Independent health care professionals are expressing concern that their professions’ regulators are not keeping pace with large corporate players that are quietly buying up medical practices.
The private-equity-fuelled roll-up in fields such as dentistry, optometry and veterinary medicine is beginning to transform these practices, which are traditionally owner-operated. And it is raising questions about the influence corporate head offices could exert on pricing and quality of care.
Michèle Brill-Edwards, an Ottawa paediatrician and board member of the Canadian Health Coalition, a non-profit that advocates for public health care, said the provincial self-regulating bodies that oversee each licensed profession, usually referred to as colleges, can be slow to act because they rely on a complaints-based system and do not make big moves until problems become serious.
“In general, the colleges are reactionary rather than forward-looking,” Dr. Brill-Edwards said.
The level of corporate ownership, and the associated risks and benefits, varies across Canada and across different medical fields. The response among the colleges has also varied.
For example, in Ontario’s veterinary-medicine profession, regulations have long required that each practice be owned by a licensed veterinarian.
Corporate chains have often skirted this requirement by essentially splitting a purchase in two: An employee of the corporation who is a veterinarian buys the medical portion of a practice, while the corporation buys the non-medical assets, such as equipment and staff. One veterinarian can be listed as the director of dozens of offices.
The College of Veterinarians of Ontario has been working to clarify its directorship requirements. The college introduced new regulations, effective July 1, that formalize the role of facility director at clinics and require the director – who must be a licensed veterinarian – to have a more hands-on role in operations.
But ownership of multiple clinics is still allowed. “A veterinarian is permitted to be a facility director at numerous accredited facilities as long as they are able to fulfill their role at each location,” college registrar Jan Robinson said in an e-mail.
Mike Pownall, an equine veterinarian, business coach and former member of the veterinary college’s governing council, said the college is trying to be responsive to changes in the profession while being officially neutral in the debate over corporate ownership.
On the other end of the spectrum is the dental profession in Alberta, which once pushed back strongly on corporate ownership in the province, but now welcomes it.
In 2018, the disciplinary tribunal of the College of Dental Surgeons of Alberta (then called the Alberta Dental Association and College) fined a dentist more than $680,000 for working with Dentalcorp, the largest chain of dental clinics in Canada, to buy practices in the province. In an interview, Dentalcorp president Guy Amini declined to say whether the company had later compensated the dentist for the fine.
In the years since, Dentalcorp and other large corporate players have continued to buy clinics in Alberta and become members of the province’s dental community. In May, Dentalcorp made a $1-million donation to the University of Alberta’s dental school, and two classrooms were named in the company’s honour. And the dental college’s current president, Troy Basarab, is a dentist who sold a practice to Dentalcorp and continues to work for the company.
The College of Dental Surgeons of Alberta has declined in recent months to answer any of The Globe and Mail’s questions about ownership practices.
Dentalcorp’s Mr. Amini said the company has overcome reluctance from authorities by building a robust compliance team that includes many former members of the colleges. For example, in June the company named a new chief legal officer, Julian Perez, who was formerly a senior legal advisor at the Royal College of Dental Surgeons of Ontario.
Mr. Amini added that Dentalcorp drafted many infection-control policies early in the pandemic that it shared with provincial colleges, some of which in turn shared the documents with their members.
“In the 10-and-a-half years of our relatively short existence as an organization, we’ve been able to strike beautiful partnerships with regulators,” Mr. Amini said.
Health professionals who own their own practices say there are some simple steps that regulators can take now to guard against problems down the road, when corporate concentration becomes too big to ignore.
One suggestion is that regulators take aim at the common corporate practice of maintaining a clinic’s old branding and keeping the former owner on contract for a short period of time after a sale. In many cases, a patient may have no idea the ownership has changed.
Kal Khaled, a dentist who co-owns Southdown Dental in Mississauga, and who leads the independent advocacy group the Ontario Alliance of Dentists, said there is a consumer-protection argument to be made that corporate clinics should have to disclose their ownership to the public.
“It’s not that we suggest that corporate offices are deficient, but the patients deserve to know who the majority owner is, especially if they have any issues with service,” Dr. Khaled said.
Mr. Amini said his company – which does not brand any clinics under its own name or provide a list of locations on its website – does not make outward changes to clinics’ branding because goodwill in the community is part of what they are buying.
He said he would be against any requirement to publicize the company’s purchases, in part because he thinks patients might leave.
“I think most Canadians like the local, community feel to their practices,” Mr. Amini said.
Another concern, especially in fields that require prescribing medical equipment, is the conflict of interest that can arise if a clinic is owned by a company that also manufactures aids.
Dino dell’Orletta, an audiologist and owner of the Hearing Clinic in Barrie, Ont., said that many corporate-owned chains in his field are owned by companies that also manufacture hearing aids, opening up the risk that a patient could be prescribed that company’s products, even when a competitor’s hearing aids might be a better fit.
He said being an independent practitioner has allowed him to give more options to his patients.
“I’m still moving across all the manufacturers,” he said. “I don’t represent them.”
Brian O’Riordan, registrar of the College of Audiologists and Speech-Language Pathologists of Ontario, said his college recognizes that this conflict of interest can be detrimental to patients. On July 4, the college sent an advisory note to its members reminding them to manage conflicts of interest by, for example, making patients aware of alternative products that may meet their needs.
But Mr. O’Riordan also cited a concern about the system that is common among both regulators and professionals: that there is a limit to what a college can do, because it only has legislated authority over individuals and not companies.
His college and a dozen others – including those representing dental hygienists, chiropractors and opticians – began discussions with the Ontario government in 2016 and 2017 about how to fix this gap.
But, Mr. O’Riordan said, the matter was dropped after the 2018 provincial election and the onset of the pandemic. He said he hopes the issue will be raised again.
“A formal discussion about such a reform could certainly take place and would be welcomed by ourselves and likely others,” he said.
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