N.S. losing out on health transfers as private medical imaging grows

Susan Hart didn't want to wait any longer. 

She injured her knee last March and got a referral for an MRI in April, but months went by without an appointment. Meanwhile, her knee was swollen, painful, warm to the touch and crunched when she moved. It kept her mostly housebound.

"In August, I just got fed up and decided to pay for an MRI," she said in an interview at her home in Halifax.

Hart waited less than a week for an appointment at a private clinic and paid $1,145 for an MRI on her right knee, which confirmed what she had suspected: a torn meniscus. She's now on a waitlist to see a surgeon.

According to the federal government, no one in Canada should be paying out of pocket for medically necessary MRIs or any other diagnostic imaging services, and it's punishing Nova Scotia and other provinces for allowing it to happen.

Over the past two years, Ottawa has clawed back more than $3 million in health transfer payments to Nova Scotia over this issue. 

The deductions amount to only a fraction of a per cent of Nova Scotia's total health transfer payment, which has been well over a billion dollars annually in recent years. But Katherine Fierlbeck, a professor of political science at Dalhousie University who specializes in health policy, says the impact on provincial coffers doesn't tell the whole story.

"It might not matter much to the province, but I think it sure matters a lot to people who are themselves paying out of pocket," Fierlbeck said.

Depending on the clinic and the body part being examined, fees for diagnostic imaging services vary. By Health Canada's estimate two years ago, the average ultrasound price was $500 and the average MRI price was a little over $800.

Hart said for her, the cost was worth it because of the time it saved her. She recently got a letter from the health authority offering her an MRI appointment in February, meaning her choice to go private shaved six months off her wait.

According to Nova Scotia Health, half of patients get an MRI within 80 days of referral, but some can wait more than 14 months.

As clinics multiply, clawbacks could increase

For more than 20 years, there was just one private clinic in Nova Scotia offering medical imaging: Healthview, which offers MRI and ultrasound.

A second clinic, Wosler Diagnostics, opened last summer, offering ultrasound only, and a third clinic, Why Wait Imaging, is slated to open this month, offering ultrasound and MRI. All three are located in Halifax.

Health Canada has been calculating Nova Scotia's clawback based on the number of clinics and how many machines they operate. For the first two years that Ottawa issued deductions, Healthview was the only clinic and it had one ultrasound machine and one MRI machine. 

The proliferation of clinics means it is likely that future clawbacks will be larger — unless the provincial government acts.

Province could recoup clawbacks, avoid future ones

Private medical imaging clinics were operating in a grey area until 2020, when Health Canada told provinces and territories they needed to find a way to get rid of patient charges for diagnostic imaging. After a two-year grace period, Ottawa started levying penalties to provinces that hadn't made the necessary changes.

If a province comes up with a way to eliminate charges to patients, it can have previous clawbacks reimbursed and avoid future ones.

Nova Scotia is in talks with Ottawa about a reimbursement plan, but it's not clear how long it might take to come to an agreement, or how the province might eliminate patient charges. 

Health Minister Michelle Thompson declined CBC's interview request. Her department sent a statement that said, in part, "Clawing back this funding takes money away from our healthcare system and the Nova Scotians who need it."

Fierlbeck said Nova Scotia is lagging behind some other provinces, including Alberta and Quebec, which quickly responded to Ottawa's policy by contracting private imaging clinics. The contracts allow the clinics to keep operating, but the bill now goes to the provincial health insurer, not the patient.

Fierlbeck said establishing the contracts is "relatively simple," but there are also legislative and regulatory changes that have to be made to clarify what private clinics can and can't do, and to enable the province to audit the clinics.

"There is a lot to be done, and it could be that [Nova Scotia] is simply trying to get all its ducks in a row … but other provinces have done so, so you could also say that it's not really rocket science," Fierlbeck said.

What a clinic operator thinks

Henry Madubuobi is the CEO of Wosler Diagnostics, the company that opened a new ultrasound clinic in Halifax last year. He said he agrees with Ottawa's position and thinks his clinic's services should be publicly funded.

"In the long term it's always beneficial for the patients, and likely for even the province, financially, because then people will just get care earlier, rather than wait later and then the cost mounts up," he said.

Wosler has been operating clinics in Alberta and Saskatchewan since 2020, and Madubuobi said he chose Halifax for his latest location because he recognized that patients were facing long waits in Nova Scotia.

According to an analysis by the Fraser Institute in 2023, patients in Nova Scotia waited longer for MRI and ultrasound than those in any other province. 

Madubuobi said he would gladly send the bill to Nova Scotia's health insurance program, MSI, rather than to patients — it's how Wosler's clinics in Alberta and Saskatchewan operate.

"It's privately delivered but publicly funded health care, which allows the province to fulfil its Canada Health Act mandate of ensuring access to medically necessary services offered to its citizens."

However, Madubuobi said it would not be entirely easy for Nova Scotia to change its model of care. He noted that the ongoing shortage of ultrasound technologists could create a bottleneck.

Ottawa clamping down on other private health services

Last week, Ottawa announced another new policy that will clamp down on private health care. Health Minister Mark Holland said that by next spring, provinces and territories have to eliminate patient fees at clinics that offer primary care through nurse practitioners, pharmacists and midwives.

If the provinces and territories don't comply, the penalty is — once again — deductions to the federal health transfer.

In Nova Scotia, one clear example of where this new policy will apply is Bluenose Health, a private clinic that offers primary care by nurse practitioners. Patients pay a monthly subscription fee of $27.70 for an adult and $9.50 for children, plus service fees that range from $45 to $299.

Like Madubuobi, Bluenose's CEO Randy Stevens said he would welcome a new model wherein the province pays, rather than patients.

In fact, he said he's been lobbying for it.

"Most of the people that are patients of ours are insured by MSI, but they just can't go see a doctor, they don't have the ability," he said, referring to the long list of Nova Scotians looking for a primary care provider.

Stevens said his clinic would likely have to eliminate its subscription fee if it started billing the province, but he took no issue with that.

He said he's received no response from the provincial government on his lobbying effort.