Delivering the Benefits of Mixed Practice to Alberta Patients: Lessons from Europe

Economic Note showing how Alberta’s mixed practice reforms can improve access to care while maintaining the province’s commitment to universality

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This Economic Note was prepared by Conrad Eder, Associate Researcher at the MEI, in collaboration with Emmanuelle B. Faubert, Economist at the MEI. The MEI’s Health Policy Series aims to examine the extent to which freedom of choice and entrepreneurship lead to improvements in the quality and efficiency of health care services for all patients.

Despite ranking among the world’s highest health spenders,(1) Canada regularly underperforms on international health system comparisons.(2) The healthcare system struggles with significant access challenges, including patients leaving emergency rooms without treatment,(3) extended surgical wait times,(4) and reports of unmet healthcare needs.(5)

Alberta’s healthcare system, to date, has been no exception.(6) The province’s recent introduction of Bill 11, however, will allow physicians to engage in mixed practice.(7) This common feature of top-performing European healthcare systems represents an evidence-based policy response. Alberta’s mixed practice reforms can improve access to care while maintaining the province’s commitment to universal healthcare. To realize these benefits while mitigating potential adverse effects, Alberta should adopt the best practices of established European systems that employ adequate guardrails without restrictive regulation.

Alberta’s Mixed Practice Policy

Bill 11 introduces a mixed practice healthcare model, allowing physicians to work in both the public and private systems.(8) While some provisions of the bill have already been implemented,(9) the substantive mixed practice elements of the legislation will come into effect later this spring.(10)

The recently passed legislation sorts physicians into three categories:(11) Participating Physicians, who exclusively provide publicly insured services through Alberta’s provincial health plan; Non-Participating Physicians, who operate entirely outside the public system, only providing services to patients who pay for them directly; and Flexibly Participating Physicians (the newly created category), who operate in both sectors, billing the public plan for covered services while simultaneously offering non-plan services that patients can pay for privately.

Alberta’s mixed practice reforms can improve access to care while maintaining the province’s commitment to universal healthcare.

The legislation requires flexibly participating physicians, before providing a non-plan service, to provide patients with written information detailing the service, its costs, direct payment requirements, and the availability of the same service as an insured service. Physicians must also maintain separate public and private records.(12)

While the minister retains the flexibility to modify those requirements,(13) the legislation as written does not include many regulatory elements common in Europe’s higher-performing universal healthcare systems. The government must strike a balance, for while inadequate guardrails can expose the public system, overly restrictive regulation can keep mixed practice from delivering its benefits.

Benefits of Mixed Practice

Mixed practice contributes to capacity expansion within healthcare systems in three main ways: enabling additional physician working hours, optimizing infrastructure utilization, and strengthening physician recruitment and retention.

By enabling healthcare workers to work additional hours beyond their public commitments, mixed practice offers physicians greater flexibility while increasing the total volume of healthcare services available to patients without increasing the total number of physicians.(14) Evidence from Denmark demonstrates that mixed practice increases total healthcare capacity without compromising public service. A study examining hospital physicians found that those engaged in mixed practice maintained public hospital commitments similar to their purely public sector colleagues while expanding their overall service provision, providing an average of 5.2 additional hours of care weekly in the private sector(15) (see Figure 1).

Public hospitals do not always use operating rooms and diagnostic equipment at full capacity. Infrastructure remains idle for various reasons, including scheduling gaps, labour shortages, and insufficient capital.(16) The last system-wide performance review by Alberta Health Services demonstrated the magnitude of hospital infrastructure underutilization, finding that operating room capacity use was just 71%.(17) Recent research out of Quebec documented similar patterns.(18) Mixed practice physicians working additional hours can make use of some of this idle capacity, enabling better utilization of existing infrastructure without requiring greater public investment.(19)

Mixed practice can also help the public system attract and retain physicians by allowing for income supplementation and professional autonomy.(20) More physicians means greater capacity for service provision, which can translate into shorter wait times for patients.(21) Research shows that physicians value mixed practice not only for financial reasons but also for clinical autonomy, professional development opportunities, prestige, and greater work satisfaction(22) (see Table 1).

Mixed Practice in High-Performing Systems

Mixed practice may be novel in Alberta, but it has existed in various forms for decades across Europe and around the world. Healthcare providers may work part-time in both sectors or full-time in the public sector with occasional private consultations. Private work may occur inside public hospitals or in entirely separate private facilities. Many systems that permit mixed practice allow workers across specialties to operate in both sectors.(23)

The Commonwealth Fund’s 2024 rankings reveal that successful universal healthcare systems permit mixed practice, rather than banning it. Of the top six (Australia, the Netherlands, the United Kingdom, New Zealand, France, and Sweden), none prohibit mixed practice, while in Canada, which ranks 7th among the 10 countries studied, most provinces do have laws that prohibit it.(24)

The last system-wide performance review by Alberta Health Services demonstrated that operating room capacity use was just 71%.

To be fair, correlation does not prove causation. These other systems each have unique elements beyond mixed practice, including duplicate health insurance, activity-based funding, and private hospitals, that also affect their outcomes. What is clear is that mixed practice coexists successfully with strong universal healthcare systems and is found in countries with systems that outperform Canada on measures of access and equity.(25)

Lessons from Europe

Reaping the benefits of mixed practice depends largely on regulatory design.(26) European systems show that well-designed guardrails do not arbitrarily restrict private practice; instead, they create the conditions under which mixed practice can deliver system-wide benefits.

Broad Scope and Specialty Eligibility
To generate system-wide capacity gains, while keeping in line with European standards, Alberta should allow mixed practice across a wide range of physician types and specialties, including primary care. As it is in France, Germany, and the United Kingdom, mixed practice should be the rule, not the exception.

Limiting mixed practice to select specialties creates coordination challenges that undermine its benefits. If only specific surgeons, for instance, can engage in mixed practice, scheduling conflicts and resource misalignment will constrain the very capacity expansion that mixed practice is designed to achieve.

Minimum Public Service Requirements
Minimum public service obligations ensure physicians remain committed to public service by guaranteeing a baseline level of availability for publicly insured patients. In Germany, for instance, physicians contracted to treat patients covered by public health insurance are required to set aside a minimum number of hours per week for those patients.(27) This ensures that publicly insured patients can access care, thus maintaining public service levels without restricting overall physician productivity.

Mixed practice coexists successfully with strong universal healthcare systems in countries that outperform Canada on measures of access and equity.

A similar model in Alberta would have flexibly participating physicians meet specified public service minimums, which could be measured in terms of service hours, visit volumes, or procedure counts. This approach protects access for those who are publicly insured while still allowing physicians to increase their overall capacity.

Revenue-Sharing Mechanisms
Revenue-sharing arrangements enable physicians to provide both private and publicly funded services within the same facilities, allowing for the optimization of public infrastructure while offsetting the costs of using public resources. In France, for example, public hospital physicians are salaried employees but may also treat patients privately, often in the same hospital. When they do, they are required to remit a portion of their private fees back to the hospital.(28) This arrangement ensures that when public infrastructure is used for private purposes, the public system is compensated. Alberta can adopt a similar approach, addressing the concern that mixed practice might lead to physicians using public resources for private gain.

Contractual Protections
Healthcare provider contracts are an important tool used by European countries to specify scheduling rules, disclosure requirements, and consequences for violations. In the United Kingdom, for example, healthcare workers are permitted to engage in mixed practice; however, their contracts and codes of conduct make it clear that publicly insured patients take precedence.(29) These protections address concerns that physicians might prioritize private work over public duties. By establishing clear contractual boundaries with flexibly participating physicians, Alberta can ensure that public hospitals retain physician services and publicly insured patients receive care when needed.

Guardrail Calibration
While the guardrails outlined above represent international best practices, Alberta’s implementation must avoid an excessive regulatory burden that would prevent mixed practice from achieving significant capacity expansion. Eligibility criteria should not create artificial barriers that prevent meaningful physician participation. Minimum public service requirements should ensure ongoing commitment without preventing considerable private practice engagement. Revenue-sharing rates should compensate public facilities for infrastructure use without eliminating financial incentives for physicians. Contractual protections should establish clear scheduling priority for public patients without creating inflexible constraints that make mixed practice impractical.

Guardrails should be robust enough to protect the public system yet flexible enough to enable meaningful private practice participation.

The goal of regulatory guardrails is to shape incentives and behaviours toward capacity expansion that benefits all patients, not to arbitrarily constrain private practice. European success stories demonstrate that this balance is achievable.

Conclusion

Canada is well positioned to benefit from mixed practice as other high-performing European healthcare systems do, as it has the stable institutions, governance mechanisms, and regulatory capacity that create the preconditions for successful implementation.(30) Combined with other reforms, such as duplicate private health insurance,(31) activity-based funding,(32) and expanded private infrastructure,(33) its impact could be even greater.

What will determine Alberta’s success, however, is not Bill 11 itself, but the regulations that follow. International experience shows that effective regulation strikes a deliberate balance: guardrails should be robust enough to protect the public system yet flexible enough to enable meaningful private practice participation. By implementing mixed practice thoughtfully, learning from European experience, Alberta has the opportunity to positively reshape Canadian healthcare for generations to come—not by abandoning universality, but by strengthening it through evidence-based reform.