What you need to know about Ontario's new health-care legislation

The Ontario government tabled a bill that will expand the role of private health clinics in an effort to reduce the surgical backlog in the province.

The 70-page Your Health Act outlines the application process for these surgical and diagnostic centres to obtain a licence, what will be covered under the Ontario Health Insurance Plan (OHIP), and what happens if a patient complains about subpar service.

Here’s what you need to know:

What is the government actually proposing?

The Progressive Conservative government is hoping to reduce wait times by allowing more private clinics to perform OHIP-covered surgeries and diagnostic procedures. This includes an expansion of cataract surgeries, MRI and CT scans, minimally invasive gynecological surgeries and, eventually, knee and hip replacements.

The surgeries will be performed at both not-for-profit and for-profit clinics.

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This will roll out in three parts, starting with cataract surgeries. The government has said about 14,000 more surgeries will be performed each year as a result.

Once the legislation passes, the changes will be permanent.

Will these surgeries be covered by OHIP?

Yes. The ministry has mandated that no resident will have to pay out of pocket for these services, regardless of where they are conducted.

Can you pay a clinic more money to skip the line and get a surgery faster?

Technically – no. The legislation prohibits accepting payments for a “preference in obtaining access to an insured service.”

However it is unclear about what happens if a clinic offers an uninsured service that is available sooner.

Can a clinic offer a more expensive option and upsell on OHIP services?

Yes. The legislation does not prevent a clinic from upselling or offering services that are not covered by OHIP. However, the government has said that a clinic will need to provide all relevant information about uninsured services, including costs, up front in a transparent way prior to obtaining documented consent from a patient.

Can a clinic refuse a patient if they do not want to pay more?

No. The legislation makes it clear that a clinic cannot refuse an insurable service if a patient cannot pay.

How will I know what is covered under OHIP?

The legislation mandates that “prescribed documents” should be clearly visible to members of the public and posted on the centre’s website. This will likely also include service fees, the ministry said, although details have yet to be revealed.

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A prescribed document is set to be defined in future regulations.

What if a clinic refuses service or doesn’t provide proper care?

The province will designate “expert organizations” that will work with Ontario Health and the Ministry of Health to ensure quality and safety standards are met. It is unclear who those expert organizations will be.

Once established, the organization will be responsible for outlining safety standards and regular inspections for each facility.

Each centre will also be required to have a process for complaints that patients can use if they do not believe they received the highest level of care. If patients are unable to have their complaints addressed at the centre, they will be forwarded to the patient ombudsman.

What are the consequences of a complaint?

The patient ombudsman will share information of the complaint, as well as the results, publicly.

An individual who fails to comply with rules under the Independent Health Facilities Act could face a fine of up to $50,000 on a first offence. This goes up to $100,000 for subsequent offences. Individuals may also face imprisonment for up to 12 months.

A corporation could be fined up to $100,000 for a first offence and $500,000 for a subsequent offence.

What does a clinic need to do to get a licence?

The application for a licence appears to be extensive. It must include, among other things, a detailed description of services provided, including uninsured services, as well as details about the business’ staffing model. This will involve rates of compensation, the number of staff needed for each position, and information regarding hospital privileges of physicians who provide services at the centre.

They will also have to prove they consulted with health-system partners and show how they will maintain those relationships.

How many new clinics will be created?

This is unclear. Health Minister Sylvia Jones said there would not be a cap on the number of clinics approved for licencing. However, as part of the application process, a number of factors will be considered, including location, wait times in the area, how it will “promote connected and convenient care”, the impact on other health services, and the projected cost for operating the clinic.

Each licence will be issued for a maximum of five years, although this could change in the regulation.

Why do we need this?

Ontario’s health-care system was hard hit during the COVID-19 pandemic. Emergency rooms and intensive care units were regularly over capacity. Staffing shortages led to closures while physicians who typically worked in surgical wards were re-routed to general or emergency care. All of this exasperated an already too-long wait list for surgeries and diagnostic procedures.

The province said last month there was about 206,000 people in Ontario waiting for surgical procedures.

What are the concerns?

Experts told CTV News Toronto last month that "very tight oversight" is needed to ensure quality of care in these independent clinics.

It’s still too early to know if the oversight outlined in the Your Health Act will be enough to alleviate this concern, but opposition parties have already begun to question the effectiveness of the “expert organizations” the government will be employing.

Staffing is also major concern.

“The idea is good, but there's still there's a tremendous lack of human resources to be able to sort of pull this one off,” Doug Angus, professor emeritus at the University of Ottawa’s Telfer School of Management the University of Ottawa, told CTV News Toronto in January.

The concern is that health-care staff working on the frontlines will leave to work at private clinics that may have higher pay and better hours.