontario Health Insurance Plan. BC and New Brunswick allow physicians to opt out, but there is little incentive to do so as physicians aren’t allowed to charge patients more for a service than they could bill the government directly. The only province that has seen a large number of doctors leaving the public system entirely is Quebec where, in the wake of the Chaoulli decision at the Supreme Court and a resurgence of double-billing known as frais accessoires, hundreds of doctors have chosen to charge patients directly. Not coincidentally, Quebec has by far the worst access to primary care in the country.
Medicare is not a gift, it’s a social contract.
Should we be angry at this doctor? A little bit, yeah. He is perfectly within his rights to make this call, but when he says that “public medicare is a gift,” this decision don’t reflect that. And perhaps some of the problem lies with that choice of words. Medicare is not a gift, it’s a social contract, one that depends on all of us paying into it and providers drawing from those funds to provide services. It’s a collective investment and one that is weakened when patients or providers check out. Being the first Saskatchewan doc to opt out of Medicare is a drastic move and one with consequences that go beyond one practice.
The first of these consequences is to patients, and not only Dr. Wilkinson’s. While some will be willing to pay the fees, others won’t or can’t. I am already hearing of patients being referred to other cardiologists, which lengthens the wait time to see them for everyone else. Taking a doc out of the “priority by need” pool and putting them in the “priority by ability to pay” pool benefits those with means at the expense of everyone else.
This immediate effect is often worsened by which patients private-pay clinics choose to see, a concept known as cream-skimming. In order to maximize profit, clinics can selectively accept referrals of patients with less complex needs or bounce those patients to the public system should their care become more demanding. In the case of one of two cardiologists in a city leaving the public system, there are likely impacts on hospital care as well. Will this doctor retain hospital privileges at all? If so, will he be expecting patients to pay him directly for his services their hospital stay? What will happen to on-call coverage and care of the sickest patients in Moose Jaw?
The biggest risk is if others chose to follow his example. The provision of medical services in a public system is complex and depends on a web of interdependent services. For one doc to operate entirely outside of that system makes it more complex, less effective and less fair. An exodus of doctors from Medicare would undermine the entire system.
Does that mean he’s entirely wrong? No, the issues he’s raising are real. Running a clinic as a solo practitioner in a smaller centre such as Moose Jaw likely does pose particular challenges. It is, however, hard to believe there’s not a model that would allow for this doctor’s practice to thrive. The 2021-22 Medical Services Branch Annual Report showed cardiologists billing $795,000,1 with the highest billing cardiologist bringing in $1.6 million. It’s important to note that these are overall billings, not salary, and these doctors are running offices with rent, equipment and staff costs. That said – and acknowledging the extensive training and high societal value of their challenging and essential work – these are without question very high-earning professionals.
Still, Wilkinson is not the first physician to raise the issue of costs making it difficult to keep staff and keep the doors open. In 2022, Dr. Tomi Mitchell shut down her Regina primary care clinic that served over ten thousand patients, citing rising overhead as the major reason. Trained staff are hard to come by and harder to keep. Not to mention the burnout so many healthcare workers are feeling after the last few years.
So, if the problems are real, what should Saskatchewan (or any other province facing a similar situation) do next? For one, we should make it clear that we value the principles of the Canada Health Act and put in place measures to protect Medicare. This includes policies that make it less attractive to leave the public system, such as those in Ontario, BC or New Brunswick.
More importantly, we need to make it attractive to stay. If growing costs are driving doctors out of practice, the province or the public system, the government and the SMA need to be revisiting the fee structure and payment model to keep them.
The first doctor to opt out of the public system in Saskatchewan, the home of Medicare, deserves more than the shrug we’ve seen so far from our provincial government. This summer, Danielle Smith warned a family practice clinic that was planning to charge a rapid access membership fee that what they were doing was illegal. This is a different situation, but when Danielle Smith looks more serious about protecting Medicare than you do, you have a problem.
In the meantime, our best hope is that the Moose Jaw experiment is a flop. That’s not to wish any ill will toward Dr. Wilkinson, I want to see him thrive as a doctor providing care for Saskatchewan people. But the damage posed to health care services for everyone when Medicare is splintered is simply too great. For his sake and all of ours, I hope he can return to a model of practice where the first question to a patient is how are they feeling, not how are they paying.
The average billings for the 30/35 cardiologists that brought in over $350,000 – which would represent those working full time in their specialty – was $890,000.
When I was having minor heart issues/questions, I went there myself to this clinic a few years ago and received excellent care from Dr. Wilkinson and the staff. I find the decision to opt out of Medicare very disappointing and I hope it doesn’t inspire a flood of docs to leave the program, particularly in the smaller centres, for many of the reasons expressed here.
It’s true that this doctor has left a bunch of his current clients in a lurch and they may struggle to find a new cardiologist. At the same time this doctor will be reducing the queue of patients in public medicine without reducing the funding for public medicine. Any patient with the means and will to see him privately pays for that privilege and still pays the same amount of taxes to fund the public system. In this way, patients who want to see a doctor privately (whether in Canada, by traveling to a Mayo Clinic, or elsewhere) still fund the public system they aren’t using. Sometimes they also bring back with them the knowledge of innovative treatments, resulting in healthy competition. Also, if the doctor makes more money in private practice he will also pay more taxes into the public system. Barring a mass walkout of doctors from public to private, I see net benefit. No need to demonize those who fund public but don’t use it. As long as those same taxpayers don’t have the choice to opt out of funding the public system. To me that’s the hill worth dying on.
Also, if we don’t have enough cardiologists (or any other kind of public health care worker), wouldn’t it be better to train more (locally) rather than to get into bidding wars? Many capable young people in our province would gladly take those jobs at their current rates of pay (or lower). This is a problem we can solve by analyzing population growth patterns and matching the enrollment numbers at our universities. Hire a few more teachers to end up with way more doctors. By not doing this type of basic planning it almost appears that we are trying to create the scarcity of doctors, an issue everyone can see.