If all goes according to plan, this summer will see another watershed moment in the relentless march of private health care across the nation. The Copeman Healthcare Centre, which already operates a private clinic in Vancouver, is planning to open three more -- in Ottawa, Toronto and London, Ont. -- as part of its push to have centres open in every major Canadian city by next year. These are not facilities offering specialty surgeries, or red-carpet care for the jet-setting elite. Instead, they will let Canadians pay for quicker, better access to the central players in the health care system -- family doctors. For an initial annual fee of $3,500 per person(their children 22 years and younger are free), and $2,300 per annum for subsequent years, patients will be able to buy a health care package including unlimited visits with a family doctor, and counselling from a range of health professionals. Patients can phone up in the middle of the night and talk to a nurse, and if necessary, they'll be transferred to a doctor. In Ontario, Don Copeman sees a huge potential market in the estimated 1.4 million people who don't have a family doctor.

"The public system will never be able to afford the provision of comprehensive, preventive health services that we offer," he says. "Governments don't have the funding to provide these services and politically it's unfathomable. They would literally have to find billions of new health care dollars and the public is no longer willing to accept an ever- increasing tax burden."

Paying for access to family doctors would mark a monumental shift in Canadian health care, says Colleen Flood, the Canada Research Chair in Health Law and Policy. For many Canadians, they are the first and only point of access to the system. They expedite a patient's access to specialists in both private and public medicine, and act as the gatekeeper to cutting-edge care. They also have a lot of influence over how long a patient waits for treatment. "They can try and help their patients get faster service with specialists by making phone calls depending on their connections and depending on the patient's need," says Flood. Doctors who have fewer patients have more time to be a patient's advocate, and Copeman's clinics promise four times more doctors per patient than in the public system.

Private medicine is rapidly altering the options available to patients in Canada. What once provided only cosmetic procedures and after-hours MRIs is now a dynamic, multifaceted industry serving thousands of Canadians and providing a host of treatment options. Cataract MD, for example, hopes to open its first Ottawa office this summer and one in Vancouver in the fall. The clinics will offer cataract surgery -- a procedure that was formerly available only in the public system in the province. Patients will be able to jump the public's median wait-list time of 34 weeks, for a cost of $1,500-$3,000 per eye. In Montreal, the country's first private emergency clinic -- Clinique médicale MD-Plus -- opened in October 2004. This month, the Westmount Square Surgical Center added total knee replacements to their menu of services, a complex procedure offered by only one other private facility in Canada. The Vancouver-based Cambie Surgery Centre plans to follow suit as soon as negotiations with the provincial government are completed.

It's difficult to estimate the full size or scale of private health care in Canada. Most provinces track only the services available in the public system, and though the private system has an advocacy group, the Canadian Independent Medical Clinics Association, it doesn't track the number of practitioners, patients or procedures. But the Maclean's complete guide to private health care reveals a growing industry: 23 private surgical centres offering medical services nationwide; 17 private cataract clinics; and in Quebec, 101 doctors have already opted out of the public sector entirely to work privately.

The Canadian Institute for Health Information estimates private-sector health care spending will reach $43.2 billion this year, up from $32 billion five years ago(with more than half of those dollars going toward drugs and dentistry). Those numbers have grown fast, and are only going to get bigger, says Brett Skinner, director of health policy research with the Fraser Institute. "There are more and more people being affected by the problems in the Canadian health care system, and that is driving acceptance of private for-profit care," he says. "The genie is out of the bottle, and there's no going back." Dr. Jeffrey Brock, who runs MedExtra, a medical consultancy firm based in Montreal, agrees. "Patients aren't getting what they need in the public system, and are looking for alternatives," he says.

In part, it's a simple matter of supply and demand. At the moment, 875,000 Canadians are on waiting lists for medical treatment, and many expect those lists to grow as the population ages. In 2004, the Conference Board of Canada reported that health care already consumes close to a third of all provincial revenues, and by 2020 that will rise to 44 per cent, just to maintain current levels of service. With medical expenses already projected to rise by $5 billion a year without doing anything to reduce wait times or improve care, it seems unlikely that governments will be able to increase spending enough to meet all the demand for service. "Health care, as it is currently funded, is unsustainable," said Glen Roberts, director of health programs for the Conference Board.

Not surprisingly, those with the means are looking for alternative, more expedient options. According to a Decima Research poll conducted in June, negative ratings of the country's health care system have now eclipsed positive ratings, increasing the pressure for change. And the qualms many Canadians had about "two-tier health care" are fading. The Decima poll found that a majority of Canadians now approve of private health care -- 51 per cent said they thought private family doctors were a good or very good idea. In Quebec and British Columbia, those figures were 58 per cent and 53 per cent respectively.

It seems the spreading dissatisfaction with Canada's publicly funded system has begun to break down Canadians' traditional hostility toward for-profit health. Maclean's recently polled 3,759 readers and found 64 per cent said they, or a family member, have waited what they consider to be an unreasonable amount of time for medical treatment or tests. And while many advocates of public health care have long decried the threat of a so-called "two-tier" medical service, many Canadians no longer see that as such a bad option. Respondents were closely split on the wisdom of establishing a parallel private/public system: 42 per cent in favour, 44 per cent opposed, and 14 per cent on the fence.

A recent Supreme Court of Canada decision has given the notion of private health care new legitimacy, says Peter Hogg, scholar-in-residence at the Toronto law firm Blake, Cassels & Graydon, and an expert in constitutional law. In June 2005, the Supreme Court ruled in favour of George Zeliotis and his family physician Jacques Chaoulli, striking down a Quebec law that said patients were not allowed to buy private insurance for health care procedures covered by medicare. Though the decision concerned private insurance, and ruled on a Quebec law only, the court did say that, in essence, if governments could not provide timely access to health care, they cannot prevent citizens from obtaining it on their own. "In some serious cases, patients die as a result of waiting lists for public health care," the decision said. "The prohibition on obtaining private health insurance . . . is not constitutional where the public system fails to deliver reasonable services. Life, liberty and security of the person must prevail."

This decision has created a fundamental shift in the legal landscape of public health care, Hogg says. "Governments are now on notice that they have to deal with their waiting lists. It's no accident that since the case there's been a tremendous amount of interest in the health care system and getting rid of waiting lists. None of that action occurred before Chaoulli. Governments were perfectly happy to just leave it all under the rug."

The decision served to embolden private health care providers, causing some to expand their menu of services. The ruling encouraged orthopaedic surgeon Brian Day to offer more complex surgeries at his Cambie Surgery Centre. The decision also encouraged management at Winnipeg's Maples Surgical Centre to expand their services. They are currently in negotiations with Manitoba Health.

Private health care in Canada is about more than increased choice for the very rich. It's about providing options to people on wait lists who are suffering in pain and have had to put their lives on hold. For some, it's about gaining access to life-saving drugs or cutting-edge treatments that aren't funded by the public system. In this, the first-ever guide to the burgeoning industry of for-profit medical care, Maclean's details what is available, what it costs and where to get the services that are increasingly in demand. We also explore private sector firms that offer ways to access public care in a more timely fashion.

The very term "private health care" often causes confusion. Some Canadians consider all for-profit facilities to be part of the private system, even when they bill the government for all services, and patients pay nothing from their own pockets. These sorts of facilities -- like the Gimbel Eye Centres in Alberta, and the Shouldice Hospital north of Toronto -- are now well-entrenched in the public system: so much so, in fact, that when NDP Leader Jack Layton had hernia surgery at Shouldice in the 1990s, he didn't realize it wasn't a purely public facility. In any case, the government paid the bill, and that makes it a public facility. "It's just part of the system," Layton said this year when questioned about the procedure. "The doctor says, 'Go there.' You pay with your [Ontario health] card. It never occurred to me [it was] anything other than medicare, which it is."

For the purposes of this guide, private systems are defined, in essence, by who pays. If the patient pays, either for purely private care, or for faster care in the public system -- paying a consultant, for example, to jump the queue and gain quicker access to a certain specialist -- then the service he's paying for is considered private.

The amount available across the country varies widely from province to province(see map, page 32). Some, such as New Brunswick and P.E.I., have no private health care providers. Others, namely Quebec and British Columbia, have seen an explosion in growth.

The discrepancy encourages those who want timely care to travel for it. Out-of-province patients have become an important market, and private providers usually cater their services accordingly. The Cambie Surgery Centre in B.C. tells its clientele when they'll be fit enough to travel home, given that so many of its patients come from out of province. Medical tourism, in other words, is not just about heading to India or the U.S., but is an industry we can call our own.

Quebec has the most comprehensive and advanced private health care in in the country. More doctors have opted out of public medicine in Quebec(101)than the rest of the provinces put together(6). There are more private cataract clinics in the province than anywhere else in Canada. Only in Quebec are there private PET/CT scanners, which are widely considered the gold standard in cancer diagnostic(page 46).

The centre of all this activity is Montreal, which local media have dubbed "the private health care capital of Canada." The city is home to the country's first private emergency clinic(page 33), and the only private surgeon in Canada doing full hip replacements(at the Duval Orthopaedic Clinic, page 37). In this city, there are more private cataract clinics(5)and radiology clinics than anywhere else in Canada(16). Only in Montreal can you pay to have your vaccines done at home, or your blood work done from the office.

"Quebec tends to look at European models rather than the American system. In France, they have a mixture of public and private health care, and Quebecers know they have one of the best health care systems in the world," says Zoltan Nagy, executive director of the Canadian Independent Medical Clinics Association. "They don't really believe in 'it's the Canadian way or the American way and there's no other option.' They are leading the way because they are more open-minded."

British Columbia is also far ahead of the rest of the country. There are 14 private clinics in British Columbia doing operations complex enough to warrant a general anaesthetic. They offer a range of adult and pediatric procedures in orthopaedics, urology, gynecology, general, cosmetic, vascular and oral surgery.

And the largest and most technically advanced private hospital in Canada is located in downtown Vancouver(page 38). The Cambie Surgery Centre was founded by Dr. Brian Day, who will become president of the Canadian Medical Association in August 2007. Known as a private health care trailblazer, he also founded one of the country's only private specialist referral clinics. This service allows Canadians from anywhere in the country to book an appointment with a medical specialist within just a few days. Patients don't even need a doctor's referral. They just phone a toll free number, and arrange for an appointment with whatever type of doctor they need. Once the appointment is booked, the clinic arranges the transfer of the patient's medical file to that specialist. The service is extremely popular, Day says, and sees thousands of appointments made every year, many for patients from out of province.

There are no private surgical clinics in Alberta, Saskatchewan, Ontario, or Atlantic Canada. There are also no private family doctors in Alberta, Saskatchewan, Manitoba, Ontario or Atlantic Canada either. Premier Ralph Klein might have a reputation for opening the doors to private health care in Alberta -- letting for-profit companies become part of the public system -- but in terms of services that patients actually pay for, the province is a closed shop. When a private Calgary clinic with 24/7 access to family doctors announced plans to open earlier this year, the province's College of Physicians and Surgeons sent letters of objection and those plans were promptly shelved.

Those patients who don't want to wait in line are often referred out of province. It's very likely that purely private care hasn't taken off in Alberta because the province has the highest per capita public health care funding in the country, which has lessened the demand for private medicine.

In Ontario, the situation is very different. In June 2004, the Ontario government brought in the Commitment to the Future of Medicare Act. This law built on the existing provincial legislation that banned private clinics from charging for medically necessary services. It also made it illegal for patients to pay for medically necessary services, with a penalty of up to $10,000. Corporations were liable to a fine of $25,000. Doctors who facilitate the offence can also be fined $10,000, and anyone who knows it's going on and doesn't report it can be fined $1,000.

Some private health services that aren't considered "medically necessary," such as expedited MRIs, or certain sports medicine or pain management services, do exist in Ontario, and that sector is growing. Because the law demands that, in essence, the government must pay for anything medically necessary, private operators are moving into those areas the province does not classify as such. The Provis Infusion Clinic, for instance, Ontario's first private cancer clinic, offers drugs that aren't funded by the public system(page 44).

The differing levels of private care from province to province are in part a function of how open provincial governments are to private medicine. Private clinics are not illegal under federal law. What does violate the Canada Health Act is charging patients for medically necessary services. However, what is considered medically necessary has changed and become more difficult to define, says Colleen Flood. "We used to have a boundary between what is medically necessary and what is not, but it was between whole categories of services, such as in vitro fertilization, or dental or cosmetic surgery that was considered unnecessary, and hip operations and MRIs that were considered medically necessary. Why else would a patient need a hip replacement unless it was medically necessary? But today, private clinics have started using this grey area of the law to muddle that distinction. Sometimes hip replacements are publicly funded and then they are considered 'medically necessary,' and sometimes they can be privately financed because they are not considered 'medically necessary.' These distinctions are more semantic than based in reality."

In the past, there have been times when clinics have charged both patients and the government for the same medically necessary service. This is known as "double billing" and violates the Health Act. But enforcement has been spotty.(Last year, the British Columbia government kept track of private clinics charging for medically necessary services by looking through old newspaper clippings.)

Some clinics charge "facility fees" to patients, while passing the doctors' fees along to the government. Through the 1990s, Ottawa kept a lid on the practice by witholding federal transfer payments to provinces that allowed it. That effectively kept for-profit medical centres confined to elective procedures like laser eye surgery, MRI tests and plastic surgery. With the rise in patient demand, however, some private clinics have found innovative ways of billing patients. For example, Cataract MD combines laser eye surgery with cataract surgery as part of a package.

But in the wake of the Chaoulli decision, there may be no more need for creative ways to stay within the law. Many private heath providers are anticipating that any and all medical services can now be provided on a for-profit basis, and are ramping up plans to expand services and open outlets across the country. "In the wake of the Supreme Court decision, a fully open parallel private system is now allowed," Brett Skinner says. "Previously, any province that said, 'We're going to allow a private payment option, forget what the Canada Health Act says,' would be punished with the reduction of federal transfer payments. Now I think they could successfully go before the courts and argue that that penalty is unconstitutional."

There remain a number of other restrictions on private health care. For example, doctors are forbidden from providing medically necessary services in both the private and the public system, and provinces have been reluctant to give hospital licences to private providers. The legal restrictions have meant that not every medical service is up for sale. The most complex operations must be done in a hospital, and private hospitals are few and far between.

Patients who can't access the care they need in this country can travel outside of Canada, and with wait lists growing, increasingly they're doing just that. This has spawned the growth of another industry in Canada -- medical brokers and medical travel agents. These middlemen help arrange travel and care at a private clinic, either in another province, or outside the country. Some medical travel agents, such as MedSolution, specialize in out-of-country care. MedSolution has business relationships with hospitals in France, Turkey and India, and arranges cosmetic and medical procedures at these locations. Other medical travel agents, such as Vancouver-based Timely Medical Alternatives, deal only with private clinics in North America. The company offers package deals on hotels and operations at U.S. clinics not more than a two-hour drive from the border.

Patients who pay out of pocket for medically necessary care may be eligible for government reimbursement, says Brian J. Cohen, a health law lawyer based in Toronto. Cohen has represented clients seeking reimbursements for medical services not covered by their government health plans and has won several precedent-setting cases for patients seeking treatment funding, both in Canada and in the United States, for care not previously covered by their provincial plans. Last year, he persuaded the Ontario Health Insurance Plan to pay for a patient to be treated with the colon cancer drug Erbitux at a Buffalo hospital. At the time, the drug had not yet been approved by Health Canada, but Cohen still won the case for reimbursement. "If the service is truly medically necessary, then the provincial health plan has to cover the cost, be it in Canada or out," Cohen says.

Cohen has helped other cancer patients win funding for hospital-based drug treatments available stateside but not in Canada. The U.S. leads Canada by several years in both cutting-edge treatment and drug availability for cancers, stresses William Hryniuk of the Cancer Advocacy Coalition. For this reason, there are several services in Canada that help patients with access to the most advanced cancer care stateside. The consulting firm MedExtra arranges appointments and treatment plans with renowned oncologists in the United States. These treatment plans can either be followed once back in Canada, or if the treatment is unavailable, pursued at a clinic in the United States. The renowned American cancer clinic M.D. Anderson has a Toronto office, which co-ordinates the travel and treatment of patients seeking cancer care at their clinic in Houston(page 46).

Currently, Canadians still look abroad for the most advanced treatments, or to cut their own waiting times. Frustration with the public system has led U.S. firms to set up shop here in part to funnel patients south of the border. Canadian companies are now capitalizing on this same demand. For the hundreds of thousands of patients on wait lists and in pain, this is a welcome shift, Day says. "Canadians are looking to new treatments and technologies to keep them in optimum health, and are happy to pay for what cannot be provided in the public system. That leaves an important role for private health care. The public sector doesn't have the resources to purchase and utilize these new technologies. This is an interesting and dynamic time in this country. There's an enormous sense of frustration with the public system. There are close to a million on waiting lists, and these people are tired of putting their lives on hold."

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