Ontario weighing nurse practitioner funding options amid extra billing concerns

Click to play video: 'Province unveils plan to allow nurse practitioners to open clinics'
Province unveils plan to allow nurse practitioners to open clinics
RELATED: The province revealed a plan this week that will allow nurse practitioners to run their own clinics. But as Kabi Moulitharan reports, questions remain how far their services can go and whether it’s the right step to solving a health care crisis – Nov 25, 2023

The Ford government is exploring options on how to bring nurse practitioners into the public healthcare system as service providers similar to doctors, Global News has learned, as the province deals with increased complaints of fee-based clinics that have popped up across Ontario.

Government sources told Global News that Ontario also wants the federal government to specifically “instruct all the provinces to bring nurse practitioners into the public system,” a position that Health Minister Sylvia Jones is expected to outline in a letter to her federal counterpart.

A federal “edict,” the government feels, would prevent a patchwork system that could lure Ontario-based nurse practitioners to other provinces.

“Ontario believes it needs to be a national-level solution so that we don’t start to see nurse practitioners moving around (to other provinces),” the source said.

“We need the federal government to come down and say all provinces and territories need to fix this, and then let each province and territory figure out how that will fit into their health care system,” the source added.

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In recent months, more than a dozen health clinics across the province, led by nurse practitioners, have started offering a range of health-care services — from urgent appointments to treat minor ailments to more in-depth mental assessments — for fees that can average hundreds of dollars.

While the Canada Health Act lays the groundwork for how medically necessary services are paid for under the country’s single-payer model, nurse practitioners are treated as employees within the health-care system rather than independent operators.

The Ford government calls it a federal loophole that has allowed nurse practitioners to operate outside the health legislation and charge patients fees that would be typically covered by the Ontario Health Insurance Plan (OHIP).

The solution, however, is proving to be more complicated than Queen’s Park simply writing a cheque.

Private Nurse practitioners question why they're not being funded

Nurse practitioner-led clinics have been an integrated part of Ontario’s health-care system since 2011, when the former Liberal government greenlit 25 publicly funded clinics across the province.

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In 2023, the Ford government said it was spending $46 million a year to fund the 25 clinics serving nearly 80,000 people who had difficulty finding access to primary care.

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“All nurse-practitioner-led clinics are funded for a lead nurse practitioner, a collaborating physician and a team of interdisciplinary providers such as nurse practitioners, registered nurses, social workers, registered dietitians, pharmacists, and health educators,” the government said in a 2023 health care document.

Nurse practitioners working in those clinics are “paid a salary and do not work on a fee-for-service basis,” according to the Nurse Practitioners Association of Ontario.

While the Ford government approved another seven provincially funded nurse practitioner-led clinics in February, as part of a $110 million increase in primary care funding, Queen’s Park has taken a case-by-case approach to the situation.

The slow pace of green-lighting clinics, the Registered Nurses Association of Ontario (RNAO) believes, has created “frustration” among other nurse practitioners who were stuck sitting on the sidelines.

“They are giving up on waiting for funding,” said RNAO president Doris Grinspun. “They’re saying the public wants us we are going to set up shop and they’re charging patients.”

Chris Savard, the owner of Holistic Solutions, a fee-for-service nurse practitioner clinic in Hamilton, said his team is simply trying to fill in the gaps in access to primary care.

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“Most of our practitioners work in the public system as well,” Savard told Global News. “We see such a need for the community we all thought that this would be a great way, an innovative way of helping people to get access to health care.”

Holistic Solutions charges patients $240 for initial intake visits, $80 for urgent appointments, follow-up appointments and prescription refill requests, and $50 for virtual episodic appointments.

If a patient is referred to a specialist, requires a diagnostic test or needs any OHIP-covered service, Savard said, the publicly funded system would cover the cost.

“It’s just our fee, our assessment fee is not covered by OHIP,” Savard said.

Savard, however, told Global News his preference would be for privately run clinics to be brought into the public system.

“Why are we not being funded?” Savard asked. “For years and years and years we’ve been asking for funding models and we don’t know why they’re not being provided.”

How much funding to fix the issue?

The RNAO claims the Ford government is sitting on “about 100 proposals” from nurse practitioners who want to open a publicly funded clinic including in Peterborough, Orillia and Toronto.

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The association has been lobbying Premier Doug Ford for an additional $15 million to fund independent nurse practitioner-led health clinics and believes the government is receptive to the idea.

But government sources indicate the situation is more “complicated” and the province is looking for a more long-term solution.

To ensure there is “zero option” for private clinics, the source said, nurse practitioners need to be “included as a care provider under (the provincial) Commitment to the Future of Medicare Act.

That inclusion would likely need to come with billions of dollars in funding, the source said, because it would need to be an “open-ended agreement” on billing, similar to family physicians who don’t face billing caps under OHIP.

Currently, the provincially funded nurse practitioner-led clinics have direct funding agreements with the Ministry of Health and don’t receive billing codes like doctors.

Heath Minister Sylvia Jones has asked the civil service for options on the best path forward.

“We are looking at what that would look like, bringing nurse practitioners into the publicly funded system. Full stop. What that would look like,” the source said.

On the federal front, the province is looking for direction, funding and implementation time.

Canada-wide direction from Ottawa, the government hopes, would prevent poaching by other provinces that would still allow a two-tier regime while also creating distinctions for individual provinces.

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Ontario, along with other provinces, also asked the federal government for increased funding if nurse practitioners are to be included into the public healthcare system.

Government sources said the province also “expects” an implementation period allowing Ontario to “properly” set up a new system for nurse practitioner-led clinics.

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