Last fall, a Montreal newspaper reported that some local pediatricians were charging parents for routine vaccinations of their children. The supplementary fee was being charged even though physicians get the vaccine for free and doctors in Quebec's community clinics (CLSCs) will inject it for free, the paper reported. What it didn't report was that not only is this type of supplementary fee common across Canada, but it is likely to grow in popularity.
“Supplementary fees are assuming more importance and will gain more importance as time goes on,” says Dr. Steve Pelletier, a family physician in Clarence Creek, Ont. “They're a direct result of a stagnant fee schedule and the rising cost of medical practice and modern equipment.”
As for the vaccination fees charged in Montreal, pediatrician Mary Gillin makes no apologies. “We try to inform everybody about which CLSCs have vaccination clinics, but the fact is the DSC [Departement de santé communautaire] encourages us to do [immunizations in our offices], because otherwise the CLSCs wouldn't be able to cope,” she says. Her office charges $10 per vaccination.
Lynda London, office manager at Montreal's Cavendish Health Centre, says patients shouldn't be surprised by the charges, particularly after doctors' fees were cut in Quebec, so an office visit that used to pay $16 now pays $14. “We're not going to eat extra charges … any more,” says London. “Overhead goes up and doctors' fees go down. Someone has to absorb these costs.”
Every provincial medical association now provides a list of recommended charges for professional acts not covered by medicare plans. These services range from providing proof of a visit to the doctor's office ($10 in Quebec, $11.19 in Ontario, $22.60 in Alberta) to giving an expert opinion ($200 an hour in Quebec, $223.65 an hour in Ontario, $285–$450 in Alberta). These are suggested amounts only; it is up to the physician to decide if and how much to charge.
Although the lack of monitoring might suggest a wild-west atmosphere of dramatically varying — and escalating — rates, Pelletier says that this is not the case because most physicians are uncomfortable about asking patients for any money. He says many doctors feel that asking patients for money “cheapens the doctor–patient relationship.”
However, Dr. Connie Ellis, a Calgary physician who routinely bills for uninsured services, thinks the opposite is true. “I really support billing for supplementary services because it values us as physicians for the work that we do.”
Pelletier thinks more physicians should support that view. “When patients are told about the time I take to provide an uninsured service, it solidifies the relationship,” he says. “They appreciate me more.”
Some doctors choose another route by charging an annual administration (block) fee that covers immunizations, completion of medical forms, photocopying of files and returning calls — in short, any professional act that uses time and resources not remunerated by provincial health insurance.
“You always have to give your patient a choice,” says Pelletier. “The difficulty is that you have to be aggressive about pursuing individual charges for those who choose not to pay an annual fee. Otherwise, it's not fair to those who pay the fee.”
Block fees do not contravene the Canada Health Act, which only prevents private billing for medical acts insured under medicare. Indeed, a ban of block fees was struck down by the Ontario Divisional Court in 1995.
Whether patients pay per photocopy, per vaccine or per year, Pelletier says supplementary fees have become an economic necessity. “Physicians have to look at all the services they used to provide for free and see if they can continue to do so,” he says. —