The Alberta government rolled out its dual-practice model last month for eligible practitioners as part of a range of changes brought in by Bill 11. The changes allow doctors to work in public hospitals and simultaneously offer private care on the side.

Proponents say that with the proper guardrails, this model will lower wait times for elective surgeries in the province by increasing surgical capacity. But health advocates warn that the new model could increase public wait times and may violate the Canada Health Act. They are concerned that dual practice creates a two-tiered system in which ability to pay, rather than medical need, determines who receives care.

"People who can afford to jump the queue will have their surgeries done sooner, and the rest of us will have a delay in surgery. This is because there is a fixed number of healthcare providers in Canada; not just doctors, but also nurses and other staff," Bolu Ogunyemi, MD, president of the Canadian Medical Association (CMA), told Medscape News Canada.

It is too early to know what impact Alberta's dual-practice model will have on public wait times, a spokesperson for the Alberta Medical Association (AMA) cautioned. "It will depend on how the model is implemented and whether it creates new capacity or draws scarce healthcare resources away from the public system…. Dual practice is most likely to achieve its intended goals if it adds capacity without shifting physicians, staff, operating time, or other resources away from publicly funded care." 

Mixed Data on Benefits 

Alberta's dual-practice model is unique in Canada but resembles the model in Quebec, where doctors can opt out of the public system to work privately. Only 54% of public patients in Quebec receive hip replacements within a 26-week benchmark set by the Canadian Institute for Health Information, according to national data. 

In Ontario, where these surgeries are performed almost entirely in the public system, 84% of patients get their surgery within that timeframe. In Alberta, it is 63%, which falls below the 69% average for all of Canada.

Even before Bill 11, the Alberta government contracted out surgeries to chartered surgical facilities, Braden Manns, MD, professor and senior associate dean of the Cumming School of Medicine at the University of Calgary, told Medscape News Canada. During this time, the proportion of breast cancer surgeries performed within clinical targets dropped, the Canadian Broadcasting Corporation reported.

"Surgeons go to a chartered surgical facility with their anesthetist and operating room team," said Manns, who coauthored a recent commentary in the Canadian Medical Association Journal about Alberta's dual practice. "As a result, there's less availability of those staff inside the public hospital system, and our operating rooms are closed."

Research in Australia found that dual practice led to "limited" reduction in wait times, while in the United Kingdom, it resulted in longer wait times for lower-income patients.

Strong Guardrails Needed 

The provincial government promises to put strong safeguards in place to protect access to the public health system. To offer private surgeries, physicians must complete a minimum number of hours in the public health system. Life-threatening and emergency care will remain entirely publicly funded. The government will also monitor the dual-practice model.

The AMA has proposed 70 key safeguards, which go beyond what was offered by the provincial government.

Ogunyemi is concerned about what he considers the lack of accountability around Bill 11. "What happens if doctors and staff only work in the private system?" he asked. "There's nothing in the legislation that defines what would happen in this case." 

Similarly, Manns questions whether the bill will function as intended. "The province is not good at regulating physicians, so [Bill 11] is not going to help public wait times," he said.

Dual practice in Alberta will spur innovation in the healthcare sector, Nadeem Esmail, director of health policy at the Fraser Institute, argues. "When no one [in the private sector] is delivering a higher standard of care or offering more patient-focused services, there is a lot less pressure on the public system to do so," he said.

But Alberta's "cautious and highly regulated approach" to dual practice, while "a step in the right direction, … is going to limit the benefits of the reform," he told Medscape News Canada. 

Calls for Federal Review 

More than 20 health organizations, including the CMA, endorsed an open letter sent by Canadian Doctors for Medicare to Prime Minister Mark Carney and Health Minister Marjorie Michel calling on the federal government to review Bill 11 and step in if it violates the Canada Health Act.

Whether Ottawa acts by taking back federal funding sent to Alberta's health system remains to be seen.

"Everyone's watching what happens in Alberta," said Ogunyemi, "including premiers from other provinces."

However, "I think that some people at the federal level are not going to say anything until the [Alberta] referendum happens," he said. The referendum includes questions about Alberta independence and healthcare funding. Voting ended October 19.

Ogunyemi, Manns, and Esmail reported no relevant financial relationships.