Is virtual care a cure for Canada's battered health-care system?
COVID-19 pandemic saw growing use of virtual care, but Ontario now pushing back
Lesley Campbell leaves the emergency department at Michael Garron Hospital in east Toronto cradling her right arm.
"I fell off my bike," she said, looking down at her white cast. "Accidents happen."
She said that for some ailments, like a broken bone, you need to go to the hospital, but for other less serious things, there should be an alternative.
"For lots of other things, like a minor contusion or whatever or a sprain, it would have been nice to just ask what do I do next?" Campbell said. For a child with a fever, for example, "I could easily call to just get some advice right on the spot. The doctors can see them on video, and that would be wonderful not to have to come downtown."
"It saves your time, saves your energy and definitely saves on gas," said Zahir Mohammed, who was also leaving Michael Garron Hospital. But while it may be convenient, he said he's not a fan of virtual care. Instead, Mohammed said, he'd rather see his physician in person, so he can better explain his symptoms and ask questions.
"Sometimes through virtual, it's not just expressible those kind of things, so ... there's more likelihood to be misdiagnosed."
Virtual care is broadly defined as the delivery of health-care services through electronic means, such as telemedicine, online video consultations and remote monitoring. During the COVID-19 pandemic, consulting with a doctor by videoconference or phone proved to be a convenient way to access care.
Pandemic led to growth in virtual care
Many provinces in Canada have turned to virtual care to lift pressure from their strained health-care systems. Hospitals have been able to divert patients from crowded emergency rooms, and it's been used to deal with problems caused by a nation-wide shortage of health-care workers and long waiting lists for family doctors.
But despite the growing use of virtual care during the pandemic, there's now pushback from Ontario, the country's most populous province, and its physicians' association.
Even before the pandemic, a number of platforms had been offering virtual medical appointments, including Telus Health, Maple, Babylon, Tia Health and Rocket Doctor. Some platforms bill provincial health-care plans, while others charge a user fee.
With COVID-19 restrictions and crowded hospitals and clinics, Dr. William Cherniak — an emergency room physician in Markham, Ont., north of Toronto, and the founder of Rocket Doctor — said it was an opportunity.
"Virtual care wasn't simply something that we tolerated during the pandemic because it filled the gap where doctors couldn't see patients in person, but rather it's something that Canada was missing for many years because it wasn't in our public funding, and we're just now starting to understand the potential of it," he said.
Cherniak's virtual care company has partnered with Georgian Bay General Hospital in Midland, Ont., on a trial for a new service giving patients an alternative option to the emergency room.
The majority of people who go to the ER have minor illnesses or injuries that could be cared for virtually, he said, leaving the emergency department for those with more serious illnesses or trauma.
"We have a huge health-care system crisis with physicians being burnt out not wanting to practise medicine, patients losing their family doctors, and we have physicians who want to see patients virtually and are willing to do it."
But in Ontario, Cherniak said, a change in policy has resulted in fewer doctors interested in signing on to provide such services.
Virtual care takes back seat in Ontario
On Dec. 1, a new physician services agreement between the province's Ministry of Health and the Ontario Medical Association (OMA) came into effect, with a new virtual care funding framework. While the new schedule of benefits for physician services made temporary virtual care billing codes permanent, the new Ontario Virtual Care Program pricing structure, rates and payment parameters have new limits on what OHIP — the province's public health insurance plan — will cover.
Sylvia Jones, Ontario's health minister, said with the worst of the pandemic over, the need for virtual care is not as urgent.
"We need to get patients in front of their physicians more regularly," Jones told reporters last month. "We need family physicians to be seeing patients in person. When that parent is concerned, when that caregiver has questions, the first place they need to be able to go and have access to is their primary care physician."
Dr. Rose Zacharias, president of the Ontario Medical Association, agrees that virtual care is not intended to replace in-person care.
"We have now pulled back, looked at how we can best leverage virtual care and also prioritize the patient-doctor relationship," she said. "We don't have enough doctors for everyone to have that relationship and therefore the urgency to license more doctors, get more doctors into this system to capture those patients inside of that relationship of care."
But Cherniak said the new agreement between Ontario's Health Ministry and the OMA will threaten many virtual care business models because doctors conducting virtual visits — where there is no existing relationship between the physician and patient — will receive only a flat $20 fee. Physicians who have previously seen a patient in person once in the prior 24 months will be paid the same fee for virtual care as in-person care, but not those providing "one-off" visits.
"So they're saying, 'Hey, we're going to actually cut your fee rates in half, in spite of all the challenges you experience fighting this pandemic,' and it's really unfortunate because a lot of patients are going to lose access to care," Cherniak said.
But some doctors see the billing change as an incentive for followup care to be done in the community.
Dr. Kyle Vojdani is chief of the emergency department at Michael Garron Hospital, which offers virtual care for minor ailments, assisting about a dozen patients a day.
"Receiving a virtual visit from a physician in another province or perhaps ... hundreds of kilometres away from you, trying to co-ordinate the followup management for you is difficult if not impossible," he said.
Studies differ on benefits of virtual care
The OMA recently cited a report linking virtual care to additional pressure on the overwhelmed health-care system. The report said a lack of continuity of care after virtual visits was leading to patients ending up in the ER.
But Cherniak of Rocket Doctor cites another study that found 94 per cent of patients who used virtual care instead of going to an ER rated their overall virtual care experience as an 8 out of 10 or greater. More than 80 per cent said they received answers to all of their questions related to their health concerns and believed they were able to manage the issue.
Another survey by the Angus Reid Institute found that half of Canadians either can't find a doctor or can't get a timely appointment with the one they have. It also found that one-third of Canadians (32 per cent) report they mostly interact with their family doctor over the phone or by video call. And of those Canadians who see their family doctor primarily over the phone or the internet, 65 per cent say they're fine with the arrangement.
Cherniak said that unlike Ontario, Canada's western provinces have been more welcoming to virtual care providers because they realize that people in isolated rural areas need access to timely care when they can't get into a physician's office.
"I mean, B.C. and Alberta have really doubled down on virtual care, you know, like the Alberta government gave in-person and virtual services parity," said Cherniak, who sees the potential to help those having trouble finding a family doctor, especially in remote areas, or those who have mobility issues that make it difficult to travel to a health-care facility.
Newfoundland and Labrador recently asked for requests for proposals to provide virtual health-care services in the face of emergency room closures in the province. It also plans to explore options to expand virtual care for people without a family doctor.
"In an ideal world, yes, everybody would have a family doctor who is available to them in a mix of virtual and in-person practice. And you could access that family doctor in a couple of days or the same day, but it's just not the world that we live in," Cherniak said.
He estimates that the 20 to 25 physicians who signed up to provide services through his platform had been seeing up to 600 payients a day, but now only one doctor is left, seeing 20 or fewer patients a day.
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