Patients in Ontario often assume that the Ontario Health Insurance Plan (OHIP) covers all aspects of their medical care. However, this assumption can lead to surprises and financial stress when they encounter services that OHIP does not cover. Understanding these uninsured services and their impact on family physicians is crucial for both patients and their physicians inside of the overall healthcare system.

The Scope of OHIP Coverage

OHIP covers most medically necessary services such as doctor visits, hospital stays, and essential surgical procedures. This extensive coverage ensures that Ontarians have access to necessary healthcare without direct costs at the point of service. However, OHIP does not cover everything. There are several services deemed non-essential or administrative, which are not included in the plan. These uninsured services often come as a surprise to patients, who may not realize the financial burden they place on their physicians' practices.

Uninsured OHIP Services

Uninsured services typically include administrative and non-medical tasks that physicians perform. Here are some common examples:

1. Prescription Renewals: Renewing prescriptions over the phone without an in-person appointment is a convenience that falls outside OHIP's coverage.

2. Sick Notes and Medical Forms: Many workplaces, schools, and insurance companies require medical documentation for absences or claims. These forms are not covered by OHIP.

3. Medical Record Transfers: When patients switch doctors or require their medical records for other reasons, transferring these records comes at a fee that is not covered by OHIP.

4. Missed Appointment Fees: If patients miss appointments without sufficient notice, physicians often charge a fee to compensate for the lost time.

Family physicians are permitted to charge patients directly for these uninsured services to cover the costs associated with them; but the fact is that many physicians absorb these costs and don’t pass them along to their patients.

Impact on Family Practices

Providing uninsured services is both time-consuming and costly for family practices. The fees charged for these services help offset the overhead expenses, staff time, and administrative work required. Without the ability to charge for uninsured services, many family practices would struggle financially. This financial strain could lead to reduced access to care, fewer available services, or even clinic closures, ultimately affecting patient care and community health.

The Role of Subscription Models

To address the gap in OHIP coverage and provide a more predictable revenue stream, some clinics are adopting subscription-based models. These models typically involve patients paying an annual fee, usually between C$150 and 500. In return, patients gain access to a range of uninsured services throughout the year. Subscription models aim to:

Provide Cost Savings for Patients: Patients who require multiple uninsured services throughout the year can save money compared to paying per service.

Ensure Financial Viability for Clinics: Subscription fees provide a predictable income stream, helping clinics, which are primarily family-owned small businesses, manage their finances more effectively and remain operational.

Reduce Administrative Costs: By streamlining the payment process, clinics can reduce the administrative burden associated with billing for individual uninsured services.

While these models can be controversial, they are a viable response to the limitations of OHIP's coverage (or indeed the coverage of any government-funded health plan), and the rising costs of operating a family practice.

Why Patients Should Be Informed

It’s important for patients to be aware that OHIP does not cover all services provided by their family physician. Understanding the role of uninsured services is crucial for appreciating the financial challenges that family practices face. Often, because physicians' offices are automatically filling prescriptions and giving their patients what they need, patients have no idea that they are being extended a privilege by their doctor. Building education among patients can make them a powerful ally. This awareness allows patients to make more informed decisions about their healthcare and consider alternatives like subscription models that can offer comprehensive coverage.

Healtheon is a state-of-the-art solution designed to transform the primary healthcare experience in Canada. Join us in setting a new benchmark of excellence in primary health care. Whether you’re a patient, physician, partner, reach out to us if you’d like to get a conversation started.