White Coat, Black Art

Many Canadians welcomed virtual health care. Where does it fit in the system now?

The pandemic-driven shift toward virtual health care has opened doors that many Canadians don't want to see closed, and that has policy-makers looking at how best to fund it.

Pandemic-driven shift opened doors that many Canadians don't want to see closed

A person consults with a doctor virtually in this stock image. Family physician and researcher Dr. Tara Kiran says that while virtual health care is convenient for patients, she's concerned about the rise in for-profit businesses offering on-demand doctors. (Fizkes/Adobe Stock)

Having the option to speak with her doctor over the phone for basic check-ins and requests has freed up Shawna Ford's energy for tasks she'd prefer doing.

"Normally, to go into the city, I don't do anything the day before. I don't do anything a few days after because it totally drains me. So having those phone appointments is amazing," the Alberta woman, 62, told White Coat, Black Art.

"The Zoom appointments with a psychiatrist have also just freed up so much of my energy that I can use, you know, on things that I want to do," she added. "Functional energy, I guess."

Ford, who has diagnoses of major depressive disorder and myalgic encephalomyelitis, the latter causing extreme fatigue, still visits her doctor in person when necessary. But the pandemic-driven shift toward virtual health care has opened doors that Ford says she doesn't want to see closed — and she's not alone in raising concerns about access to quality virtual health care.

While British Columbia and Alberta have embraced access to virtual health care, Ontario and Manitoba have scaled back funding for services not paired with in-person doctor visits. 

"I don't think the system has their finger on the pulse of what patients need and want, because if it did, we wouldn't be in this predicament," said Dr. Aviva Lowe, a Toronto-based pediatrician and lactation consultant.

'Two classes of Ontarians'

Until December, when a new billing framework came into effect in Ontario and lowered what health-care professionals can get paid for some virtual appointments, Lowe saw patients on KixCare, a virtual, app-based health-care service for children and teens. KixCare, Lowe argues, offers a way to address health inequities by making doctors more accessible for those without a family physician or pediatrician.

"These changes have really created two classes of Ontarians when it comes to accessing virtual care," Lowe told White Coat, Black Art host Dr. Brian Goldman.

A blonde, smiling woman looking directly at the camera poses in front of a grey backdrop.
Dr. Aviva Lowe is a pediatrician and lactation consultant. Until December, she was also a doctor with KixCare, a virtual health-care platform offering on-demand services for children, teens and their parents. (Doug Sturgeon)

"By that I mean there's the group of patients who can continue to access it, and those are patients who can access it with their own doctor or with a consultation to another doctor."

The other group are those without a regular family doctor who may now be limited in accessing health care virtually, she said.

Changes to provincial billing schemes

When the pandemic began, doctors across the country rapidly shifted their practices to phone and video calls, rather than in-person appointments. 

For many patients, it was a welcome change. A recent Western University study found that the shift reduced barriers to accessing care, particularly for people who rely on public transit, and others who may be unable to take time off work.

Governments across the country quickly implemented emergency billing codes for virtual appointments — often paid at parity with in-person appointments. 

But when the Ontario government introduced permanent billing codes for virtual appointments last year, rates paid to doctors for virtual appointments dropped in some circumstances, leading to outcry from providers.

In Ontario, doctors with an ongoing relationship to their patient — a family physician who provides regular, follow-up care, for example — can bill virtual appointments at the same rate as in-person ones, provided they see the patient in-person once every 24 months.

For services where doctors have a one-off interaction with a patient — as is the case with some virtual "walk-in" services, like Lowe's KixCare — the rate is much lower: $15 for a phone call, or $20 when it's over video, compared to $67 or more previously.

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"I would conduct a thorough, comprehensive assessment for whatever the matter would be, which would include taking a detailed history, physical examination through a virtual platform," said Lowe.

"It's different than in person but, in pediatrics, observation and interaction can give us a lot of important information as to how well or how unwell a child is."

She added that the "vast majority" of patients did not require a follow-up appointment, and she rarely referred patients to an emergency department.

Since the changes to Ontario's doctors billing schedule came into effect, KixCare has stopped offering publicly funded appointments and instead are promoting a $29 per month subscription to access its services.

Virtual walk-in services double ER visits: study

An Ontario-based study published last month in the Canadian Medical Association Journal reported that even though in-person appointments with primary-care physicians dropped by 79 per cent in the first year of the pandemic, visits to hospital ERs did not increase due to an increase in virtual appointments.

"We did not find evidence that enrolled patients substituted emergency department visits because of less availability of in-person care," the study's authors wrote.

However, a separate study published in the Journal of Medical Internet Research (JMIR) — also published last month and based in Ontario — found that patients who used virtual walk-in services for one-time appointments were twice as likely to visit an ER.

Dr. Tara Kiran, a family doctor and researcher at St. Michael's Hospital in Toronto, says while virtual appointments are convenient, having a long-term relationship with your doctor can improve survival rates while reducing costs on the health-care system. Kiran, who is also Fidani Chair in Improvement and Innovation at the University of Toronto, was a co-author of the JMIR study.

"Virtual care has its place … but I think the place in an ideal world is within a continuous relationship with the family doctor," she said.

"That, of course, gets us to the point that many people don't have a family doctor, nurse practitioner or a primary care team, and we need to address that."

Dr. Tara Kiran is a family physician at St. Michael's Hospital in Toronto. Her research has found that many Canadians are concerned about for-profit businesses in health care. (Ed Middleton/CBC)

Virtual walk-in clinics may offer convenience for patients, but Kiran says that comes at a cost to the overall system as family doctors working with those clinics are not setting up practices that provide comprehensive care.

"Why I worry about the growth of [virtual] walk-in clinic, urgent-care type of medicine is that I feel like it is a Band-Aid that is growing the wound," said Kiran.

It's estimated that approximately six million Canadian adults — or in in five — do not have a family doctor

Survey finds Canadian wary of for-profit services

A cross-country survey led by Kiran gathered information from Canadians last September and October about their experiences accessing health care, and their thoughts on virtual health care. 

When asked how willing they would be to pay for services offered by new, virtual health-care services that they would otherwise get for free, more than half of respondents said they were not at all willing, while a quarter said they aren't very willing.

Similarly, more than half of respondents said they were not at all, or not very willing, to use a service operated by a for-profit company. When asked if they would use a service that receives payments from a pharmaceutical company, 70 per cent responded negatively.

The web-based survey was conducted by VoxPop Labs and over 9,200 completed responses were analyzed. 

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Ontario is moving more medical procedures into privately run health clinics. The province says the move will cut down on surgical waitlists, but critics argue it will poach staff from already under-staffed public hospitals.

While the results can't be generalized to the overall population, Kiran says they signal a problem with the existing system — many of the virtual care services now being promoted are for-profit.

The government of Alberta, for example, has contracted with Telus Health and covers the cost of Albertans' appointments on the virtual platform Babylon.

"They're not being transparent, fully transparent with people in a way that people can understand about what is happening," Kiran said.

Virtual a 'patient-centred' approach to health care

Lowe says that it shouldn't be a surprise that patients who rely on a virtual service like KixCare because they don't have a family doctor would use the emergency room more frequently. 

"The patients who had care with their doctor are, in general, in a better medical situation because they have the luxury of having a doctor," she told Goldman.

But for those patients — children who otherwise didn't have regular access to a pediatrician for assessments, or teens without a family doctor to speak with mental health challenges — Lowe argues services like KixCare fill a crucial gap.

"These are families that, you know, mid-weekend or late at night or all alone without access to any other doctor would otherwise be going to the emergency room," she said.

For Ford, whose conditions mean she relies on disability support payments, ensuring access to virtual care is crucial — especially for people with disabilities who may find it challenging to access services outside the home.

"A lot of disability is made more disabling due to poverty, and having virtual appointments reduces my costs," she said.

"It's sensible and it's very sensitive to a patient-centred approach to health care."

White Coat, Black Art episode produced by Amina Zafar.


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