The Canadian Health Care System, Your Rights and the Rights of Your Patients
There is evidence that knowledge about the Canadian health care system, including the rights of employees and patients, is a concern for ITDs. The following information is intended to give you an overview of the Canadian health care system, medicare (the system of funding for health care services), how dentistry is regulated in Canada, and your rights as a dentist as well as the rights of your patients.
The Canadian Health Care System
The Canadian health care system and the system of public funding (i.e., Medical Services Plans) provide publically funded, tax supported coverage for almost all doctor and hospital health care costs (Kenny and Chafe, 2007). The majority of the responsibility for health care planning and delivery, however, lies with the province and territories. This also means that the regulation of health professionals like dentists is a provincial/territorial responsibility.
Indeed, the current Canadian model of health care is decentralized and aims to respond to the context-specific issues associated with Canada's expansive geography which consists of 10 provinces and 3 territories. This model has developed gradually since World War II and was codified most recently in the 1984 Canada Health Act (CHA). The CHA is a piece of federal legislation consisting of five principles that set out the criteria and conditions to which health insurance plans throughout the country must conform in order to receive the full federal cash contribution under the Canada Health Transfer (CHT) (Fard, 2009.)
It is important to understand that the CHA applies to the publicly funded components of health care services, the majority of these consisting of hospital and physician delivered care.
There is also a provision for private health care in Canada; indeed the delivery of health care in Canada has always been a mixture of public and private providers. While 70% of the total cost of health care is covered by public insurance, there has always been a strong role played by private out-of-pocket and employer-based insurance for services not covered publicly, such as dentistry and nonsurgical vision care (Sanmartin et al., 2014).
Dental services provided by dentists in their offices are not included in the public funding envelope; however, some dental services provided in hospitals are covered under Medicare. It is important to note that public dental services represent a very small proportion of the overall dental services in Canada. For example, in 2014 approximately 5% of overall dental expenditures in Canada consisted of public sector dental expenditures.
Public Oral Health Services
As mentioned above, in Canada dental care is largely a publicly uninsured service. In some cases, however, if care is received in-hospital, or if the patient belongs to a particular institutionalized and/or at-risk population, dental services may be publicly insured (Quiñonez and Locker, 2007). For example, federal public health programs—that is, dental services financed by the federal government—are available to:
- Military personnel
- Those with recognized indigenous status
- Social assistance recipients and their dependents
- Some seniors and/or those with developmental disabilities
- Federal prisoners
The bulk of public oral health programs fall under provincial and territorial jurisdiction. These include programs that are administered at the regional and municipal level, as well as through universities. At this time, it is important to note that while certain services are covered by public insurance, many of these oral health care services are delivered by allied oral health care professionals such as dental hygienists and dental therapists. Public oral health programs at the provincial/territorial level tend to include:
- Surgical-dental services requiring hospitalization or associated with a congenital anomaly or medical need
- Social assistance recipients and their dependents
- Targeted child and adult populations (e.g., low income families)
- Targeted disabled and institutionalized populations (e.g., those in long-term care)
- Provincial prisons
Private Oral Health Services
Approximately 55% of all private dental care expenditures are from private insurance sources, and 45% come directly from out-of-pocket. Therefore, private health insurance plays a crucial factor in Canada in pursuing dental care, and pays for the majority of dental care services in Canada. For this reason, dealing with insurance companies, processing payments, understanding dental procedure codes and discussing dental insurance issues with patients is a very important aspect of practice.
It should be noted that 17% of Canadians avoided going to a dental professional in the last year because of the cost, and 16% of Canadians avoided having the full range of recommended treatment due to the cost. In addition, 32% of Canadians have no dental insurance (CDA, 2013). This is an issue of growing significance. These are important factors to be taken into consideration during discussions with patients.
The Regulation of Dentistry in Canada
The regulation of health professionals in Canada falls under provincial jurisdiction, meaning that each province has its own legislation that affects dental services. The body that is in charge of regulation is called a college (not to be confused with a training college); it is typically separate from the professional association, but sometimes joined (e.g., Alberta). Moreover, regulatory authorities in some provinces require applicants to complete a Jurisprudence and Ethics examination which tests knowledge of local law, ethics, and regulation of the profession in that jurisdiction. It is important to be familiar with the provincial regulations within your jurisdiction of practice.
Moreover, dental regulatory colleges that exist in every province and territory are generally responsible for:
- Setting the education and other qualifications necessary to enter the profession
- Setting standards of professional practice for the dental profession
- Setting ethical standards
- Investigating complaints for people who feel that the standards have not been met
- Taking appropriate disciplinary action as necessary
- Protecting the public's right to quality dental services
- Providing leadership to the profession in self-regulation
In addition to a dental regulatory college, each jurisdiction also has a dental association. Membership in the provincial/territorial and national dental associations is a necessary component of licensure in all provinces except Ontario and Quebec. Also, in the territories, membership in the Yukon Dental Association and the Northwest Territories/Nunavut Dental Associations is not mandatory for registration and licensing. Membership in your association is recommended.
See Table 1 for a list of the professional regulatory bodies and associations and click here for contact information.
Table 1: Professional regulatory bodies and associations
*Please note that the Yukon Dental Association is a separate entity from the Northwest Territories and Nunavut Associations. However, these associations are represented as a federation by a single voting member and a single Board member on the Canadian Dental Association
National Dental Examining Board
This guide is intended for dentists already licensed to practice in Canada; however, should you need information on the examination and licensure process please see the following section and refer to the National Dental Examining Board (NDEB) website at http://www.ndeb.ca.
The NDEB of Canada is the organization responsible for establishing and maintaining a national standard of competence for dentists in Canada. Graduates of accredited dental programs and accredited qualifying/degree completion programs, and individuals who have successfully completed the NDEB Equivalency Process are required to complete the NDEB of Canada's written examination and Objective Structured Clinical Examination (OSCE) to become eligible for licensure as a general dentist in Canada.
In Canada, there are various laws and regulations involved in the practice of dentistry. It is important to refer to the laws and regulations in your province of practice for more information specific to your jurisdiction.
While there is legislative variability across the country, it is typical for each province to have a Dentistry Act. The Dentistry Act is usually accompanied by a more general piece of umbrella legislation known as the Regulated Health Professions Act (in Ontario) or a variant of a similar title, like the Health Professions Act (in British Columbia). The Regulated Health Professions Act, as it is known in Ontario, applies to the province's regulated health professions and their respective regulatory colleges.
The laws, regulations and standards that apply to each provincial regulatory college vary across the country. These include:
- The Dentistry Act
- Standards of Practice/Guidelines/Practice Advisories
The Dentistry Act
The Dentistry Act is the legislation, specifically for dentists, that sets out the scope of practice and controlled or authorized acts for the profession. The Dentistry Act, through the Health Professions Procedural Code, gives the provincial regulatory college the authority to develop numerous types of regulations that establish obligations for members' registration requirements. The Dentistry Act also gives the college the authority to develop numerous by-laws. By-laws usually have a broad scope and are generally concerned with administrative matters within the college.
Provincial and Federal Laws
Beyond profession-specific regulation and legislation there are also several provincial and federal labour laws that dentists must abide by. Provincial and federal labour laws are designed to protect employees and employers. These laws do many things, such as:
- Set minimum salaries
- Regulate health and safety standards
- Set hours of work
- Specify parental leave and annual paid vacations
There are also laws that prevent employers from treating employees unfairly based on sex, age, race, religion, disability and sexual orientation.
The Canada Labour Code provides federal labour standards that employers and employees must follow. For example, the Canada Labour Code provides federally regulated employees with a number of leaves. The employer cannot dismiss, suspend, lay off, demote or discipline an employee when they are on leave or intend to take such leave. Different forms of leave include:
- Sick leave
- Leave for work-related illness and injury
- Maternity related reassignment and leave
- Maternity leave
- Parental leave
- Compassionate care leave
- Leave related to death or disappearance
- Bereavement leave
Another prominent feature of the Canada Labour Code is the protection from sexual harassment while on the job. More specifically, the Canada Labour Code defines sexual harassment as:
Conduct, comment, gesture or contact of a sexual nature that is likely to cause offence or humiliation or that might be perceived as placing a condition of a sexual nature on employment or on any opportunity for training or promotion.
For information on filing an individual complaint for sexual harassment, please consult the Canadian Human Rights Commission. It is not uncommon for the provincial and territorial colleges to have specific guidelines on sexual harassment. Also, your workplace may offer anti-harassment training.
Clients and Dental Health Care Professionals
In Canada, people are often called "clients" in health care environments and they expect to participate in decision-making about their oral health concerns (Health Canada, 2012). In dentistry, the term "patients" also continues to be used and dentists engage in full, open communication that respects the rights, responsibilities and power within the dentist/patient relationship. Respect for the autonomy and personal dignity of the patient is central to the provision of ethically sound patient care.
Patients must provide informed consent to treatment and it is the ethical responsibility of dentists to ensure patients are fully and appropriately informed about their oral health care (Health Canada, 2012). This principle is affirmed in law through decisions by the Supreme Court of Canada and in some provinces, specific legislation sets out the fundamental right of individuals to decide which health care interventions will be accepted and which will not.
Consultation between dentists and other allied oral health care professionals is common practice. You will find that dentists will acknowledge to clients when they do not have the information required and either seek it out or refer the client to an appropriate colleague. A referral is usually requested by writing a letter to a colleague and by scheduling an appointment on behalf of the client.
Dental Practice Ownership
Legislation in all jurisdictions in Canada mandate that all or the majority of directors of a dental professional corporation must be dentists. All or the majority of voting shares of the corporation must belong to dentists as well.
In most cases, there is clear terminology in regulations that specify that no member of a dental regulatory authority can practice the profession of dentistry under the control of or for the benefit, profit or advantage of a corporation, or for any person not being duly qualified and lawfully entitled to practice dentistry (directly or indirectly).
No province/territory permits under any circumstances business corporations to have any form of ownership by non-licensees.
Patient Billing and Remuneration for Services
Dental offices are encouraged to assist patients in understanding their dental insurance benefits. In most cases, the patient will be responsible for the full cost of the dental services rendered including what portion may or may not be covered by their private dental insurance. To make sure that billing and receiving payment for your services is an easy and straightforward process try to use the following strategies:
- Ensure that all dental insurance claims accurately reflect the work completed.
- Make records and document that you have made every effort to collect the full amount of all dental fees charged including the co-payment.
- If you accept assignment and discount your fee for an insured patient, the amount submitted to the insurance company must reflect the overall discounted amount.
- It is fraudulent to only discount the co-payment amount of any claim.