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Fearful of drawing attention from critics and regulators, private health-care clinics are quietly multiplying in Ontario even as the Health Ministry admits it is unable to keep track of them.

Private clinics, where patients pay an annual membership or buy additional services even when receiving publicly funded treatments, usually open quietly, hoping to avoid the scrutiny or even government intervention, that may follow media coverage or public outcry.

Zoltan Nagy, interim president of the Canadian Independent Medical Clinics Association, said he knows of five to 10 private clinics, including some that perform operations, that have opened in Ontario within the past few months. He declined to give an exact number or name clinics.

"We are hearing there are new clinics opening up across the country, they do that below the radar scene, they do it quietly," Mr. Nagy said in an interview.

Private clinics do not need to be registered as such in Ontario. Only doctors, not the clinics, need to register with the ministry.

Once doctors are registered with the College of Physicians and Surgeons of Ontario for a certificate for independent practice -- which "authorizes the holder to engage in independent, unsupervised medical practice" -- they need only register for a billing number for OHIP.

From there, opening up a clinic is just like opening any other business.

The ministry does not require that private clinics register, and does not keep a list of these clinics. It only investigates if there are complaints.

A year ago, the province reacted strongly to complaints about the Copeman Healthcare Centre opening in Toronto because the centre charges annual membership fees.

The ministry used the 2004 Future of Medicare Act, legislation that prohibits charging patients for medically necessary services, to prevent it from opening.

"My understanding is that the Ontario Health Ministry is fine with [private clinics]as long as it doesn't end up on the cover of the Toronto Star, that's why more and more groups are opening up in Ontario," said Mr. Nagy, who later added there are more private clinics set to open in Ontario in the new year.

British Columbia and Quebec are the leaders in private care. British Columbia is said to have around 70 private clinics operating, and though some of these are small plastic surgery clinics, it is a number that is estimated to have doubled over the last 10 years.

A private emergency clinic in Vancouver that wanted to charge patients at least $199 a visit made national headlines when it opened in early December, prompting the provincial government to step in.

B.C. Health Minister George Abbott moved quickly to enact provisions of his government's Medicare Protection Amendment Act and threatened to take legal action against the False Creek Urgent Care Centre if it charged patients for urgent procedures that are covered under the public health system.

According to the deal struck between the clinic and the government, the centre has had to change its billing plans and will bill the B.C. Health Ministry rather than charge its patients.

At the semi-private Mom and Baby Depot, which opened in Whitby last January, Dr. Karen Dockrill said she kept the opening of the family care clinic low-key to avoid the kind of reaction the Copeman centre received.

"We were being very cautious, we didn't even use the word private for several months into our venture," Dr. Dockrill said.

Enrolment at the clinic was slow to start, she said, and many who called to inquire did not want to be identified for fear they were doing something wrong.

But with the support of her patients, the clinic has since evolved into a more private model and will soon be membership only, costing up to $1,200 a child.

In exchange, patients receive OHIP-insured services as well as access to educational and supportive programs and 24-hour pager contact with a physician, among other services.

Dr. Dockrill said frustration with the public hospital system is what prompted her to open her clinic, an experience that has been the most rewarding of her medical career.

She said she informed Health Ministry of her plans, but has received no feedback.

In mid-December, the private Health for Life Medical Centre opened in Kingston without attracting much attention.

"This opened very quietly, I couldn't find it on the Internet, and even in the community it was really hush-hush," said Ross Sutherland, co-chair of the Kingston Health Coalition and an advocate for medicare.

The clinic, which is geared to patients 50 and older, charges a $2,500 fee before an initial visit and $2,000 annually thereafter.

Mr. Sutherland said that charging people before they can have access to a family physician, a publicly funded service under the Ontario Health Insurance Plan, is wrong and he has asked the Ministry of Health to investigate. Calls to the clinic were not returned.

The private clinic openings have been spotted as a potential opportunity for a marketer in Montreal who three months ago started up a website -- -- that lists up to 250 private clinics operating across the country.

"I can't help but be interested. I am probably, as far as I can tell, the only guy out there with this type of directory," said Jason Wright, who said he watches for press releases, advertisements, industry papers and even online discussion forums to find the clinics.

Speaking on behalf of Ontario Health Minister George Smitherman, press secretary David Spencer said there is no acceptance, "passive or otherwise," of clinics that charge for access to insured services.

But, he said, the province's size makes it difficult for the government to know how each doctor is operating, so the ministry often relies on the public for information.

Danielle Martin, chair of Canadian Doctors for Medicare, said the problem is really the grey zone surrounding private care, and that some clinics that have opened recently in Ontario do so under questionable legal terms.

Dr. Martin cited colonoscopy clinics that are opening up "under the radar" as one example.

Doctors bill the public system for the colonoscopy, which is often offered to the patient at a faster rate than in the hospitals, but charge for other non-insured services such as nutrition counselling.

Family physician Gayle Climpson-Kennedy, who has worked in the public system for 25 years but is a proponent for alternative systems, said the government is surely aware that alternatives must be explored because the public system is failing to provide timely care.

"The politicians shouldn't be afraid to say that. I think they have such tunnel vision, they're only looking at their four years in office and staying inside the box," she said.

Indeed, exploring alternatives is something more Canadian doctors appear poised to do.

The Canadian Medical Association, with a membership of close to 60,000 physicians, recently elected Brian Day -- a well-known advocate for expanding private care -- as its next president. Dr. Day runs the private Cambie Surgery Centre in Vancouver and is founder of the Canadian Independent Medical Clinics Association. Dr. Day, who has never been active in the CMA, was chosen over five other candidates for the top spot.

"I think, most people now believe that there's a role for the private sector in health care," Dr. Day said in a telephone interview, adding that the CMA is considered one of the most important and influential groups in determining policy on health care.

"I think doctors can use that to help introduce positive changes in the system."

Nicholas Duval said he was "hiding a bit in the shadow" when he opted out of the public system five years ago to start up the private Duval Orthopedic Clinic in Montreal.

"I was in a grey zone, so I think it was not a wise choice to make a lot of noise around it," Dr. Duval said in a telephone interview. "So people would not find a negative thing and kill what I was doing before I could start something good."

Dr. Duval said he's sure the Quebec government was aware of his clinic when it opened, but likely wanted to see how his venture would turn out. In the past year, Dr. Duval's clinic provided 496 operations to patients willing to pay out-of-pocket.

Dr. Duval said Quebec's progression toward increased privatization within the system is a sign that selections need to be made about which services should remain publicly funded, and which ones the government should allow to be privatized.

"We all look at data for the future, with the aging population in the next 30 years, we know we are in trouble," he said.

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