A View Royal woman was confused by a letter from her doctor last week, introducing a new “operational and service fee” of $125 a month. 

“My first thought was, ‘Could this be a scam?’” she said. “What the heck is this? Then I immediately thought, ‘This is a two-tiered system.’”

She asked that we not use her real name out of concern for her ability to find a doctor in the future (“I certainly don't want my name out there as somebody who's a shit-disturber for doctors,” she said) so we’re calling her Alyssa. 

Her doctor, Dr. Perpetua Nwosu of Perpetual Health Clinic in Victoria, wrote in the letter that the clinic has faced increasing challenges meeting the needs of patients over the last year, and this “retainership service” is needed to keep the clinic from closing. 

“Over 70% of our patients are elderly with multiple health concerns requiring multiple appointments within a month,” she wrote. “At the risk of closing the Practice and denying our patients the much-needed health care, we would like to offer some specific non-medical services (the ‘Services’) to meet the demands of every patient or meet the demands of most of the patients of the Practice.”

The $125 retainer, she wrote, will help cover building costs, salaries, materials, software, and more. Patients can book 30-minute appointments with her to discuss multiple medical concerns, and she’s also offering home-visits to people who are housebound within three kilometres of the clinic, or further for an extra fee. 

But the letter doesn’t specify what services a paying patient gets access to compared to a non-paying patient. Nwosu wrote she wants to hire registered and licenced practical nurses, a physiotherapist, and a mental health counselor. The latter two are not covered by BC’s health insurance so separate charges for those appointments are typical. Charges for meeting with a nurse are not.

Dr. Nwosu did not respond to questions regarding the retainer.

“It just feels like blackmail. It's like, you pay this fee or, ‘Sorry, you no longer have a doctor,’” another patient of Dr. Nwosu’s told Capital Daily. “Knowing what the situation is with how hard it is to find a doctor, that's really scary.” 

This patient, a Saanich woman in her early 70s, also didn’t want to be named for fear of losing her doctor, so we’re calling her Hayley. 

“It's upsetting because I really believe in a healthcare system that is available to all. And this, to me, is the way that we move towards a two-tier system, where you're rationing the delivery of health care. Anyone who can't pay—too bad, you are second-class,” Hayley said. “I know our healthcare system has got serious issues right now, and they need to address it, but this is not the way to do it.
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Health Insurance BC, which manages Medical Service Plan (MSP) charges from physicians to the government, does allow doctors to bill patients an optional administration fee. The fees must be optional, and patients cannot be denied service if they choose not to pay. 

But, there’s nothing stopping doctors from charging an enrollment fee for preferential service.

“That's not something that we condone, or do we suggest engaging in; it just basically jumps you ahead of the queue of other patients,” a representative of Health Insurance BC told Capital Daily. 

But they say they can’t do much about it. 

“It's not something that's an accepted practice and if there is a doctor doing it, I'd recommend writing to MSP indicating the doctor's name and we can have it looked into. But there's nothing prohibiting them from … signing [patients] up for a monthly subscription fee.” 

Renoviction

The glaring omission in Dr. Nwosu’s letter is: what happens to patients who choose not to pay? Hayley called to find out more and asked the clinic receptionist if patients were able to opt out of the retainership service. 

“Her response was sort of a ‘Yeeess?’” Hayley said, mimicking the hesitation she heard in the receptionist’s voice. 

“But she then went on to say that within a period of time—probably around six months—they plan to close the office and reopen it [with a new list of patients]. So my comment was, ‘Oh, so people that don't sign on for the fees will not be in the newly created practice.’ And she basically agreed.”

“It’s like a renoviction from a doctor,” Alyssa said. 

Health Services BC said if a patient believes they have been denied service for opting out of an administrative fee, to file a formal complaint with the College of Physicians and Surgeons of BC.

Both patients Capital Daily spoke to are at an age where they expect to need more involved medical care in the near future, though both are currently healthy. “I’m 69, and things start to break down,” Alyssa joked. 

Hayley’s husband does have serious medical issues, however and needs a consistent physician. They’re trying to decide if they’ll pay the premium fee, not because he needs the extra services, but just to keep him on the doctor’s roster. “I have no idea how we would find another physician, and he does need one. So puts us in a precarious situation,” she said.

A shortage of doctors has been top-of-mind for many in BC in recent years, with about a million people in the province lacking a primary care physician. In Greater Victoria, that number might be as high as 100,000, or roughly one in four people. Every time a doctor leaves town or a clinic closes, thousands more are added to that roster, while new urgent and primary care centres have fallen short of filling the gap.

After a couple secured a doctor by placing an ad in the Times Colonist, Premier John Horgan quipped that he might do the same to get more funding from the federal government. 

Alyssa can afford to pay the $125 a month, but on principle has decided not to. "I'm very concerned, because it is a loophole that could create a two-tiered system. ‘Here's a couple of hundred bucks, do I get a GP now? Can I be on your list?’ That’s not how the Canadian health system is supposed to be.”

A legal question

An advocate for private care in Vancouver, Dr. Brian Day, recently lost a court appeal in which he argued that the ability to pay for private care should be constitutionally protected. The lower court and BC Court of Appeal disagreed, saying while access to care is important, the Medicare Protection Act clearly protects individuals without the ability to pay from being “deprived of medically necessary care.”

Both women have reached out to their local MLAs, called the Ministry of Health, Health Insurance BC, and the College of Physicians and Surgeons of BC. The Ministry was interested but referred them to the College. Health Insurance BC was alarmed, but had no jurisdiction. 

Hayley was later contacted by someone from the Medical Services Commission, a body who enforces the Medicare Protection act, who told her it and the College will send a letter to Dr. Nwosu. She expects a follow up letter from the doctor backpedaling on the retainer idea. 

“Hopefully, she doesn’t pack her bags and leave town, because then we’d all be worse off,” she said.

Capital Daily reached out as well. The College of Physicians and Surgeons BC confirmed it was aware of the situation, but declined to comment, “until the matter has been thoroughly reviewed.” 

A spokesperson for the Ministry of Health said, in a statement, “We’re grateful this case has been brought to our attention and can confirm the Medical Services Commission is reviewing this case,” and declined to comment further. Island Health said billing issues are outside of its jurisdiction, as did Dr. Bonnie Henry when asked at a press conference.

Green MLA for Saanich North and the Islands Adam Olsen said schemes like this are becoming common.

“They're absolutely counter to the promise of universal health care,” he said. “The longer it takes to address it, the more entrenched they become, and the more people accept this as the solution to the healthcare crisis.”

What the solution might be, neither patient suggested they have the answer, but Alyssa suggested it might start with changing the way general practitioners are the gatekeepers for diagnostic tests. She recalled needing to see a doctor just to get a referral for a routine pap smear. As walk-in clinics close, she’s left with the emergency room as a place to get a referral for an x-ray to see if she can have bunion surgery. “It’s madness.”

“My greatest concern isn't a personal one; my greatest concern is that this is allowed to happen—and if more doctors see this as, ‘Boy, this is a great way to make a lot of money,’” Alyssa said. “I have no idea how many patients Dr. Nwosu has, but you think $125 a month for even 100 patients. That’s a huge amount of money.”

Hayley fretted about the precedent it would set for other doctors if the fee is able to be established here.

“It's a loophole that—you know, even if it is legally right—morally, it goes against the whole idea,” Hayley said. ”If this is legit, if they are legally able to do this, then I suspect this is going to become standard practice for GPs in all of BC. Why wouldn't they be able to charge a monthly fee in order for people to have a physician?”