Calgarian Robin Arseneault visited her doctor's office in Marda Loop this week for a routine physical. 

Along with her husband, Robert, the Arseneaults visit the neighbourhood clinic often. That's because Robert has high medical needs as someone with primary progressive MS, heart and bladder dysfunction, diabetes and kidney concerns. 

So the couple was surprised to see an email land from the Marda Loop Medical Clinic in their inbox that same week, stating that the clinic would be moving to a membership system.

The pricing under that membership, shared with CBC News by Arseneault, is listed as $4,800 per year for a two-parent family membership, which covers two adults and their dependent children.

Other memberships include a $2,400-per-year membership that covers one adult and their dependent children, and $2,200 per year for an individual adult membership.

"First off, we can't afford $4,000 a year," Arseneault said. "Secondly, I fundamentally disagree with that tiered system of health care. I can't stand the idea that if I have more money, I get more privileged care, than say, my neighbour. It's just against my beliefs."

In return for the membership, the Marda Loop Medical Clinic promises reduced wait times and extended appointment times, among other benefits. The clinic also says it will continue to provide care one day a week for non-members.

CBC News was told an administrator at the clinic wasn't available for an interview. In an email sent to the clinic's members, Dr. Sally Talbot-Jones wrote that the clinic's aim was to alleviate stress expressed by patients due to extended waiting times, the challenge of scheduling family appointments, and more.

"This decision was driven by my commitment to providing you with the level of care you deserve. I have extensively researched the most successful healthcare models around the world, and I am confident that our new program is designed to deliver excellence," Talbot-Jones wrote.

The program at the Marda Loop clinic isn't the first along these lines in Calgary. Such arrangements date back years, and they aren't all structured in the same way.

But as the Canadian and Alberta health-care systems struggle under the weight of increased pressure — whether that's rural emergency room closures, ambulance shortages, or overwhelmed hospitals — experts say arrangements like the one being offered at the Marda Loop clinic are becoming increasingly common.

'Skirting the boundaries' of what's allowable

Back in 2008, Alberta's health minister at the time was asked whether he had any concerns about a private clinic opening up shop in downtown Calgary, charging $2,900 per year.

The clinics didn't contravene the Canada Health Act because they didn't charge patients for medically necessary services, CEO Don Copeman said at the time. 

Given that, Alberta Health Minister Ron Liepert said there should be little need for such clinics if Alberta made changes to its publicly funded health-care system.

"The findings were that there was no contravention of the Canada Health Act so I wouldn't be proposing to do any kind of review," Liepert said.

The Canada Health Act stipulates that patients can't be charged for "medically necessary" services, provided in a hospital or by a doctor.

There are some blurred lines here, though, when it comes to privatization in Canada.

Consider services like chiropractic services, which are not deemed medically necessary and aren't covered in Alberta, meaning patients have to pay for those themselves, or through private insurance.

If private health-care providers charge patients for medically necessary services, the provinces that allow that have dollars clawed back by the federal government.

"So, it is not allowable that you would charge a patient as they come in to see a doctor for the care that you provide them," said Fiona Clement, a professor who specializes in health policy in the department of community health sciences at the University of Calgary. 

"But what is being tried, and I think kind of skirting the bounds of what's allowable, are these membership fees."

Controversial, but no clear policy to regulate

Since the Copeman Healthcare Centre opened in 2008, many more such arrangements have followed — in Alberta, and across the country.

In 2022, researchers from Dalhousie University and Simon Fraser University released a paper tracking the number of clinics taking private payment across the country.

At the time of the analysis, which was between November 2019 and June 2020, there were 14 private clinics in Alberta with a range of membership fees and private payment. During that same period, there were 24 in Ontario and 30 in Quebec.

"While reports have documented the operation of corporate or boutique clinics in Alberta and Ontario, we do not yet have national information on the extent of these practices," the authors wrote in the report.

In any effort to document the number of such operations, there would be some error and misclassification involved, Clement noted, as there's no formal registry list, and no necessity to register this sort of approach.

There have been ebbs and flows in the conversation at a policy level about what to do about this issue, Clement noted, but added that everyone's a little bit hamstrung, as technically there's nothing wrong about what's happening.

"The college who deals with governing the professionals and making sure that doctors are adhering to their professional ethics, they're still offering medically necessary care, and they're not charging patients," Clement said.

"So there's technically no violation there. So, I really think it would have to come from the government to sort of ban these kinds of things."

When the Copeman Healthcare Centre opened in 2008, a Calgary spokesperson with the public health non-profit group Friends of Medicare bemoaned the trend, questioning whether society wanted to allow people who have an "extra $3,000 to spend [to go] to the front of the line and everybody else can fall where they may."

The group is increasingly concerned today.

Chris Gallaway, executive director of Friends of Medicare, called such arrangements "a violation of the Canada Health Act" and called for them to be investigated.

"We shouldn't be creating two tiers, where some people pay to get into a certain clinic that others can't access," he said. 

Province says it will continue to monitor situation

In a statement, a spokesperson with Alberta Health Minister Adriana LaGrange wrote that the government remains committed to the principles of the Canada Health Act, adding that Albertans don't need to pay out of pocket for insured health services.

"All physicians must also follow standards of practice set by their regulatory colleges. The government will continue examine these cases to make sure all legislation is being followed," Scott Johnston, press secretary for LaGrange, wrote in a statement.

While the province monitors developments, another health policy expert says it's not surprising to see some doctors experiment with these kinds of solutions given the pressures they are under in terms of patient demand and rising financial pressures.

"A combination of pressures related to increasing rental prices, and for increasing staff wages, as well as just general inflation in their daily lives, I think there is a pretty large pressure to increase revenues, however possible," said Rosalie Wyonch, lead of the health policy research program at the C. D. Howe Institute public policy think tank.

In provinces across Canada, there is a lot of grey area about what makes up a full, publicly-insured service, what could what is definitely a private service, and what could be either-or, Wyonch noted.

"All of that uncertainty, it creates in some cases opportunities to generate revenue or improve access to services with some fees," she said.

"It could also create equity concerns in terms of only being able to access services if you can afford one of these concierge services."

In the midst of all this uncertainty, some patients like the Arseneaults worry they'll be left behind, without many options in front of them.

"I mean, we enjoy our doctor, we get good services from the clinic. And, yeah, it's a upsetting situation," Arseneault said.

"It's actually quite frightening. And it causes a lot of stress for us."

The Alberta government says it is checking into a Calgary clinic that is promising fasttrack access to a family doctor along with other perks to patients who pay up to $4,800 a year.

“The Government of Alberta remains committed to the principles of the Canada Health Act. Albertans don’t have to pay out of pocket for insured health services such as seeing a family doctor or a hospital visit — that won’t change,” Alberta Health spokesman Scott Johnston said in a statement Monday.

“All physicians must also follow standards of practice set by their regulatory colleges. The government will continue to examine these cases to make sure all legislation is being followed.”

Johnston was responding to a recent email obtained and released to media Monday by the Opposition NDP from the Marda Loop Medical Clinic to its patients.

The email informs patients that as of Aug. 1, the clinic will move to a membership-based service with a suite of annual fees including $2,200 for an individual adult and $4,800 for a family.

For that fee, patients are promised reduced wait times to see a physician, extended appointments if necessary, at-home blood tests, collaborative care from the health team and discounts on skin care and physiotherapy.

The email from physician and clinic owner Dr. Sally Talbot-Jones tells patients the decision was made to provide better care in response to patient concerns about long waits for appointments.

The email promises to keep one day a week open for patients who do not sign up for the membership.

Information about the new membership program could not be found on the clinic’s website.

The Marda Loop clinic and Talbot-Jones could not be reached for comment.

The clinic is open weekdays but a message on the clinic’s answering machine Monday said it was closed for the rest of the day.

An email to the clinic asking for information and an interview with Talbot-Jones was not immediately answered.

The College of Physicians and Surgeons of Alberta did not immediately return a request for comment.

Chances of success rank along with winning the 6/49.

Alberta Health Services has more than 100,000 employees but three people now run it with total authority - Premier Danielle Smith, official administrator Dr. John Cowell and Health Minister Adriana LaGrange.

Key decisions are made by Smith and Cowell, the hired hand who is supposed to be temporary but had his contract renewed ($360,000 for every six months.)

Mauro Chies, the CEO of AHS, takes his orders from this tiny politburo.

There's never been a time in Alberta health care when political rule over the system has been so complete and unquestioned.

The premier fired the appointed AHS board and installed Cowell. She said they would meet regularly, collaborate and make the calls.

Conveniently, they declared before the election campaign that the health-care crisis is over due to their wise actions.

Any dissent in the top layers of AHS remained as contained as light in a black hole.

This trembling, timorous system is suddenly expected to decentralize, to give more authority to local institutions and managers.

Muddle is already evident. Asked how she'll implement Smith's wishes, LaGrange essentially

said she hasn't a clue what's to be done.

Re-create genuine regional authorities, the way most other provinces still do it?

Somehow give real local power to the five existing health "zones" within AHS?

Encourage a culture that lets local people make decisions, without fear of the central power in Edmonton?

Nobody knows, least of all LaGrange. But the challenge is daunting because no system in Canada is so conditioned to central autocracy.

There's no questioning the need for change. Care often suffers because local managers can't make decisions.

The central system was created in 2008 to save money, bring efficiencies and standardize care - all the usual buzzwords.

In some ways, it has worked.

Alberta's single-purchaser power led to early acquisition of COVID supplies.

But problems emerged very quickly after nine regional authorities were merged into one, under then premier Ed Stelmach and health minister Ron Liepert.

Many a study has since been done, including some by the Health Quality Council of Alberta when Cowell was in charge. But the most striking came from the political side, after then PC premier Jim Prentice appointed a panel to examine problems in rural areas.

In one community after another, health officials voiced frustration with sclerotic decision-making from Edmonton, to the point where they bought supplies with their own money.

"One site manager described having to obtain approvals from six different managing directors in six different communities," said the report, released early in 2015.

"Acting out of frustration, site managers described proceeding without prescribed approval because they were tired of waiting months for an answer. "The committee heard that basic items (screws, Band-Aids, bleach) were often purchased using personal funds because the supplies were clearly needed and it would take too long to get approval, if it came at all.

"Simple and routine maintenance tasks (changing light bulbs, fixing toilets and installing new equipment) were delayed by months and even years while awaiting approvals from 'up the ladder.'

"Every site manager that met with the committee expressed a keen desire to actually fully manage all operations at their facility."

Health managers from decades ago, before there were health regions, still express nostalgia for the days when each hospital ran its own operations while co-operating closely with other sites.

Now we have the opposite extreme - a system utterly dependent on central authority, with results that often defy common sense.

Doctors, nurses and other health workers somehow manage to provide excellent service to many people most of the time. They aren't responsible for absurd surgery wait times, the upheaval in southern lab testing and many other problems.

Smith likes to blame managers for the problems; the very people who don't have the autonomy to do what's needed, partly because of her own acute centralization.

As any doctor would say, you can't cure one illness with another.

Don Braid's column appears regularly in the Herald. Twitter: @DonBraid