Competition and the common cold

Health care regulators are encouraged to review restrictions on the ability of nurse practitioners to operate independently

Many Canadians have experienced difficulties when trying to get an appointment with their family doctor on short notice.

When your child has been running a fever for more than 24 hours, the last thing you want to hear is that your doctor is not available that day.

But what if a qualified independent nurse practitioner could examine your child that afternoon? Would you use the service if you had the choice?

Regulations make it difficult for nurse practitioners to operate independently

Nurse practitioners are registered nurses with advanced education and training that allow them to provide a broad scope of health care services, including diagnosing and treating many common illnesses, ordering some tests and prescribing certain medication. If a patient’s needs are beyond the scope of their practice, nurse practitioners must consult with, or refer the patient to, a doctor. Nurse practitioners are regulated by provincial or territorial bodies, and provide valuable services in communities across Canada.

While most nurse practitioners are salaried employees who work as members of health care teams, some have opened independent practices. This represents a new business model that could provide patients with an alternative way of receiving certain health care services. These practices could be particularly convenient for Canadians living in areas where there may not be enough doctors to meet the community’s needs. Recognizing their potential, a number of provinces have already begun to open the door to these new models or are considering alternative ways of incorporating nurse practitioners into their health care frameworks.

However, challenges remain. For instance, regulations may require nurse practitioners to work within the same premises as physicians or other health care professionals, or raise other barriers to nurse practitioners operating independent practices. Billing may also be an issue, as independent nurse practitioners are generally not permitted to bill the province or territory for their services. This means that even though these practices can provide high quality care for everyday health issues at a potentially lower cost to health care systems, their success depends on whether a sufficient number of patients are willing and able to pay "out of pocket".

Although competition may be viewed as playing a limited role in Canada's health care system, regulators could benefit from applying a "competition lens" to their policies. Regulations can sometimes distort marketplace outcomes, and consumers can be unintentionally deprived of innovation and choice.

Even well‑intentioned regulations may be more restrictive than necessary

The Bureau recognizes that regulators must balance competition considerations with other important policy goals. For health authorities, these goals may include important considerations, such as patient safety and promoting long‑term health while limiting pressure on health care budgets.

However, as highlighted in our 2016 Competition Advocate publication on balancing regulation and competition, regulations should be reviewed regularly to ensure that they are based on the best available evidence and that they are no more restrictive than necessary to achieve appropriate policy goals.

For example, current restrictions on independent nurse practitioners may be based on a belief that patients would receive less comprehensive care from a nurse practitioner that operates without doctor supervision. Yet some research appears to suggest that independent nurse practitioners can provide quality of care that is comparable to that provided by doctors for health issues within their scope of practice (see US FTC Staff Paper, 2014 and Heale and Pilon, 2012). There may be other concerns — including the fiscal impact — with allowing independent nurse practitioners to bill provinces or territories for their services.

Competition benefits seen in other professions

Experience shows that when different types of professionals who offer some comparable services are allowed to operate independently of one another, the competition that results can lower costs and improve access.

Dental hygienists in Ontario are one example. Research suggests that independent dental hygienists practising in Ontario charge 30 per cent less for the same oral hygiene services that dentists’ offices offer (see Sobie, 2012). Dental hygienists who offer mobile services may also offer better access, including to patients living in remote locations, at seniors’ residences and to other Canadians with mobility issues.

Paralegals are another example. Some commentators have argued that expanding the ability of paralegals to offer basic legal services could reduce costs and improve Canadians’ access to the justice system (see Prince & Gillis 2013 and Smolkin 2012).

New models could improve access and value for money

In many parts of Canada, it can be a challenge to find a family doctor, and demand for their services is high. But not all Canadians who visit a doctor necessarily require the services of a doctor (see Report of the Advisory Panel on Healthcare Innovation 2015), and some could be effectively served by a nurse practitioner.

If health regulators could find ways to reduce barriers that may be preventing or discouraging the independent nurse practitioner model, this could potentially result in a greater number of patients receiving care, with shorter wait times.

In addition, the cost to the system per patient could potentially be lower, as research suggests that nurse practitioners generally cost provincial health care systems less than doctors (see Chassin and Moreau 2016).

A regulatory "check‑up" may be needed

Health care regulators are well‑positioned to evaluate what is best for their respective health care systems; however, the Bureau encourages regulators to apply a "competition lens" to their policies. In particular, regulators should consider whether current policies that restrict the ability of nurse practitioners to operate an independent practice are in fact necessary to protect patient safety, promote long‑term health or achieve other important policy goals.

If the answer is "no", then the Bureau encourages regulators to pursue less restrictive policy options that can achieve important policy objectives while minimizing harm to competition and innovation. Reducing barriers to entry for innovative business models — while achieving policy goals — could be a prescription for success.