Chartered surgical facilities are back in the headlines. What are they?
Facilities are a relief valve the public system can turn to when they lack hospital capacity, experts say
Chartered surgical facilities are at the centre of an Alberta political controversy that includes allegations of conflicts of interest.
Alberta's auditor general is investigating how Alberta Health Services has procured goods and awarded contracts.
Auditor General Doug Wylie announced the review last week after AHS's fired CEO alleged there was political interference, according to a letter from her lawyer obtained by the Globe and Mail.
Alberta's premier on Saturday said she'd ask the auditor general to expedite this review, which also is examining AHS's purchase of pain medication and COVID-19 supplies.
But what is a chartered surgical facility (CSF), and how do they fit into Alberta's health-care system?
Steven Lewis, a health consultant and Simon Fraser University adjunct health policy professor, said governments use these facilities as a relief valve when they feel they need to do more surgeries than hospitals can accommodate.
"They're high-volume procedures that can be done safely in a community-based setting rather than in an acute care hospital," he said. "Rapid turnover, high-volume cataracts, hips and knees are by far the most common."
How did private surgical facilities become an option?
The College of Physicians and Surgeons of Alberta (CPSA) says it began accrediting non-hospital surgical facilities in 1995.
Ralph Klein's Progressive Conservative government opened the door to more publicly funded, privatized surgeries in 2000 with the adoption of Bill 11, the Health Care Protection Act.
The legislation allowed private surgical clinics to keep patients for overnight stays, and allowed operators to perform both publicly funded and private-pay operations under the same roof.
Watch | How chartered surgical facilities work:
When the United Conservative Party government was elected in 2019, then-premier Jason Kenney created the Alberta Surgical Initiative. It aimed to double the number of surgeries happening in private clinics from 15 to 30 per cent of all procedures by 2023.
The province has not yet met that goal. According to data posted by Alberta Health, 22 per cent of scheduled surgeries recorded to date in 2024 took place in a CSF.
In 2020, the UCP government passed legislation making it easier for corporations to found a surgical centre and receive payments for publicly funded procedures.
The next year, the government said it would try to boost the total number of surgeries happening in Alberta by 55,000, relying heavily on private facilities. Alberta Health data shows the number of surgeries actually increased by 646 the next year — about three per cent.
The government also aimed to eliminate waits longer than clinically recommended for surgeries by 2023. The Alberta Health Services 2023-24 annual report says it did not reach that goal, and more than 27,000 people were waiting longer than they should as of March 31, 2024.
Alberta Health data shows in December 2024, nearly 43 per cent of people on surgical lists had waited longer than recommended, and that number has been trending upward since June.
What kinds of surgeries happen in a CSF?
Alberta Health Services has posted contracts with CSFs online. AHS spokesperson Holly Budd says the authority now has 48 contracts with 38 private entities. Most of the CSFs are in Edmonton and Calgary. Some contracts date back to 2013.
They include agreements to perform publicly funded eye surgeries, oral and maxillofacial procedures, ear, nose, and throat surgery, plastic surgery, pregnancy terminations, dermatology, bone and joint surgeries, and some general surgery. There are legal limits on what procedures CSFs can perform.
The CPSA currently has a list of 82 approved non-hospital surgical facilities. Not all of them perform publicly funded procedures.
How much do we pay for private surgeries?
Although contracts posted online include the estimated and total value, they don't include details on how each procedure is priced.
Some of the largest contracts are for orthopedic surgery or plastic surgery.
A drawback of contracting out surgeries is that the public can't see how the contractor is spending the money, said Tom McIntosh, a political science professor at the University of Regina who studies health policy.
"This is a public health-care system to be managed for the public good," McIntosh said. "We can't know that if we can't see where the money goes."
Lewis said the opacity makes it impossible to determine whether surgeries are more cost-efficient in public or private settings, or how much funding goes to profits, he said.
What are their advantages?
Lewis said the surgical centres can add capacity, if operating room space is a pinch point in the public system.
They're most useful if a private facility is already built and running and can handle a temporary surge of cases when the public system needs flexibility, he said.
Lewis said, in theory, a private surgical centre could also work through a list of non-complex surgical cases to create more room in hospitals for patients with complex health needs.
McIntosh said people who support the idea of contracting out surgeries argue they can help reduce wait times in the public system. It also leaves a private company responsible for the cost of construction and purchasing equipment for surgery.
What are some drawbacks?
McIntosh says it's health-care workers who are the scarce resource, and opening private operating rooms doesn't train or attract more doctors and employees — it just "moves the same pieces around the chess board."
A study from the Parkland Institute that examined the early years of the Alberta Surgical Initiative found that while surgeries taking place in CSFs grew between 2018 and 2022, the number of surgeries in public hospitals had not rebounded to pre-pandemic levels by 2022 — likely because workers changed systems.
AHS's annual report also says a shortage of anesthesiologists, nurses and surgeons stood in the way of meeting its surgical targets in public facilities.
McIntosh said in provinces that have pushed to expand private surgeries, the outsourcing did not reduce wait times or drive down costs in the long term.
Lewis says CSFs that can offer private and public services also create an option for queue jumping. For example, a person who can afford to pay for a private MRI might have that result sooner, allowing them to book surgery faster.
Private clinics can also "up-sell" patients extra procedures or features they pay for out of pocket, Lewis said, which raises questions of equity.
What's the province's plan?
This year's provincial budget and health ministry's annual report refer to performing more surgeries in underused rural hospitals and CSFs to try and decrease wait times. They do not include any targets for the number of surgeries to complete, what proportion should be in private clinics, or wait time goals.
Jessi Rampton, press secretary to the Alberta health minister, did not directly answer questions about whether the government has any such targets.
"Alberta's government is focused on ensuring every Albertan receives requires surgeries within clinically recommended wait times," Rampton said in a statement.
Although the number of patients waiting longer than recommended for hip or knee replacements during the past three years has improved, Rampton said the government recognizes it has more work to do.
"That is why we are using all the tools at our disposal to get as many surgeries done as possible — including the use of chartered surgical facilities to increase capacity and reduce wait times," she wrote.
Rampton said the government expects to pay for 310,000 surgeries in the 2024-25 year. Surgical teams completed 304,595 operations in 2023-24.
This year's provincial budget also included $313 million to open and renovate operating rooms in public hospitals and purchase new equipment.
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With files from Travis McEwan