JANUARY

CANADA
Teams, the average practice size is approximately 10 physicians, and ranges from seven to 14 physicians in
other models (Rudoler et al., 2015). In Ontario, team composition varies among practices, and interdisciplinary
providers are generally salaried employees of the practice.
Patients have free choice of primary care doctor, although in some areas choices are restricted owing to
limited supply.
Provincial and territorial ministries of health negotiate physician fee schedules (for primary and specialist care)
with provincial and territorial medical associations. In some provinces, such as British Columbia and Ontario,
payment incentives have been linked to performance, and also are used to encourage the provision of a
number of services including, but not limited to, delivering “guideline-based” care for specified chronic
conditions, offering preventive services, developing care plans for patients with complex needs, and registering
complex or vulnerable patients.
Outpatient specialist care: The majority of specialist care is provided in hospitals, although there is a trend
toward providing services in private nonhospital facilities. Specialists are mostly self-employed and paid fee-forservice.
Specialists in Canada received an average of CAD379,051 (USD300,545) annually in clinical fee-forservice
payments in 2013–14 (Canadian Institute for Health Information, 2015c). In most provinces, specialists
have the same fee schedule as primary care physicians. In 2014, 65 percent of specialists reported to work in
a hospital, compared with 24 percent in a private office or clinic (National Physician Survey, 2014). Patients can
choose, and have direct access to, a specialist, but it is common for GPs to refer patients to specialty care.
Specialists who work in the public system are not permitted to receive payment from private patients for
publicly insured services. There are few formal multispecialty clinics, although in some provinces, such as Ontario,
there are informal, or virtual, networks of specialists that share patients and information (Stukel et al., 2013).
Administrative mechanisms for paying primary care doctors and specialists: The majority of physicians and
specialists bill provincial governments directly, although some are paid a salary by a hospital or facility. There
are no direct payments from patients to physicians; there is no cost-sharing, although patients may be required
to pay for services that are not medically necessary—for example, physician letters sent to employers when
employees are ill.
After-hours care: After-hours care is provided generally by physician-led (and mainly privately owned) walk-in
clinics and hospital emergency rooms. In most provinces and regions, a free telephone service (“telehealth”)
is available 24 hours a day for health advice from a registered nurse. Traditionally, primary care physicians were
not required to provide after-hours care, although many of the government-enabled group practice arrangements
have requirements or financial incentives for providing after-hours care to registered patients. For example, in
Ontario, physicians practicing in non-fee-for-service models have to provide sessions during some evenings and
weekends. In some models, this amounts to a single three-hour session per week per physician in the group, up
to five sessions per week (MOHLTC, 2009). These physicians are paid a 30 percent bonus for primary care
services provided during evenings, weekends, and holidays (MOHLTC, 2011). Manitoba has implemented
QuickCare clinics, staffed by nurses and nurse practitioners, to meet health care needs after hours (Government
of Manitoba, 2015).
The 2012 Commonwealth Fund International Survey of Primary Care Doctors found that only 46 percent of
physician practices in Canada had arrangements for patients to see a doctor or nurse after hours, with the
highest rate in Ontario, at 67 percent (Health Council of Canada, 2013). The same survey found that only
30 percent of physicians received notification of hospital emergency department visits by their patients, and
only about a quarter received a full report on specialist consultations.
Hospitals: Hospitals are a mix of public and private, predominantly not-for-profit, organizations, often managed
locally by regional authorities or hospital boards representing the community. In provinces with regional health
authorities, many hospitals are publicly owned (Marchildon, 2013), whereas in other provinces, such as Ontario,
they are predominantly private nonprofit corporations. There are no data on the number of private for-profit
clinics (which are mostly diagnostic and surgical). In Ontario, as of May 2014, the government was providing
International Profiles of Health Care Systems, 2015 23