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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.

Doctors have argued in the past that they need the extra money to pay their operating costs, but the report recommended the health department take time to really “assess the operating costs of clinics, determine the funding to be granted and consider the funding already paid.”

Lawyer Jean-Pierre Ménard insisted last week Quebec is the worst offender when it comes to over-billing patients, and that the fees are creating a two-tier health-care system that may violate the Canada Health Act. With Ménard’s help, various patients’-rights groups have come together to launch legal action against the federal government to make sure the Canada Health Act is applied in Quebec and other provinces. Reacting to the report Tuesday, Health Minister Gaétan Barrette reiterated his recent promise to abolish add-on fees by possibly rolling them into doctors’ salaries. “For care that is medically required, there won’t be any fees,” he told reporters.

Parti Québécois MNA Diane Lamarre said Barrette’s “about-face” is the result of relentless criticisms by her and the PQ. “When we started studying Bill 20, we were fighting the fact that the minister introduced an amendment that authorized accessory fees,” Lamarre said. “It was a new opportunity to charge, legally, new medical fees. … We asked the minister many times to (scrap) his amendment and he refused. “(It) was a way to introduce accessory fees and make some patients with no money unable to have access to medical services, which is completely against the law. Now we’re proud that he changed his mind,” she said. Both Lamarre and Coalition Avenir Québec MNA François Paradis said they are concerned Barrette will not be able to convince doctors’ associations to include the fees in their remuneration. If doctors’ salaries are boosted by an additional $50 million in the next contract agreement, for example, it will mean that collectively we will all be paying the fees indirectly, Paradis said.

The Quebec government has negotiated with the medical federations a list of fees that are permitted, such as the use of liquid nitrogen to remove moles ($10) or the use of a topical anesthetic for a minor eye wound (also $10). Over the years, many physicians in private practice have started billing for many more items and services, occasionally prompting investigations by the Régie de l'assurance maladie du Québec (RAMQ).

In a statement made public Tuesday, College president Charles Bernard countered that the researchers based their conclusions on "impressions and partial data ... without taking the time to analyze in depth an issue so complex." Bernard noted that the College produced a report on accessory fees in 2011, and in January, it modified its code of ethics warning doctors that they cannot bill patients "disproportionately high" fees and that they must produce detailed invoices.

In April, the College called on the provincial government to modernize its system of accessory fees. In November, the National Assembly adopted Law 20, which gave the health minister the power to expand the range of fees now charged in private practice and to limit certain amounts. "We need to calibrate the expectations of pressure groups that would wish that the College - through its code of ethics - defend the public coverage of fees for medical services," Bernard added.

The number of Quebecers filing complaints about excessive fees soared by 374 per cent during the past five years, according to a report by the College in April. The complaints jumped from 31 in 2010-11 to 147 in 2014-15. To date, two cases over abusive fees have gone before the College's disciplinary board. In one of those cases, a Westmount physician was fined $10,000 in 2013 for charging patients "excessive and unjustified fees."

An Oct. 1 report by Quebec's Ombudsman found that some private clinics have billed patients $300 for eye drops; $100 to freeze offa wart; $40 to apply a four-centimetre bandage; and $200 to insert an intrauterine device. aderfel@montrealgazette.com Twitter.com/Aaron_Derfel

Dr. Charles Bernard, left, president of the Quebec College of Physicians, seen at a February news conference with college secretary Dr. Yves Robert, says researchers based their conclusions about accessory fees on "impressions and partial data."

What is especially disturbing, said Amy Ma, co-chair of the central users' committee, is that the above-ground parking lot was constructed 30 years ago, and so there is no justification for charging such a high fee. In contrast, the MUHC is charging the same rate for its new underground parking lot that opened at the superhospital's Glen site in April, arguing that the higher fees are necessary to pay back a $266-million loan for the lot's construction. "Recently, I was talking to a parent who had to bring her child to the newly opened external clinic of the Children's at 5100 de Maisonneuve," Ma said. "In addition to having to pay $25 for an allergy shot, she also had to pay $25 for parking. The $25 for parking ... is just mind-boggling because it's not even a brand-new, multi-storied parking garage.

"It's definitely going to add yet another barrier in terms of access to care," Ma added. In September, Quebec's ombudsman vowed to investigate "excessive" parking fees at the $1.3-billion superhospital following a formal complaint by the users' committee. The MUHC levies patients and visitors $25 after 90 minutes of parking - the highest rate of any hospital in the province. On Aug. 1, the MUHC also "harmonized" its parking rates to $25 after 90 minutes at the Montreal General and Montreal Neurological hospitals. Previously, the rates were $19 after 90 minutes.

Despite this harmonization, the users' committee found that a patient who parked at the Montreal General and the Glen site on the same day was charged $50. The ombudsman warned that such doubledipping is "abusive and shows a lack of inter-hospital coordination." A report by the ombudsman's office on Oct. 27 recommended that the MUHC "revise" its parking rates by Monday so that the fees "do not hinder the right of an individual to access to health care." The ombudsman's delegate, Léa Préfontaine, did not recommend by how much the rates should be lowered.

A week before the report, the MUHC lowered the maximum rate for express parking at the superhospital to $30 from $50 for cars parked between 61 minutes and 24 hours. But the $25 fee for general parking has not been changed. In fact, the hospital network raised the fees for employee parking by $120 a year, going from a monthly rate of $105 to $115. What's unusual about the parking at 5100 de Maisonneuve is that it does not fall under the jurisdiction of the MUHC, since it's a private facility. On Oct. 13, the Brunswick Medical Group opened "The Children's Clinic" at that address. The clinic is staffed by doctors from the Montreal Children's Hospital that is part of the superhospital complex.

Parents who go there must present their children's medicare card before each consultation. If a child is in need of an allergy or blood test, the parent is offered one on the spot for a fee, or can go to the hospital and wait for one that would be covered under medicare. Shortly after the Montreal Gazette reported that children were being charged fees for tests at the private clinic, Health Minister Gaétan Barrette ordered the MUHC to remove its signs from the building. He also demanded that the MUHC cancel as soon as possible a 30-year lease it signed with the Royal Victoria Hospital Foundation regarding the property.

an Popple, a spokesperson for the MUHC, confirmed that the hospital network is managing the parking lot at 5100 de Maisonneuve through a private company. Popple added that the "MUHC plans to announce modifications to its parking policy over the coming week," but declined to provide details. aderfel@montrealgazette.com twitter.com/Aaron_Derfel

DAVE SIDAWAY, MONTREAL GAZETTE / The parking at 5100 de Maisonneuve Blvd. does not fall under the jurisdiction of the MUHC.

When the Canada Health Act passed in the House of Commons in 1984 with unanimous support from all political parties, its primary purpose was to put an end to extra billing like this. Charging patients at the point of care for medically necessary services strikes at the heart of the principle that access to health care should be based on need rather than ability to pay. It undermines equity, increases system costs and reduces commitment to the public health care system. It's also illegal.

Why are we not hearing resounding denunciations of Barrette's plan from our federal politicians? Research has consistently demonstrated that forcing people with less money to pay a fee to access care means they might not seek out medical attention until later in the course of their illness. This means patient outcomes are likely to be worse and treatment more complicated and costly. Given higher levels of illness among people in poverty, these fees also shift costs to those who use the system most but can least afford to pay.

Doctors in Quebec and across the country have expressed alarm at Barrette's amendment to Bill 20, which regulates extra billing rather than prohibiting it. The Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, Médecins Québécois pour le Régime Publique, and the Quebec College of Family Physicians have all come out against this decision, joining patient groups, all of Quebec's opposition parties, and Raymonde Saint-Germain, the independent Quebec Ombudsman. The measure was passed on Oct. 7, with no public debate. Bill 20 is currently before the National Assembly and is expected to become law this fall.

Barrette is effectively bringing user fees in through the back door. Rather than introducing user fees charged by government, he would let clinics do so. This further fragments care and makes access even more inequitable.

In this federal election campaign, the talk has been around reducing barriers to access by improving coverage of prescription medicines, home care and mental health care. Yet at the same time that our federal parties are committing to such muchneeded expansion, they are silent on protecting the core of medicare: publicly funded doctor and hospital services.

Any party that claims to be committed to the Canada Health Act should immediately state its position on the amendments to Bill 20 in Quebec. To do less is to skirt the core federal responsibility for medicare in Canada. Ryan Meili is a family physician in Saskatoon and an expert adviser with the Evidence Network. Danielle Martin is a family physician and vice-president Medical Affairs and Health System Solutions at Women's College Hospital in Toronto. Both are members of the board of Canadian Doctors for Medicare.

JACQUES BOISSINOT, THE CANADIAN PRESS / Health Minister Gaétan Barrette has put forward a measure that would regulate extra billing rather than prohibit it. It will become law when Bill 20 is adopted.

According to the registry, 527 patients were billed a total of $40,775 between Feb. 15 and Aug. 2015. Respondents noted feeling indignant about the injustice of having to pay amounts they considered exorbitant for medical care. Some said they couldn't afford to pay - they needed the money for groceries or rent. User fees for insured medical services covered by the provincial health insurance board are illegal. But there's a grey zone, and for years many physicians and clinics have quietly been applying extra, arbitrary or excessive fees for exams and medications covered in hospitals. Led by the clinic's Comité de lutte en santé, the registry also showed that rates for medical services levied on patients varied among professionals, the clinic's co-ordinator Luc Leblanc said Sunday.

"It's a two-tiered system. One for those who can pay and one for those who can't," he said. Data analysis shows the average amount demanded by family doctors was $63, and the average for specialists was $91. The biggest category is medications or anaesthetics, followed by administrative charges like photocopies or filling forms. Adopted last week, Quebec Health Minister Gaétan Barrette's Bill 20 included a set of amendments to legalize fees charged to patients in clinics for insured services, commonly called "accessory fees." The list of regulated ancillary fees will come later, after the government hires an independent accounting firm to determine real costs.

But Leblanc noted the public wasn't consulted because "initially Bill 20 made no mention of the possibility of accessory fees," Leblanc said. And there are no prior government studies or surveys to determine the scope or impact of current fees on patients, he added. The introduction of user fees is a serious threat to universal care, critics said, including the Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, and Médecins québécois pour le régime publique (MQRP), who asked Barrette to hold offon regulating fees in October.

Charging patients at doctors offices and clinics for medically necessary care isn't acceptable, said Isabelle Leblanc, president of the pro-medicare group, Médécins québécois pour le régime publique. It strikes at the heart of the principle that access to health care should be based on need rather than ability to pay, she added. The clinic's health committee is calling on Barrette to suspend extra fees and on the new federal Health Minister Jane Philpott "to act immediately to force Quebec to respect the Canada Health Act," said Louis Blouin of the committee. The committee is continuing to document billing in its online registry. It can be found on the Pointe-Saint-Charles clinic website cfidelman@montrealgazette.com twitter.com/HealthIssues

The penalties are assessed on a dollar-for-dollar basis, meaning they are equal to the amounts patients complained about paying for procedures. B.C. and Newfoundland were the only provinces assessed penalties for the last three years. When the 2013-14 annual report comes out soon, B.C. will once again be penalized, this time $224,000, said provincial Health Ministry spokesman Ryan Jabs.

Since 1994, the federal government has docked B.C. $3.2 million, slightly lower than the record-holder Alberta ($3.6 million). Since 1994, provinces have been assessed nearly $10 million in penalties for extra billing charges. A Health Canada spokesman could not explain why Quebec has never been penalized, even though it reportedly has a thriving private medicine sector. Ontario has also not faced any penalties.

The penalty to B.C. is paltry in relation to the province's $20-billion health budget announced Tuesday. It is also insignificant relative to the federal transfer payments B.C. will collect this year ($4.4 billion) and next ($4.7 billion). In 2006, the then-deputy health minister of B.C., Penny Ballem (now Vancouver city manager) questioned whether B.C. was really the only province where extra billing and private sector queue jumping was taking place. Jabs said Wednesday he can't comment on what happens elsewhere.

In 2005, the B.C. government did not submit a dollar value to the federal government for such extra billing, so Health Canada bureaucrats based the penalty sum on news releases from anti-privatization unions and newspaper clippings about patients who accessed the private system. The Sun learned about that through a Freedom of Information request. The story detailed how discretionary the penalties appear to be and that they are based on "guesstimates" of user fees. Provincial Health Ministry officials often base their reports submitted to the federal government on complaints from patients who go to private clinics for expedited care and then try to collect the fees paid from government. One such patient is Mariel Schoof, who had sinus surgery at a private clinic in 2003. She paid $6,150 for the "facility fee" and then tried to recover the fee from the provincial government or the clinic. She is now one of the interveners in a private versus public medicine trial starting March 2 between Dr. Brian Day and the provincial government. Timeline of Canada Health transfer compliance in B.C.

Early 1990s: As a result of a dispute between the British Columbia Medical Association and the B.C. government over compensation, several doctors opt out of the provincial health insurance plan and began billing their patients directly, some at a rate greater than the amount the patients could recover from the provincial health insurance plan. May 1994: Canada Health deductions began and continue until extra-billing by physicians is banned when changes to B.C.'s Medicare Protection Act come into effect in September 1995. In total, $2,025,000 was deducted from B.C.'s cash contribution for extra billing that occurred in the province between 1992-1993 and 1995-1996. These deductions were non-refundable, as were all subsequent deductions. January 2003: B.C. provides a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts charged with respect to extra billing and user charges during fiscal 2000-2001 totalling $4,610.

Accordingly, a deduction of $4,610 was made to the March 2003 federal transfer payment. 2004: A $126,775 deduction was taken from B.C.'s March 2004 Canada Health Act payment, based on the amount of extra billing estimated to have been charged during the 2001-2002 fiscal year. Since 2005: $786,940 in cash transfer deductions have been taken from B.C.'s federal health transfer payments on the basis of charges reported by the province to Health Canada. January 2011: Vancouver General Hospital begins charging patients a fee when they elect to have robot-assisted surgery versus the conventional surgical alternative for certain medically necessary procedures. 2013: Deductions in the amount of $280,019 are taken from the March 2013 federal transfer payments of B.C. in respect to extra billing and user charges for insured health services at private clinics. Source: Canada Health Act Annual Report 2012-2013

The branch investigates about 30 cases a year of extra billing, usually related to private surgical facilities or expedited visits to specialists. The government is not sure whether it will be penalized in the future for allowing Vancouver General Hospital to charge patients fees for robotic surgery. VGH spokesman Gavin Wilson says since 2012 patients choosing to have surgeons remove their prostates using the robot have been charged on a partialcost-recovery basis. The B.C. government allows the extra billing because robotic surgery is discretionary, not medically necessary, and there are higher costs associated with it. In 2012, however, Health Canada began examining the Canada Health Act implications of patient charges for robotassisted surgeries. The process convinced the health minister that VGH should stop charging for robot-assisted surgeries as of Jan. 1, 2015. Vancouver Coastal Health collected $345,000 a year for the procedures; most recently, the patient fee was $5,700. Sun health issues reporter pfayerman@vancouversun.com

"It's now up to the government to act and decide whether it will cover the cost of certain services and the use of medical equipment in private practice, or if it wants to revise the agreement on the accessory fees with the medical federations." Under the Quebec Health and Social Services Act, doctors who work in hospitals cannot bill patients for medically necessary services. These same physicians must abide by certain conditions in their private practice, since they have not opted out of medicare. They can only charge for "medications and anesthesia agents" in private, and they are not allowed to bill patients for the use of medical equipment. However, there is one exception to the rule: private radiology clinics in Quebec can bill patients for MRI scans - a sore point with Health Canada, which has argued that the exception violates the accessibility provisions of the Canada Health Act. In addition, Quebec did negotiate with the medical federations a list of fees that are permitted, such as the use of liquid nitrogen to remove moles ($10) or the use of a topical anesthetic for a minor eye wound (also $10). Over the years, many physicians in private practice have started billing for many more items and services, sometimes prompting investigations by the Régie de l'assurance maladie du Québec (RAMQ).

He also cited Scotland, which got rid of most hospital parking fees in 2008. The government saw it as a matter of principle, arguing that hospital parking fees went against the idea of free health care, as well as being a source of stress for patients.

Just now in Ontario this arrangement would appear to have hit a wall. Having negotiated a four-year deal offering average annual fee increases of 2.5 per cent, the Ontario Medical Association executive was dismayed to find it rejected by nearly two-thirds of its members, who complain it does not make up for cuts in fees imposed last year. How things should have broken down to this extent need not detain us here. But it does perhaps point to the need to find another way.

Because doctors' fees, as such, are not the issue. To be sure, they are part of the puzzle: at $11.5 billion annually, they are roughly one-fifth of Ontario's health-care budget. But all the hard bargaining in the world isn't going to rescue Canada's health-care system from the fiscal cliff to which it is headed. Much more important than doctors' fees are doctors' decisions, as the gatekeepers dictating how resources are allocated within the system: how many tests are ordered, what procedures are done, and so on.

The problem is that decisions about treatment are too often divorced from decisions about budgets. Governments set a budget constraint at the macro level, which filters down through the various regional health authorities and local health networks the provinces have seen fit to establish. But doctors typically do not: they make whatever they can bill. And the incentives of feefor-service are to perform as many surgeries and other treatments as they can. Absent changes in those incentives, simply capping fees isn't going to change much.

You can see why doctors felt the need to organize. Governments had set themselves up as sole purchasers of medical services. The idea was supposed to be that they could exploit that monopoly power to drive down costs. But it didn't quite work out that way: politicians in need of re-election, it seems, do not make terribly tough negotiators (who knew?). It was always easier to pass the problem on to the next government, or the next generation - or, as federal governments got in on the act, Ottawa. In consequence, health-care spending skyrocketed through much of the 1970s and 1980s.

Only with the onset of the early 1990s recession, and particularly the sharp cut in federal transfers as Ottawa tried to stabilize its finances, was there the first serious effort at retrenchment. But as the fiscal crisis eased, and particularly after the 2004 health-care accord, with its massive 10-year increase in federal transfers, whatever impetus for reform there might have been dissipated. Rather than "buying change," most of the new money went to increases in provider compensation.

Even in the more recent wave of cuts following the last recession, these have been largely untouched. As documented in a new study by the C. D. Howe Institute

("Hold the Applause: Why Provincial Restraint on Healthcare Spending Might Not Last"), governments have largely resorted to the familiar public-sector strategy of starving the capital account to feed the operating account: while capital spending has been sharply curtailed, physicians' fees have not.

This is not sustainable in the long run - as new doctors enter the profession, and most of all, as the population ages. As it is, provinces are now spending more than 40 per cent of their budgets on health care; by 2030, a recent Fraser Institute paper projects the number will have risen to nearly 50 per cent. Yet wait times continue to mount: at more than 18 weeks, on average, from GP referral to treatment, they are nearly twice what they were 20 years ago.

Clearly the answer does not lie in more money, least of all more federal money: for every additional dollar in federal transfers the Howe study's authors find that provincial health spending increases by 36 cents. But neither is the answer ever stricter doses of austerity - any more than one would improve a car's mileage by putting less gas in the tank. Rather, what's needed is systemic reform, altering the way that public funds flow through the system, and how the different players within it are remunerated.

Traditionally, doctors have been paid per service, while hospitals have been funded on a block grant basis. The key to reform is to turn this around: giving groups of doctors a fixed amount per patient, with which to purchase services from hospitals, clinics and other providers, that is on a per-treatment basis. Paying doctors a lump sum localizes the budget constraint, forcing doctors to take account of costs in decisions on treatment; paying hospitals per service makes it possible for lower-cost competitors to undercut them.

In sum, rather than doctors and governments negotiating with each other at one gigantic bargaining table, what we need are lots of little bargaining tables, at which providers can haggle with each other.

He wants the OMA to return to the negotiating table and discuss lowering some of the 7,300 fees on the physicians’ pay schedule. He said the province has made no less than 80 offers since talks broke down two years ago — close to one a week — to no avail. If they don’t, he said he’s prepared to make another unilateral cut (even though the cuts imposed in 2015 have already sparked the second Charter challenge from the OMA this decade). “If necessary we will be forced to make those changes,” he said. Hoskins doesn’t want to cut back on all doctors’ pay, but create a more equal system that doesn’t go over budget every single years, as has historically been the case.

“The top biller, an ophthalmologist, billed more than $6.6 million last year. The top diagnostic radiologist billed more than $5.1 million and the top anesthesiologist billed more than $3.8 million,” a government fact-sheet states. That’s far above the average doctor’s gross payment of $368,000 a year. And though the OMA argues that often doesn’t account for overhead and staffing costs, the province also subsidizes pay in many indirect and direct ways, including allowing doctors to incorporate, which reduces tax and liability burdens. Ontario, unlike many provinces, covers 80 per cent of doctors’ liability insurance. Hoskins said the ministry even sometimes covers hardware costs like computers.

Hoskins says his goal is to make things more equal and better distribute the money going to certain specialists whose work has gotten easier. MRIs and CT scans used to take an hour, now they take 20 minutes. Same with cataract surgery — that’s why diagnostic radiologists and eye surgeons are so disproportionally represented on the list.

However, Barrette issued a statement Thursday saying that the goal of his proposed amendment to the medicare law is to end the "abuse" of incidental fees that some private clinics have been billing patients. In some cases, patients have been charged almost $200 for eye drops. But Barrette will also make it possible for some private clinics to charge fees that would now be considered illegal. "We believe that the amendment that will be debated ... constitutes a balance between the protection of the public against excessive fees and the preservation of services that are provided in private clinics," Barrette said in the statement. "The clinics that offer these services have always been part of the health and social services (network), and it would be irresponsible on our part to act in such a way that could lead to their closing."

But Roy countered that accessory fees are a form of two-tier medicine, allowing some patients with private insurance to bypass lengthy waits in the public system by going to private clinics. He noted that the government already subsidizes many private clinics, and there is no reason for patients to be charged extra. François Loubert, co-president of the Association des cliniques médicales du Québec, acknowledged that doctors who bill the medicare board for certain procedures in a private clinic do get paid more than if they carried out the same medical act in a hospital. He cited as an example a $40 fee for a type of consultation that a doctor in private practice can bill the Régie de l'assurancemaladie du Québec. For the same consultation in a hospital, the doctor could bill RAMQ only $25.

In Ontario, the cost is typically much lower at $45 per trip, but increases to $240 if the receiving physician deems it unnecessary. The reality on the ground violates the spirit, if not the letter, of the Canada Health Act: Equal access to physician and hospital services means little if safe passage to them is anything but. There are a variety of options to reduce this inequity in access. One option is to follow New Brunswick's lead and offer full coverage. An alternative would be to only charge users if the ambulance ride is deemed medically unnecessary. However, differentiating "appropriate" from "inappropriate" ambulance use isn't straightforward, and can vary between providers. What's more, evidence suggests that institutions - schools, long-term care facilities, hospitals and police services - more often initiate potentially unnecessary ambulance services than do individuals, as a result of compliance with internal policy or protocol.

As with other areas of health care, user fees are a blunt tool: they reduce both necessary and unnecessary use of services. The risk of footing the bill could deter people, especially those living in poverty, from calling for help. This would deny them not only safe transport to hospital, but also the initial emergency interventions by paramedics that can mean the difference between life and death. Public education and enhanced availability of primary care are more effective ways to decrease unnecessary ambulance use. Ideally, ambulance services should be fully covered for everyone. This would, however, require provincial governments to take on more of the costs. In Nova Scotia, that cost is an estimated $9.7 million, according to the Nova Scotia Citizen's Health Care Network. This is a drop in the bucket of the $6.2-billion Nova Scotia health-care budget; a small investment to ensure everyone, regardless of income, has access to vital emergency care. The variety and inequity of ambulance charges in Canada is a policy mess. Canada's health ministers should work together to establish a consistent and compassionate approach that balances cost with the need to remove barriers to care. Ryan Meili is an expert adviser

with EvidenceNetwork.ca, a family physician in Saskatoon and founder of Upstream: Institute for a Healthy Society. @ryanmeili Carolyn Nowry is a family physician in Calgary. They are both board members with Canadian Doctors for Medicare.

However, until now no federal government has had the nerve to take on serial offender Quebec. Quebec has been allowing its doctors and clinics to charge extra user fees since 1979. The province's current health minister, Gaetan Barrette, freely acknowledges this. In some cases, these fees were truly exorbitant. The Montreal Gazette reported last year that some colonoscopy clinics were charging patients an extra $600 for medications - on top of the publicly paid medicare fee. Many Quebecers were outraged. The provincial Liberal government's somewhat peculiar response was to pass a bill codifying the practice of extra-billing but giving itself the authority to regulate it. In March 2015, the then-Conservative government in Ottawa formally notified Quebec that it would be looking into the issue. This March, Liberal Philpott sat down with Barrette to discuss the practice. On Sept. 6, she sent her provincial counterpart a letter threatening cutbacks to Quebec's health transfer. A few days later, Barrette announced that extra billing will end as of next January.

It is hard to gauge the importance of Philpott's threat. User fees have become widely unpopular in Quebec. That alone may have been enough to drive the provincial government to disavow them. Still, it was bracing to see a federal health minister publicly standing up for the principles of medicare. It is not an everyday occurrence. It is particularly interesting that she targeted a province that is notoriously touchy about what it sees as federal interference. Perhaps she will do more. Certainly, more needs to be done. The latest annual report on the Canada Health Act filed with Parliament notes that private MRI clinics in British Columbia, Alberta, Quebec, New Brunswick and Nova Scotia are charging user fees to patients. It says some hospitals are avoiding the ban on charging for drugs by routing the sick through outpatient clinics - which do charge. It also notes that the portability requirement of medicare, which allows Canadians to receive care outside their home provinces, is routinely ignored.

Quebec routinely refuses to fully reimburse other provinces that provide health services to Quebec residents. Yet it has never been penalized by Ottawa for this. Nor have an unspecified number of other provinces that, at one time or another, did the same. Except for Prince Edward Island, the report says, no province appropriately reimburses residents who obtain medical care outside Canada. Such patients aren't necessarily entitled to the full cost of their out-of-country care. But they are entitled to be reimbursed for the amount it would have cost them to be treated in their home province. To work as a national program, Canadian medicare needs two things. First, the federal government must put up enough money to give it a real financial role in the system. The 2002 Romanow royal commission suggested that Ottawa provide at least 25 per cent of medicare funding. That figure still makes sense. Second, Ottawa has to use its financial clout to enforce those few national standards that do exist. A former Liberal health minister, Diane Marleau, tried to do this back in the 1990s. She was sandbagged by Jean Chrétien, the prime minister of the day. Let's hope Philpott has better luck.

It was bracing to see a federal health minister stand up for medicare principles, writes Thomas Walkom.

An economic adviser to Premier Dalton McGuinty says the government won’t meet its commitment to erase the province’s deficit by fiscal 2018 unless it caps annual spending growth at 1 per cent for the next six years. The deficit is projected to hit $16-billion in the current fiscal year.

the government wants doctors to accept a fee reduction for cataract surgery – which the province has already cut twice – as well as other unidentified procedures

As a policy under the workers' compensation insurance system, expedited fees were effective in reducing wait time to surgery. While a difference of only two weeks may not improve longer-term clinical outcomes post-surgery, it represents a reduction in the total disability duration (i.e., pain, suffering, quality of life) for the injured worker and increases the worker's likelihood of successfully returning to work; the reduced disability duration also represents a cost saving to the workers' compensation system for time-loss benefits and to employers who pay compensation premiums based on the frequency and duration of their claims experience.

the provision of surgeries "after hours" or within private clinics may result in a redistribution of finite resources (e.g., surgeons, surgeon time, surgical staff) from one insurance provider to another, favouring those associated with higher fees, thus creating inequities. An evaluation of the effect of workers' compensation policies on inequity in the provincial healthcare system was not part of this study and warrants future investigation.

the time leading up to surgery may be confounded by co-morbidities and that individuals with complications may be directed to the public system

A difference of approximately two weeks in surgery wait time associated with the expedited fee policy may have meaningful clinical and quality-of-life implications for injured workers, in addition to being cost-effective policy for workers' compensation insurance systems, but did not affect the return-to-work time post-surgery as part of total disability duration. Minimal (and not statistically significant) differences in disability duration were observed for surgeries performed in private clinics versus public hospitals.