Integrated community health services centres
This is the first in a series of articles on Bill 60 and its implications for health sector stakeholders.
On February 21, 2023, the Ontario government tabled Bill 60: Your Health Act, 2023, which outlines the province's next steps in its plan to reduce wait times for surgeries, procedures, and diagnostic imaging, while introducing its new "as of right" rules to automatically recognize the credentials of healthcare professionals licensed in other Canadian provinces and territories.
If passed, Bill 60 would, among other things, enact the Integrated Community Health Services Centres Act, 2023 (the Proposed Act), repeal the Independent Health Facilities Act and its regulations (the IHFA), and make consequential amendments to several other provincial Acts. In short:
- The proposed new "integrated community health services
centres" (Centre(s)) regime appears very similar to the
current "independent health facilities" (IHF(s)) regime,
with the following key differences:
- The definition of a Centre under the Proposed Act has been expanded to include a specific reference to "community surgical and diagnostic centres".
- The provincial government has indicated the Centres would be licensed to provide a broader range of services, including hip and knee replacement surgery.
- The Proposed Act introduces new public interest requirements that applicants would need to satisfy in order to be granted a licence. Applicants would need to provide details on how the proposed Centre would provide connected and convenient care. Applicants would also need to provide a detailed staffing model and an overview of how they have consulted with health system partner(s), including any endorsement(s).
- The Proposed Act signals that the provincial government intends to start issuing licences to new Centres after not having issued IHF licences in nearly two decades.
- Currently, a number of entities, including corporations that operate public hospitals, cannot be licensed as IHFs. It is yet to be seen if regulations under the Proposed Act will restrict similar entities from becoming licensed as Centres.
- The Proposed Act includes provisions to address public concerns surrounding upselling and queue jumping, which reflect already existing legislation protecting the integrity of our public healthcare system.
Integrated Community Health Services Centres versus Independent Health Facilities
If passed, the Proposed Act would create a framework for the regulation of new "integrated community health services centres" which are health facilities, including community surgical and diagnostic centres, that would be licensed to provide services in respect of which facility costs are paid for by the provincial government.1 In other words, these Centres would provide health services that are covered by OHIP under the Health Insurance Act (insured services) and the provincial government would pay the fees and operating costs related to the provision of the insured services by the facility (facility costs). As is the case with any clinic, the Centre would also be able to provide health services that are not covered by OHIP, which might include, for example, a more expensive cataract lens (uninsured services).
The proposed definition of an "integrated community health services centre" is practically identical to the current definition of an "independent health facility" under the IHFA. However, the definition has been expanded to include a specific reference to "community surgical and diagnostic centres". This leads us to believe that the provincial government will be focusing on the issuance of licences to these types of Centres.
Ontario currently has hundreds of IHFs, but no new licences have been issued under the IHFA in nearly two decades. IHFs are privately-owned facilities that provide insured and uninsured health services to Ontarians. The Ministry of Health pays facility owners' facility fees, through a combination of "fee-for-service" payments as set out in a Schedule of Facility Fees to the IHFA, and direct funding agreements. The Proposed Act provides a similar approach for the Minister of Health to pay all or part of the facility costs or operating costs of a Centre, in addition to any costs prescribed by regulation. The IHFA and the Proposed Act both prohibit unlicensed facilities from charging facility fees.
Once in force, the Proposed Act would repeal the IHFA and provide for the continuation of currently licensed IHFs under the Proposed Act. Licensees would be governed by the Proposed Act but subject to the same limitations and conditions that applied to licences under the IHFA.2 Currently licensed IHFs provide services such as:
- diagnostic imaging;
- nuclear medicine;
- pulmonary function studies;
- sleep studies;
- ophthalmic, plastic, and gynaecologic surgery;
- MRI/CT and PET/CT scans; and
- labour and delivery services at birthing centres.
The provincial government has indicated that new Centres would be licensed to provide a broader range of services, including hip and knee replacement surgery.
Who can be licensed? How are licences issued?
The Proposed Act contemplates that licences would be issued following a call for applications by the "Director", who is the person to be appointed by the Minister of Health as the Director of Integrated Community Health Services Centres. There is no requirement in the Proposed Act that a licensee be for-profit or not-for-profit. This is currently the same for IHFs, the majority of which are for-profit corporations.
Under the IHFA, a number of entities, including corporations that operate public hospitals, cannot be licensed as IHFs. Under the Proposed Act, the Director will be prohibited from issuing a licence to any person who is exempt from the application of the Proposed Act by way of regulation; however, those regulations are not yet available. It therefore is yet to be seen whether the regulations under the Proposed Act will restrict similar entities from becoming licensed as Centres as were restricted from becoming licensed as IHFs.
Impact on the public health system
When Bill 60 was first announced, there were public concerns surrounding its impact on the public healthcare system, particularly whether the new regime would create a "brain-drain" effect such that hospitals would lose already scarce health professionals to new Centres. While the new regime is very similar to the existing one, as noted, no new IHF licences have been issued in nearly two decades.
The Proposed Act attempts to address these concerns by requiring that applicants satisfy public interest requirements and expectations to be granted a licence.
Each application for a licence would need to include a detailed description of the service(s) to be provided in the proposed Centre and how the proposed Centre would provide connected and convenient care, including the applicant's capacity to improve wait times, plan to improve patient experience and access to care, and plan to integrate with the health system.
Applicants would also need to provide a detailed staffing model for the proposed Centre, evidence of sustainability of this model, and details on how the applicant has consulted with health system partner(s), including any endorsement(s).3 The detailed staffing model would need to include information on:
- staff classification with rates of compensation and ranges of compensation;
- the number of staff required for each position;
- the model for staffing anaesthesia delivery (if applicable); and
- the hospital privileges of physicians who provide services at the Centre (if applicable).
Quality and oversight
The Proposed Act would also introduce several new quality and oversight measures, some of which include:
- enabling the regulations to prescribe one or more organizations as inspecting bodies of the Centres. The provincial government is currently working with health system partners to determine what organizations are best positioned to serve as inspecting bodies, and is considering several options, including continuing the role of regulatory colleges, such as the College of Physicians and Surgeons of Ontario (the CPSO), which is currently responsible for conducting quality assessments of all Out-of-Hospital Premises and IHFs in Ontario;
- requiring details of quality assurance and continuous quality improvement programming, including infection prevention and control measures in the application for a licence;
- requiring details on the hospital privileges held by physicians who would provide services at the proposed Centre in the application for a licence; and
- requiring every licensee to have a process for receiving and responding to patient complaints.4
Concerns about fees and upselling
Another concern that has been raised regarding the new Centres is that patients may be pressured to pay for services or aspects of their care that are not covered by OHIP when they attend the Centres for insured services. The Proposed Act contains provisions, which are not in the IHFA, that attempt to address this concern by prohibiting the Centres from refusing to provide insured service for any reason relating to a patient's choice not to pay for any product or service (e.g. an upgraded cataract lens).5 It also prohibits preferential treatment, or queue jumping of those who pay for uninsured services.6
These provisions reinforce the already existing federal and provincial healthcare legislation on insured services, including the Canada Health Act, which is the federal statute that establishes the framework for publicly funded healthcare insurance in Canada.
The Proposed Act would require that Centres have processes in place for providing information and obtaining patient consent for the provision of uninsured services.7 Physicians would also continue to be governed by the Medicine Act, 1991 and CPSO standards of practice, which include restrictions on the provision of uninsured services and the fees that may be charged to patients.
As is currently the case under the IHFA, charging or accepting payment of a facility cost to a patient is also prohibited under the Proposed Act.
Bill 60 represents a potential step towards health system transformation by the provincial government. At first glance, the Proposed Act appears to be an attempt to re-invigorate the current IHF regime under a new name. However, there are key differences between the current and proposed regimes, including the broadening of the scope of services that may be offered at new Centres and the emphasis on public interest and quality in the licensing application process. The issuance of licences to new Centres would also represent a significant policy shift by the provincial government given that no licences for IHFs have been granted in nearly two decades.
It remains to be seen what the practical implications of the Bill have in store for healthcare organizations and providers. The Bill will need to go a through a second and third reading at the Legislative Assembly of Ontario before it can receive Royal Assent and be proclaimed into force. We will continue to monitor Bill 60 and provide updates in this series of articles.
1. Your Health Act, 2023, Schedule 1, s. 1(1).
2. Ibid at s. 5(1).
3. Ibid at s. 5(4).
4. Ibid at s. 22.
5. Ibid at s. 29(6).
6. Ibid at s. 29(5).
7. Ibid at s. 5(4)(i).
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