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A new private clinic in Toronto has begun booking appointments for patients who can afford to buy the costly cancer drugs Ontario's public system does not provide, foreshadowing what could become a standard feature of medicare.

"We're receiving faxes from doctors, who have had discussions with their patients, pretty much every day now," said Graham Vincent, chief operating officer of Provis Infusion Clinic Inc., which provides intravenous cancer drugs at a downtown centre.

He said the clinic will treat its first patient on Thursday, less than a month after opening. "We're very pleased with the response we're getting from customers, who are the patients and the oncologists."

The enterprise is a concrete example of the private sector's possible role in Canadian health care -- and one the country's medical establishment cautiously endorsed for the first time last week.

At its annual meeting in Edmonton, the Canadian Medical Association, which represents 62,000 doctors, said all Canadians should be able to buy private insurance for medically necessary services.

Delegates also refused to rule out the creation of a parallel, private system to bolster the public health-care system.

"It's interesting how the tides have changed. I don't know how government can ignore it," Mr. Vincent said.

He said that when government "delists" funded services (as Ontario recently did with eye examinations) or chooses not to fund others, it invites private care "slowly but surely."

Six of the drugs available at Provis have been approved for sale by Health Canada, but either are not funded under the provincial formulary or receive funding for a specific purpose.

Among them are chemotherapy agents to treat leukemia, cancers that have spread to the bone, and rare cancers of the abdomen or chest cavity. None of the drugs come cheaply.

So far, two of the clinic's most-requested drugs are Velcade, a last-resort medication for multiple-myeloma blood cancer, and the breast-cancer drug Herceptin. They cost about $55,000 and $70,000, respectively, for a full course of treatment.

This cost does not include the clinic's administrative fees, which can vary depending on the time it takes to deliver the medication.

(Although Ontario announced last month it would fund Herceptin as a treatment to prevent recurrence, Mr. Vincent said it will not pay for patients who completed chemotherapy before Nov. 1, 2004, because that falls outside the period that clinical trials showed Herceptin to be most effective.)

Only patients referred by oncologists and able to pay out of pocket, or through a private insurance plan, are eligible for treatment at Provis.

As a result, the business has sparked fears, notably from the Ontario Health Minister, that it signals the advent of "pocketbook medicine." But it seems clear that doctors and patients hope to make use of the service.

Donna Reece, a hematologist and oncologist at Toronto's cancer-oriented Princess Margaret Hospital, has made one referral to Provis for a patient who needs Velcade, and is looking into sending as many as 11 others.

"It's just not acceptable to watch your patient die without benefit of this drug," she said, explaining that it can add a good-quality year to a patient's life. "To get another year of life is a very precious thing."

Ontario oncologists had been prescribing Velcade to patients for more than two years as part of late-stage clinical trials, Dr. Reece said. It was approved for sale by Health Canada in January, but became unavailable in Ontario as the provincial government began its review to decide if and how it should be funded.

"None of us dreamed we wouldn't have access to it for several months," said Dr. Reece, noting that Velcade is available in every other province and in the United States. She said several colleagues are also making arrangements to send patients to Provis.

Bob Bell, president and chief executive officer of the University Health Network, which includes Princess Margaret Hospital, said there is no policy to stop doctors from referring patients to a private clinic such as Provis.

"If I was a patient, I would be happy to get access to a clinic like that if I could afford to pay for the treatment," Dr. Bell said. "Doctors are expected to do what they think is best for their patients. We certainly wouldn't prevent them from making referrals there [to Provis]or out of country, to the U.S., if they thought it was best."

Mr. Vincent estimates that drug prices at Provis are roughly 40 per cent cheaper than those in the United States. He said he received a call last week from a man taking his wife to Buffalo to receive Velcade who is paying $5,100 (U.S.) per injection. Provis charges $2,500, or about $2,065 (U.S.), he said.

Mr. Vincent said there has so far been no discussion as to whether the Ontario Health Insurance Plan, which sometimes pays for cancer treatments administered in the United States, could save money by covering the same costs at a Canada-based private clinic.

He said the only discussion of issues he had with OHIP officials at a recent meeting was to give them assurance that Provis doctors would not bill the province for services connected to the clinic.

While doctors will be available to patients at Provis, Mr. Vincent said the clinic will be staffed primarily by experienced oncology nurses. "The majority of our nurses are working full-time at Princess Margaret Hospital," he said. "In their private time they have chosen to work here."

But Dr. Reece worries that only a small minority of eligible patients will be able to afford treatments at Provis. After looking into the private insurance plans of 12 patients, she found that only two had coverage that included paying for an intravenous treatment usually provided in a hospital.

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