Infertility care in Ontario, Canada: an anomalous funding structure and example of two-tiered healthcare in Canada

Consider This
Infertility care in Ontario, Canada: an anomalous funding structure and example of two-tiered healthcare in Canada

Authors:

Stephanie C. Lapinsky, MD, MSc a,b

a University of Toronto, Department of Obstetrics and Gyncology

b Institute of Health Policy, Management and Evaluation, University of Toronto

Consider This:

Canada has a universal, publicly funded healthcare system, underscored by a belief that access to healthcare is a right which should be based on need rather than ability to pay. All medically necessary physician and hospital-based services are funded through provincial health insurance plans, such as the Ontario Health Insurance Plan (OHIP). Funding for the provincial insurance plans is provided by the federal government in the form of the Canada Health Transfers, and receipt of these federal funds is contingent upon the provinces adhering to the principles of the Canada Health Act (CHA) (1).  These principles include the principle of Universality, which stipulates that all Canadians must be covered under the provincial insurance plan without any premiums or copays, ensuring that all Canadians receive the same quality of care regardless of income; and the principle of Comprehensiveness which stipulates that provincial insurance must cover all medically necessary services provided by physicians and hospitals “for the purpose of maintaining health, preventing disease, or diagnosing or treating an injury, illness or disability” (1). The Canada Health Act is thus designed to prohibit any sort of parallel system of private insurance for those services covered under provincial health insurance funding.

In Ontario, the majority of infertility care, including assisted reproductive technology (ART), is funded privately, through out-of-pocket payments and private insurance, at costs of over $10,000-20,000 per cycle of IVF (2-5). Some public funding for ART services, primarily physician fees, is available through the Ontario Fertility Program (OFP), which was established in 2015 and is separate from OHIP. Both publicly and privately funded ART procedures are performed by the same OHIP-billing physicians, who may also provide other forms of OHIP-covered gynecological care (6). Infertility care and ART services in Ontario therefore represent an irregularity where dual public-private funding for physician services has emerged. The following commentary aims to discuss how government interests and societal ideas, led to the development of this parallel public-private funding structure, and its impacts on fertility care and the healthcare system.

The development of this funding arrangement was likely influenced by the unique interests of the Ontario Liberal Government at the time (7, 8).  Prior to the development of the OFP, OHIP provided limited funding for IVF for women with bilateral fallopian tube blockage (6). This had resulted in a human rights complaint against the government for discriminating against other medical conditions, providing strong incentive to make changes to the funding system (7). The OFP was revealed through the minority Liberal Government’s 2014 spring budget announcement, which risked prompting an election if not supported by the opposition parties (7, 8). The government at the time was facing dual pressure to improve affordability and accessibility of ART by the New Democratic Party, as well as various advocacy groups, while also facing pressure to cap spending and control the deficit from their own party as well as the Progressive Conservative Party (7-9). In an attempt to appeal to the majority and avoid triggering an election, the OFP was created as a significant improvement to existing funding for ART in Ontario, which addressed the human rights complaint, but which also allowed for the ability to strictly regulate and cap program spending in a way that would not have been possible though OHIP funding. This ability to cap spending was achieved through stringent restrictions including a maximum number of funded IVF cycles per year, one lifetime IVF cycle per individual, and exclusively single embryo transfers (4, 7, 10, 11). This is in stark contrast to OHIP covered services for which the provision and specifics of care are at the discretion of individual physicians and their governing organizations. At the same time, coverage was expanded significantly to include all eligible individuals with need for fertility services, regardless of indication, including those with male-factor infertility, and some coverage for same-sex couples requiring ART (4, 7, 11).  

Societal ideas surrounding infertility also likely influenced policymakers and the resulting funding structure. There are two fundamental ways to conceptualize infertility; either as a medical condition, or as a social issue or desire. Infertility can be viewed as a medical condition, specifically a disease or dysfunction of the reproductive system, which is how it is defined by the World Health Organization (12). Although infertility is not always considered to impact ones physical health, it stems from organ dysfunction and can be related to underlying physical health conditions (6). Furthermore, it does significantly impact quality-of-life, in a similar manner to other physical disabilities or impairments (13, 14). It follows then that ART could be viewed as a medically necessary physician service under the Canada Health Act, aimed at improving quality-of-life by overcoming abnormalities or deficiencies of the reproductive tract or gametes (2, 6, 7). Many OHIP-covered services target quality rather than quantity of life, for example, medical and surgical gynecological care for menstrual suppression in women with normal menses. However, infertility can also be viewed as a social issue related to growing ones family, and often tied to issues such as adoption, parenting and social support for families (2, 13, 14). Having children may thus be viewed as a preference or desire rather than a medical issue, and it would follow then that ART would not be considered a medically necessary procedure (6, 7, 14). This viewpoint is corroborated by findings from a large survey across developed countries which found that only 38% of respondents would classify infertility as a disease (15). These prevailing views of infertility as a social issue likely helped create a situation where ART was removed from provincial health insurance, and an alternative public funding source was created.

The Ontario Fertility Program is thus a unique funding setup in Canada, in which dual public and private funding sources exist for a physician service, which would generally be considered to be in violation of the Canada Health Act. However, these public funds are derived from an alternative source, outside of OHIP, circumventing the principles of the CHA and allowing this dual funding system to exist (7). The OFP has resulted in demonstrable improvements in the accessibility of fertility care, and has allowed many to access ART who otherwise would not have been able to (4, 5, 10). However, it has also resulted in significant disparities between public and privately funded ART, most notably in waitlist time (4, 5, 10, 16). Whereas privately funded IVF can be accessed immediately following initial consult and investigations, average wait time for a publicly funded cycle of IVF is approximately 12 months, and up to several years in specific clinics and specific fiscal years (4, 5). In contrast to the philosophies of the Canadian healthcare system, wait time for ART is therefore determined predominantly by ability to pay rather than need or acuity (4, 10, 16-18). The funding also comes with restrictions limiting what physicians can provide in public cycles (4, 7, 10). Many patients accessing publicly funded ART would be treated differently if they were paying privately, with impacts on their risks and success rates. The stringent limits on ART funding may also have secondary costs to OHIP, and thus the province (6). Individuals who are ineligible for public funding, those who have exhausted their public options and those on long waitlists may pursue alternative treatment options, including more affordable ART treatments with lower success rates and higher risks, such as gonadotropin intrauterine insemination, which is associated with a much higher risk of multifetal gestation (19, 20). They may also turn to alternative OHIP-covered procedures as a substitute for ART, which may not be the recommended approach in the absence of cost constraints (6). For example, a patient with tubal factor or unexplained infertility may opt for a diagnostic laparoscopy, rather than pursuing IVF. 

While the OFP represents an unusual funding structure, the concept of privately funded healthcare within Canada’s universal healthcare system is not unique, with private expenditures (out-of-pocket payments and private insurance) accounting for 25-30% of total health expenditures in the nation (21). Within Ontario specifically, there are examples health-related services which are funded exclusively, or near-exclusively, through private payments, such as laser eye surgery (22). There are also several examples where OHIP funding is available only for specific populations, specific indications, or in specific settings, such as within the fields of cosmetic surgery, optometry, and dentistry (22). Additionally, examples of “two-tiered” delivery of healthcare are emerging throughout Canada, including primary care clinics offering “executive physicals” funded through a combination of OHIP billings and substantial additional out-of-pocket costs (23, 24). These clinics circumvent the CHA by charging privately for services that are not OHIP-covered (and therefore not governed by the CHA), and using these fees to supplement OHIP billings (23, 24). Nevertheless, despite these examples of private healthcare in Canada, examples similar to the OFP, where dual funding exists for a physician service provided by the same physicians, in the same settings, and for the same indications, are rare. Infertility funding in Quebec offers a similar example of dual public and private coverage, through two funding structures, the first in place from 2010-2015, and the second from November 2021 onwards (25, 26). The 2010-2015 system offered particularly comprehensive public support, with minimal exclusion criteria, and funding for multiple rounds of IVF, including medication costs (25). The program was terminated in 2015, and from 2015 to 2021 limited funding for ART existed in the province (25). In November 2021, a new system of public funding was initiated, which is more restrictive than the 2010 system, with similar but slightly more extensive coverage than the OFP (26). Similar to the OFP, a simultaneous private market for infertility care exists alongside the public funding (25, 26).  Throughout all other provinces in Canada, infertility care is predominantly privately funded, with most provinces offering no public support at all, or very limited support. For example, Manitoba provides tax credits, and New Brunswick provides a one-time reimbursement (7, 27).

In conclusion, this paper aimed to demonstrate how government interests and societal ideas led to the development of a unique two-tiered funding system for ART physician services in Ontario. This funding system, while increasing accessibility, threatens equity for an important physician service. This could be seen to be in violation of the Canada Health Act principles of comprehensiveness and universality, depending on how infertility and its treatment are viewed on the spectrum of medically necessary healthcare. However, the principles of the Canada Health Act are effectively circumvented by deriving funding from outside of OHIP.

Acknowledgements: none.

Note: No ethics review was required for this paper.

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