Jan 2, 2023

Mon., Jan. 2, 2023timer8 min. read Ontario’s decision to lower the payments that doctors receive for one-off virtual fees has led a number of websites to start directly charging clients for virtual medical services. One site is charging $75 up front for a virtual appointment with a doctor, and another is offering an optional subscription for enhanced medical care. For critics, such fees raise questions about whether federal and provincial legislation that says patients can’t be charged for insured services or for special access to them is being respected. Other services, meanwhile, are using loopholes in that same legislation to legitimately charge patients for medical appointments using chat. Chat appointments are an uninsured service, not covered by OHIP. It’s a model that may be adopted by other companies who say they can’t survive the recent cuts to fees for one-off virtual appointments. The changes are the latest sign of a shifting landscape for virtual health care, which flourished during the pandemic, but is now facing pushback as officials and regulators try to shift doctors and patients away from one-off, virtual visits and toward ongoing care. The owner of MD Connected, the site offering an optional subscription for “enhanced care benefits,” says the new payments for one-off virtual appointments under OHIP — $20 for a video consult and $15 if it’s by phone — aren’t enough for his company to survive. “The (enhanced) package was, from our perspective, a way to provide patients with the ability to get access to a few more benefits,” says Venky Weylagro, CEO and founder of MD Connected. And “quite frankly, to make our model more sustainable,” says Weylagro. “Just trying to provide OHIP coverage to patients for $15 and $20 — it’s legitimately, physically impossible. You cannot do it.” The province’s Commitment to the Future of Medicare Act (CFMA) prohibits extra-billing and queue-jumping, which the province defines as “requiring or accepting a payment or other benefit in exchange for the provision of access to an insured service.” MD Connected’s optional subscription package includes same-day or next-day appointments, which could be considered queue-jumping. But Weylagro says it doesn’t contravene the act, because he says the site offers same-day or next-day appointments whether you buy the subscription package or not. The provincial act also “supports the prohibition of two-tier medicine, extra-billing and user fees for receipt of, or access to, insured health care services,” according to an Ontario government bulletin. “Canadians should be able to access medically necessary health care based only on need and not on ability to pay.” “If you’re starting to put access to health-care professionals for medically necessary care behind a paywall, that’s two-tier health care,” says Dr. Danyaal Raza, a family physician and assistant professor at the University of Toronto and the former chair of Canadian Doctors for Medicare. It’s only recently that fees for virtual-only health care have become an issue. During the pandemic, video and phone appointments became a necessity and the government allowed doctors to bill OHIP for one-off virtual appointments on par with what they billed to see a patient in person, typically around $36. But when the economy opened up again, the government reduced the payments in a bid to ensure that doctors who see patients virtually also see them in person, a model of ongoing care that many experts believe is the best for patients. The lower fees came into effect on Dec. 1 as part of a new Physician Services Agreement negotiated by the government and the Ontario Medical Association. The agreement, the first to include OHIP payments for virtual video and phone appointments, was ratified by doctors last March. Raza believes it was the right move to discourage “episodic, virtual-only, walk-in-style care.” “It means that there’s less of a financial incentive, there’s less of a profit motive to set up these virtual-only walk-in clinics that don’t provide good care.” But that hasn’t been the end result. Virtual services such as Rocket Doctor , which was founded by Dr. William Cherniak during the pandemic, couldn’t survive when the new OHIP fee structure came into effect. It has now transitioned to a chat-based service. “As a result of decisions made by the Ontario Medical Association (OMA) and the Ontario Ministry of Health, virtual primary care and urgent care services are unfortunately no longer a service that patients can access for free on Rocket Doctor,” according to a statement on the company’s website. Fees for a chat consultation on Rocket Doctor range from $55 for a single virtual chat consultation to packages that include 36 chat visits annually for $113 a month. Virtual companies can charge for chat consultations because they aren’t an insured service covered by OHIP. The reason for that, according to the OMA, is because they don’t always happen in real time and are considered “asynchronous,” unlike phone or video calls, which happen in real time. Maple, another virtual company, was already thriving during the pandemic using chat. It says it still offers virtual video appointments to OHIP patients but if the appointment is with a doctor in another part of Canada, and not Ontario, the patient pays. (The OMA confirmed to the Star that appointments with out-of-province doctors aren’t covered by OHIP.) Still other loopholes exist. Kixcare began as a virtual site with pediatric doctor consultations covered by OHIP, but the company has now transitioned to a subscription-based service using registered nurses and nurse practitioners who answer questions about pediatric care. Nurse practitioners are usually salary-based and paid by whoever they work for, not by OHIP, which means they can charge privately for their services. The company didn’t respond to questions from the Star about the changes. Raza believes “any service that locks doctors or nurses behind a paywall must be questioned. Health-care workers not just across Ontario, but across Canada and in other countries, are in short supply.” Venky Weylagro, of MD Connected, says he is considering going to a nurse-practitioner or chat model. “We’re like the last virtual company that’s still seeing patients through OHIP right now,” says Weylagro. “And I think that speaks to like how good our intentions were. We really wanted to try to make this work. “I didn’t get into this to necessarily get rich or anything,” says Weylagro. “I actually really wanted to try to make a difference.” For now, the virtual site is still taking OHIP patients, but Weylagro says they’ve encountered another problem that has made it even tougher to continue: the challenge of making the higher-paid video appointments a priority over phone. “We’re having issues from a user perspective where, even if we want to just do video, we can’t even execute that because they are challenges with patients not having proper access to internet,” he says. Or “with patients just not being tech-savvy enough to operate a video call.” “Given the challenges that we’re seeing and the fact that most of our patients actually want phone consults and not video, it’s just not sustainable for us,” says Weylagro. Another site, VirtualDr.ca, is charging $75 up front for virtual appointments. Fees for “medically necessary” services insured by OHIP aren’t allowed under federal legislation. VirtualDr.ca didn’t respond to questions from the Star about the fees, but a statement on its site says: “Dear Patient Due to recent changes by the Ministry of Health, we no longer accept patients with Ontario health cards. Paid appointments are available for non OHIP patients.” However, the site asks for payment up front, and doesn’t appear to screen people for OHIP coverage before payment. Raza believes the government should consider what’s behind the demand for virtual services. “It’s because we don’t have appropriate access to primary care and family medicine,” he says. “Of course medical care shouldn’t be based on ability to pay. And if a business is trying to change that then that’s a problem and it needs to be stopped. It’s potentially a very dangerous precedent. “But we have to also address the underlying issue.” Other provinces have dealt with virtual-only care differently. Manitoba has made it almost impossible for doctors to practise virtual-only medicine. “It is not an acceptable standard of care to solely practice virtual medicine,” according to an email from the College of Physicians and Surgeons of Manitoba. “Virtual online platforms generally do not meet the Standard, unless the individual physician that has provided the virtual care can also provide in-person care within 24-48 hours in a geographic location close to the patient’s location or through an arrangement with a regional health authority.” In B.C., virtual-only care hasn’t become an issue and one-off virtual appointments are still being paid on par with what a doctor can bill when he or she sees a patient in person. But the province has taken a hard line on private bricks-and-mortar clinics that offer access to enhanced health care at a price. British Columbia’s Medical Services Commission recently issued an injunction against the Telus LifePlus Program after a patient was told that he would have to pay thousands in subscription fees to see his family doctor, who moved to the program. “Allowing for the privatization of publicly insured medical services is illegal under the Canada Health Act and Medicare Protection Act,” said Adrian Dix, B.C.’s minister of health, in an email. “In addition to being illegal, two-tiered medical systems inevitably lead to a decrease in the quality of the public system. “At a time when many people are struggling with access to a family doctor, this is wrong.” Dix said the commission is reviewing several other fee-based programs for potential contraventions of the province’s Medicare Protection Act. In Ontario, patients who believe they have been charged unfairly can contact the CFMA program, at 1-888-662-6613 or by email at protectpublichealthcare@ontario.ca . “Insured Ontarians cannot be charged for insured virtual physician services and cannot be refused access to these insured services by the physician on the basis that they do not want to pay a block fee for uninsured services,” the Ministry of Health said in an email. The federal government also has a department, called the Canada Health Act Division, that uses official sources as well as media reports and complaints from the public to monitor the provinces and territories for compliance with the Canada Health Act. Patty Winsa is a Toronto-based data reporter for the Star. Reach her via email: pwinsa@thestar.ca SHARE: