Wayne Hildahl has been on both sides of the private-public divide. He founded the Pan Am Clinic in 1979 as a private, for-profit sports medicine centre and 22 years later, it became an arm of the Winnipeg health authority.
When the clinic was private, he had the advantage over government officials negotiating contracts to provide medical services, because he knew his costs right down to the penny. He likened the process to shooting fish in a barrel.
"We knew exactly what our costs were, right down to how much water we used and how much we paid for it," said Dr. Hildahl.
Pan Am specializes in bone and joint surgeries. Private, for-profit clinics offering the same services cannot compete against it because they have to build in a profit, he said.
Dr. Hildahl has first-hand experience doing just this. He "cut corners" to boost the clinic's profits when it was private, he said. While patient safety was never jeopardized, the clinic's equipment wasn't always state of the art.
After the government acquired Pan Am, the clinic's payments for cataract procedures fell to $700 from $1,000. And any surplus these days is plowed back into patient care.
"I don't think private for profit care is the way to go," he said. "It's a short game strategy, not a long game strategy."
Ontario: On both sides of the public-private divide
Don Copeman, founder of a medical clinic in Vancouver, is puzzled about the Ontario government's stance on for-profit, health care. When he looked at opening a clinic in Ontario in 2006, George Smitherman, health minister at the time, threatened to use the full force of provincial law against Copeman Healthcare Centre.
"We have a law in Ontario that says we're not going to stand idly by and see patients charged a fee in order to be able to access an insured service," he told reporters.
Mr. Smitherman objected to Copeman Healthcare's one-time enrolment fee plus annual dues.
Mr. Copeman put his expansion plans on hold. But he notes that another clinic, Medcan in downtown Toronto, charges patients a membership fee.
Medcan opened in 1987. Its most popular service is a comprehensive health exam, also known as the "executive medical," that costs $2,395. It consists of a five-hour head-to-toe medical exam, including an ultrasound, chest X-ray, blood testing, nutritional analysis and fitness assessment.
The provincial Commitment to the Future of Medicare Act says companies can be fined for charging a fee for a service covered by the Ontario Health Insurance Plan.
Physicians at Medcan also bill OHIP but Bronwen Evans, a vice-president at the clinic, said most of its services are not covered by OHIP.
"I don't get how the Medcan model is surviving under the legislation," Mr. Copeman said.
Quebec: Public standards in private care
Early on the morning May 23, 2008, Valérie Castonguay, arrived excitedly at the private clinic operated by Montreal plastic surgeon René Crépeau. The young woman had saved up for a rhinoplasty - a "nose job" in common parlance - she hoped would improve her breathing and her looks.
After the surgery, which was done under general anesthetic, Ms. Castonguay was hooked up to an oxygen tube to assist her breathing. But the oxygen was badly calibrated, giving the patient a massive dose of oxygen that caused extensive damage to her lungs and brain. When the problem was discovered, Ms. Castonguay was rushed to hospital where she was declared brain dead.
Paul Dionne, the coroner who investigated the death, issued a scathing report, saying the clinic did not meet basic safety standards. But he noted that while the standards of practice are the same for health professionals in privately- and publicly-funded health facilities, there is actually no oversight and inspection in private clinics and they are not required to have the same equipment and safety standards as hospitals and public clinics.
The provincial government, in part because of the publicity surrounding the case, responded with legislation. Under Bill 34, private clinics must now undergo an accreditation process similar to public institutions and appoint a medical director responsible for all aspects of care.
Nova Scotia: A military solution
Two years ago hernia patients at Nova Scotia's Capital District Health Authority were waiting more than six weeks for surgery. To break the backlog the health authority moved some patients out of Halifax and struck a ground-breaking deal with the local military hospital.
Procedures were done by civilian doctors at Canadian Forces Health Services Centre - Atlantic, popularly known as Stadacona Hospital. The health authority provided doctors and anesthetists. The military paid other staffing costs, as well as facility maintenance.
It was a first in the country and so effective that last year the experiment ceased to be necessary.
"We used the space and we achieved our goal," said Capital Health spokesman John Gillis. "We've been able to clear the backlog so there's little or no wait for hernias."