Opinion: Scandinavia's dual-practice health care won't work in Alberta

Alberta’s government wants us to believe that physician dual practice is a proven European solution to long surgical wait times. Last week, Hospital and Surgical Health Services Minister Adriana LaGrange visited Sweden and Denmark to examine their health-care systems.

Learning from other countries is sensible, but there is a fundamental problem with the comparison.

Physicians in Nordic countries have radically different pay, incentives, employment structures, and dual-practice regulations, making it impossible to conclude that Alberta’s new private-pay dual practice model will work the same way.

One major difference is physician supply. Sweden and Denmark have 4.5 physicians per 1,000 people; Alberta has just 2.4. When Alberta doctors treat private-pay patients, even fewer will be available for those who can’t pay.

Tuition for medical school is free in Sweden and Denmark. Every Nordic country rejects the model of students needing lines of credit to pay for food and rent. Doctors enter practice with almost no debt. In contrast, Alberta doctors often enter practice with at least $200,000 in debt, potentially increasing the appeal of dual practice and diverting physician time away from publicly funded care.

Although apples-to-apples international comparison of physician incomes is imperfect, physician compensation, taxation, and benefits differ substantially between Sweden and Denmark compared to Alberta, shaping dual practice incentives. Nordic physicians earn considerably less and pay higher taxes than Alberta physicians. Alberta physicians are among the highest-compensated in the OECD. With twice as many doctors working in Sweden and Denmark but earning less, Nordic dual practice operates in a very different context, making its outcomes difficult to replicate in Alberta.

Nordic governments cover 100 per cent of doctors’ malpractice costs through state-managed no-fault pools, contribute to pensions, and provide six weeks of paid vacation. Alberta doctors receive partial rebates for liability insurance and can only dream of government contributing more than $0 to their retirement funds or paid vacations. These differences may reduce Nordic physicians’ financial pressure to pursue dual practice.

These big differences in health-system design matter.

Physician employment structures also differ fundamentally from Alberta, with tighter dual-practice controls in Nordic countries.

Unlike Alberta’s predominantly self-employed, fee-for-service physicians, doctors in Sweden and Denmark are generally salaried employees whose working conditions and benefits are governed by collective agreements.

Swedish regions employ physicians, set their contractual public duties and working hours, and can restrict private-pay dual practice as a secondary occupation— moonlighting — when it competes with public services.

That’s very different from Alberta’s self-employed, relatively well-paid physicians who enjoy considerable autonomy over where, when, and how they practise. Under Alberta’s dual-practice model, approved doctors can move seamlessly between two markets: one publicly funded and based on medical need, and another where doctors charge patients for faster access. The government calls this flexibility. But flexibility for physicians does not create additional public capacity.

Dual practice is ultimately a competition for scarce physician time.

Since private-pay markets compete for the same surgeons, anesthetists, and clinical staff, dual practice risks shifting capacity toward patients who can pay, rather than increasing total supply of care. That threatens equitable access.

Alberta should learn from the stronger health system performance in Sweden and Denmark. But attributing their success to dual practice as the secret sauce ignores key differences in physician supply, compensation, incentives, employment relationships, and system design.

The minister’s visit may prove useful in other ways, but it doesn’t prove that Alberta’s experiment with dual practice will work. Alberta should instead strengthen publicly funded health care for everyone, consistent with the Canada Health Act, rather than shift scarce resources toward those who pay.

Alberta and the Nordic countries may share a love of snowy winter days, but our similarities do not extend to our health-care systems. We cannot pluck one incidental feature — dual practice — and parachute it into Alberta, expecting shorter waits.

If Alberta wants health-system metrics more like Sweden and Denmark, it must import the whole Nordic health care ecosystem. Otherwise, importing dual practice alone risks longer waits for everyone, except those who can pay.

Karen S. Palmer is an adjunct professor at Simon Fraser University and the University of Toronto. Born and raised in Calgary, she lives in B.C.

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