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Fair Market Value for Uninsured Services

A number of eye health services provided by physicians are not considered medically necessary and are therefore not insured under provincial and territorial health insurance legislation. These services are outside the scope of the Canada Health Act.

Canadian ophthalmologists asked the Canadian Ophthalmological Society (COS) to provide guidance with regards to physician fees for these services. COS commissioned Health Intelligence Inc., an independent and well-respected health economics analysis firm, to conduct a study using recognized conventional methodologies to determine fair market value for these services.

It their 2010 report, Health Intelligence Inc. (HII) concluded that:

“The advent of new ophthalmic technologies provides exciting opportunities to give people better vision. When these are not insured under provincial or territorial health plans, ophthalmologists should be allowed to offer them to their patients at reasonable fees. These fees need to be clearly delineated so that it will be transparent to patients what they are paying for. It also must always be made clear that these uninsured services are optional and not medically necessary and that patients have the right to refuse them, without affecting the quality of their insured service.”

View full COS Statement on Values for Uninsured Services, including the underpinning formulae used in HII’s study.

View Valuation of Uninsured Ophthalmological Services: A Report to the Canadian Ophthalmological Society*

*Please note: this report is meant to provide ophthalmologists with an overview of guiding principles for patient billing practices for uninsured services. It offers examples of reasonable costs for some uninsured services.

Further, the report is not intended to define fixed charges for uninsured services but, instead, to explain why there will be differences in fees, as for any other goods or services, due to factors such as variation in cost of living between regions, and variations related to equipment costs, volumes and overheads.

As such, the report is not a prescriptive document, nor is it intended to be legal advice since it is not exhaustive of all questions or nuances that may arise.

Canadian Vision Care by the Numbers:

$15.8 billion: Cost of vision loss in Canada annually

$8.6 billion: Direct health care costs annually

$7.2 billion: Indirect costs (lost earnings, care & rehabilitation, special equipment, etc.)

$30.3 billion: Annual cost of vision loss in Canada by 2032

[Source: Vision Loss in Canada 2011]

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