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Recently, Centric has been buying up market share across Canada, acquiring surgical centres, diagnostic clinics, medical equipment companies, and Lifemark, the largest rehabilitation company in the country. It’s a vertically integrated company that looks to rival our public health-care system with its array of services and products.

could expose Canadian governments to sanctions under the investment provisions of NAFTA

claim damages should the province of Ontario regulate the services provided by Centric in a manner that diminishes the profitability of its investments

there is a lack of transparency and accountability

Just ask Dr. Wayne Hildahl of the Pan Am clinic in Winnipeg, a clinic that was previously for-profit but now operates publicly through the Winnipeg Health Authority. Hildahl has publicly said that when the clinic was for-profit, he had the advantage over government officials negotiating contracts to provide medical services because he knew his costs and they didn’t. And under its investor-based ownership, the Pan Am clinic cut corners, with outdated medical equipment — including dull scalpel blades! — to increase profit margins. His clinic now charges the government $700 for a cataract procedure instead of the $1,000 it charged when Pan Am was a for-profit facility.

Centric is also pushing for physicians to invest in the company

Researchers in Arizona found that those doctors with a financial interest in their facilities treated more patients whose conditions were least severe and would bring in the most money.

These conflict-of-interest problems led the U.S. Congress to deny medicare reimbursements to doctors for procedures done in hospitals in which they are shareholders.

While private facilities like the Cambie Surgery Centre and the Centric Health Surgical Centre (formerly False Creek Surgical Centre) consider themselves hospitals, the college makes a distinction and Oetter said private facilities are inspected and accredited for one-night stays only. "We think of them as private facilities, not hospitals. When you think of hospitals, you think of 24-hour staff, security guards, meals and so on," she said.

There are nearly 80,000 adults and children waiting for surgery in B.C. hospitals and median waiting times have not changed in several years despite reforms. According to the policy paper, 90 per cent of elective surgery patients got their surgery within 40 weeks in 2013/14, while the rest waited longer. In 2013/14, 5,503 publicly funded operations were performed in private facilities, down from the 7,839 cases performed in private clinics the year before. Another 541,886 scheduled (elective) operations were done in B.C. public hospitals. There are about a dozen private surgery centres in B.C. offering a range of operations, general anesthetics and overnight stays.

About 50,000 people pay for their procedures themselves each year in private facilities. Renee Hourigan, spokeswoman for Centric, declined to comment. Dr. Brian Day, owner of the Cambie Surgery Centre, said it would be easy to accommodate patients for longer periods and to meet any new requirements. "We're not going to hire a chef, but we already provide snacks and meals to patients. We give them menus and they choose what they want and the food is delivered."

Cambie has five operating rooms plus a dental procedure suite and seven private post-op recovery rooms. He said whether the facility is a hospital or not is really a matter of semantics. "Think about all the tiny community hospitals around B.C. and you can see that we are far more advanced and closest to the best hospital in B.C. Our staff are all the best you can get." Day said Cambie has been inspected and approved not only by the college but by the national body that audits and accredits hospitals - Accreditation Canada. Such accreditation isn't mandatory, but college approval is required.

About 700 B.C. surgeons have privileges to work at private surgery centres. Under B.C. law, any facility where surgeons work must be inspected and accredited by the college to ensure high standards of care and patient safety. Sarah Plank, a spokeswoman for the Health Ministry, said the government is analyzing what kind of cases might be suitable for funded private surgery centres. The process is in the early stages so a timeline of up to two years is "not unreasonable," she said.

Both developed and developing countries report geographically skewed distributions of health-care professionals, favouring urban and wealthy areas, despite the fact that people in rural communities experience more health related problems.

Eight collaborative emergency centres have opened in Nova Scotia since 2011.

In Nova Scotia, where we remain married to the old physician-centric delivery model, this has become an obstacle to change. It really should not be about warm bodies, it should be about health outcomes.

At Chartwell, a chain of 27 homes, chief operating officer Karen Sullivan said the pharmacy that services the chain, MediSystem, pays for "many additional valued-added services" such as employee education, nurse leadership sessions and conferences for leaders of homes. MediSystem also pays for Wi-Fi systems and therapeutic care equipment at the homes, Sullivan said in an email. The Star asked pharmacies what they are told the money is used for. Among the responses from pharmacies were "staff education," "resident programs" and payments toward Wi-Fi systems. Classic Care, a pharmacy, said the money it pays covers monthly rent of an area in the nursing home, staff education, technology and "donations and sponsorships" for conferences and other training. Other pharmacies, such as Rexall, say their fees have paid for diabetes education, for example. The largest pharmacies serving long-term-care homes in Ontario include Medical Pharmacies Group, MediSystem (owned by Loblaw), Classic Care (Centric Health) and Rexall. The fees are not new. Pharmacies have willingly offered money or agreed to demands for years. But there's a growing outrage among some who say homes are more interested in "inducements" than "clinical excellence" that pharmacies can provide seniors. Last year, after the Ontario government cut each dispensing fee by $1.26 (it is now $5.57 per prescription in nursing homes), sources said some pharmacies wanted to stop paying the fees. The problem was, the sources said, that the homes refused to give up the extra cash flow and other drug companies were willing to pay, so nothing changed.

It's usually the larger companies that can afford to pay. One insider said smaller pharmacies now ask the homes, "Do you want the money or do you want good service? Because we can't afford to give both." Sources said the Ontario Ministry of Health and Long-Term Care knows the money changes hands but does nothing to stop it. Instead, pharmacies are "held hostage" by the homes, the source said. One home that no longer charges the fees is John Noble Home in Brantford, a municipally operated 156-bed facility. The Star obtained a 2010 request for proposals (RFP) that noted "only proposals with a minimum rebate of $20,000 annually will be considered for the project." A spokesperson for the city said the RFP "references a previously approved practice employed by several long-term care homes." A recent RFP did not ask for a rebate, though some offered to pay. The city spokesperson, Maria Visocchi, said it chose a pharmacy that "demonstrated qualifications and experience, project understanding, approach and methodology, medication system processes and quality control." This pharmacy did not offer a rebate. Not all pharmacists pay. Teresa Pitre runs Hogan Pharmacy Partners in Cambridge and serves long-term-care homes that don't ask for money. Instead, she signed contracts with several homes in the People Care chain to provide a "highly personalized approach." Pitre sends a registered pharmaceutical technician into each home daily to relieve nurses of much of their work regarding medication, confusion over communications and extensive paperwork. Her company also puts a bookshelf-sized dispensing machine in each home, which holds medication (pain relievers, antibiotics or insulin) that residents need on short notice but, in the traditional system, often can't get for hours. "I really wanted our pharmacy to be a partner with homes instead of servicing them and just meeting the requirements," she said. Meadus says the added cost of bed fees means pharmacies have no reason to reduce their rates, either by lowering dispensing fees or not charging the $2 co-payment.

A recent Star story revealed that pharmacies serving nursing homes typically charge dispensing fees for drugs once a week, rather than once a month as they typically do in a community pharmacy. Long-term-care pharmacies told the Star they charge the weekly fee because the medication for frail residents can change weekly. That was a claim hotly disputed by some family members the Star spoke to, including Margaret Calver, who has spent years documenting the costs of dispensing fees at Markhaven Nursing Home, where her husband is a resident. "This needs oversight and that's the problem," she said. "Nobody is doing the checks and balances." Moira Welsh can be reached at mwelsh@thestar.ca.