A new rule introduced by the Blaine Higgs government is raising concern among nurse practitioners, who believe it will introduce yet another barrier for the more than 44,000 New Brunswickers who do not have a primary care provider.
Under the policy, which came into effect April 1, any medical practitioner who is operating outside of the public system and charging patients directly, will be billed by the regional health authority for any diagnostic or laboratory tests ordered.
Chantal Ricard, president-elect of Nurse Practitioners of New Brunswick, said the decision is "impeding access to care."
"We believe that these tests should be insured because they're medically necessary and ordered for patients with valid Medicare cards and ordered by licensed health professionals."
Nurse practitioners can diagnose illnesses and injuries, order and interpret tests, and prescribe medications. They are also able to refer patients to a specialist or transfer care to a physician if required.
No explanation for policy
CBC News requested an interview with Health Minister Dorothy Shephard but she was not available to explain the rationale for the decision.
"We've met with them on a few occasions," nurse practitioner and association president Raelyn Lagace said when asked if she knew why health officials made the change, "But we haven't come to any conclusion as to what they're trying to accomplish."
In a letter obtained by CBC News dated June 19, 2020, and addressed to the Vitalité and Horizon Health board chairs, then-health minister Ted Flemming writes that the change is meant to establish "consistent policies and bylaws related to the granting and use of privileges for ordering tests and diagnostic services."
He said government has been made aware "in recent months" of instances where nurse practitioners and doctors are "utilizing publicly funded resources such as laboratory tests and diagnostic services, while charging patients fees."
Lagace said about 150 nurse practitioners are working in New Brunswick. Many are salaried employees with the health authorities, and others work independently, charging patients directly for their visits.
'I'm not quite sure what's going on'
Nurse practitioners who billed patients for a consultation in the past could then order medically necessary tests, which would be covered by Medicare. Lagace said nurse practitioners wouldn't charge anything for tests, only for the consultation.
"If you are a citizen in New Brunswick and require medically necessary tests, you already are paying taxes and should have access to these publicly funded systems that your tax dollars pay for."
Health policy expert Gregory Marchildon agreed. The Ontario research chair in health policy and system design said the move by government strikes him as "a bit of a shift."
In New Brunswick, an increasing number of patients have been forced to seek care outside the public system because they can't get access to a family doctor, or to specialists with long wait lists.
"The fact that these residents are charged for their medically necessary, primary care services only because they can't get access to a physician or nurse practitioner with a Medicare billing number seems contrary to the whole purpose of Medicare," Marchildon said.
"I'm not quite sure what's going on here in New Brunswick, but the rule is that every Canadian should have access … to every medically necessary hospital, diagnostic and physician service. And it seems to me that there is no loophole for that."
Marchildon said if a test isn't medically required — for instance, if someone just wants an MRI "to see if there's possibly anything wrong"— the hospital shouldn't charge for that test. Rather, "they should be just simply refusing to do it."
"The way in which this is being dealt with doesn't sound helpful or constructive," he said. "And it could be very much contrary to the Canada Health Act."
The Department of Health said it does not track how many physicians are working outside the public system in New Brunswick.
Policy impedes access
A March 2021 memo to Horizon Health physicians and nurse practitioners, from two Horizon vice-presidents outlines a range of examples of when physicians or nurse practitioners would "receive a bill directly from Horizon Finance Department."
The list includes services that would be considered medically necessary such as "a patient who requires investigation for anemia," and those that wouldn't, such as "a patient who requires a chest X-ray for a scuba diving licence."
While the new policy charges the medical practitioner who orders the tests, Ricard and Lagace said the costs would ultimately be passed on to the patient.
Lagace said nurse practitioners charge between $29 and $49 for a consultation with a patient, and it's not feasible for them to then pay between $128 and $600 for diagnostic tests.
"We don't want to pass that bill on to the patient," said Ricard. "We've been working with government for the last two years trying to make changes that would improve access for patients and remove barriers for care, but government chose to take this direction.
"In essence it ties our hands. It shuts us down."
Government goes ahead, despite 'gaps' in care
At the end of the day, Lagace said, the Higgs government is hurting those without access to primary health care the most.
That's something Flemming recognized in his letter from June 2020.
"Please note, Government is also aware of gaps in access to primary health care that would occur should [nurse practitioners] no longer be able to see their existing patients as part of a private practice," Flemming wrote. "This is evidenced in our commitment to fund the establishment of [nurse practitioner] staffed clinics in the province."
Lagace said new clinics, staffed by nurse practitioners, are set to open in Moncton, Saint John and Fredericton. Each nurse practitioner will eventually be able to take between 800 and 1,000 patients and will operate within the Medicare system.
While that is good news, she still questioned the direction the government is heading and pointed out the new policy doesn't fit with other goals.
"We want to increase the population of New Brunswick." she said. "But if we can't provide health care, then that's not an option. People are not going to stay if they cannot get access to care.
"People in New Brunswick in the Fredericton region have been on these wait lists for five, seven, 10 years and are not able to get access to care."
Call to revise policy
Ricard and Lagace are calling on the government to change the new policy, arguing New Brunswick citizens are entitled to these tests through the Hospital Services Act.
"There's a need and there's room for all of us and I think that all available health care providers should be on deck," Ricard said.
"We don't understand why government would choose to take away this only option for many patients before having something better to offer them."
Marchildon said New Brunswick should immediately contract with whatever health providers it can, including independent nurse practitioners, to offer care to everyone, "rather than penalizing New Brunswick residents for something they have no control over."