It all started with a mechanical bull and too much tequila.

Mike McClenahan wasn’t initially sold on virtual physiotherapy when he first met with Phzio, a telerehabilitation provider, back in 2018. But after a client’s Christmas party at a country and western bar that involved too much liquid courage, the then-managing partner of Benefits by Design Inc. decided to test out the service’s effectiveness — and maybe, in the process, improve his injured shoulder.

Through the service, he had a video consultation with a physiotherapist to assess his injury. The practitioner was equipped with tools that could measure McClenahan’s range of motion virtually and also took him through a standard questionnaire. After the assessment, he was given exercise videos tailored to his needs and logged into the app regularly to update his progress. It was an improvement from the in-person experience, he says: the app would send notifications if he hadn’t reported doing his exercises in a certain timeframe, which kept him on track.

Read: Phzio Canada, Benefits by Design and Green Shield Canada partner for virtual physio pilot

“When you go to a bricks-and-mortar physiotherapist, what’s the first thing they ask you? [It’s] ‘Have you been doing your exercises?’ If you’re like me, the answer is, ‘Sort of.’ . . . [The app] adds a layer of accountability that’s hard to mimic with a bricks-and-mortar model.”

McClenahan got relief for his shoulder. And in June 2019, Benefits by Design and Green Shield Canada announced a pilot partnership with Phzio that would give BBD’s group benefits members access to virtual physiotherapy. This April, People Corp. acquired BBD and McClenahan is now vice-president of partner solutions with People Corp.

At the time, virtual physiotherapy might have seemed like a bit of a novelty. But then, roughly half a year later, the coronavirus pandemic arrived in Canada, sending employees to work from home and forcing a sudden change in how benefits were delivered. Virtual physiotherapy — and virtual everything else — was no longer a niche offering.

Read: People Corp. acquiring B.C.-based benefits provider

Benefits experts say the past year has prompted multiple changes to the traditional bundle of paramedical benefits, speeding up trends that were already underway in terms of how they’re accessed and what’s highly valued by plan sponsors and members. While it’s hard to predict the future, experts say these changes could be here to stay.

“We were seeing a lot of trends before COVID . . . and I would say [the pandemic] has just accelerated everything we were seeing,” says Bernard Potvin, principal at Mercer Canada.

Benefits go virtual

While some Canadian insurers had covered virtual paramedical services prior to March 2020, the majority quickly moved to do so when the pandemic forced practitioners to shut their doors.

“Prior to the pandemic we were much more limited in what our extended health- care paramedical program covered. In some cases we did not cover virtual physiotherapy or a virtual psychologist, for example,” says Marie-Chantal Côté, vice-president of market development for group benefits at Sun Life Financial. “We did offer virtual services through specific providers, such as virtual [cognitive behavioural therapy], but for virtual appointments on Zoom or other platforms, we didn’t even have that selection available through our website or mobile app for plan members to submit claims.”

Read: Manulife making virtual physiotherapy platform available to plan members

Côté says the insurer turned to many trusted and scientific sources to determine that certain paramedical services can be accessed virtually while still providing strong continuity of care for patients. Insurers can also broaden the accessibility across the country via virtual offerings, including for rural plan members with no nearby providers and for those who need to access treatment for injuries that make it painful to leave their home.

“That’s something that changed and will remain post-COVID. It wasn’t 100 per cent on our radar [pre-pandemic], but the need really grew quickly and we found people needed the continuity of care and we needed that broad access.”

More providers, more problems?

While adding to the list of covered mental-health providers can help plan members get support more quickly, Hub International Inc.’s Ken MacDonald says it comes with its challenges. Unlike psychologists and social workers, not all mental-health practitioners have governing bodies in every province. “Insurers struggle to figure out, ‘How do we allow these practitioners for coverage under a plan when they might not be registered [in all provinces]?’”

Plan members have embraced the new virtual offerings. According to a June 2020 Canadian Medical Association survey, 47 per cent of Canadians have used virtual care during the pandemic. RBC Insurance found in October 2020 that 67 per cent of working Canadians were open to using video chats, web portals or the telephone to consult with a mental-health practitioner. And even traditionally in-person practitioners have seen more virtual uptake during this ongoing public health crisis. Data provided by Curtis Hollister, chief operating officer and chief technology officer at Phzio, showed that during the first four months of the pandemic the telerehab provider had 19,450 episodes of care, with patients having an average of 2.48 treatments — representing 48,221 treatments in total. He says this was close to a 50-fold increase in Canadians accessing the platform.

Read: 67% of working Canadians would use virtual tools for mental health: survey

Even when Canada begins a return to normal once the country reaches herd immunity, experts say plan members will still have an appetite for virtual services.

“Having to go see a practitioner physically, it takes time out of your day,” says Ken MacDonald, associate vice-president of national accounts at Hub International Ltd. “I think practitioners will maintain that as an option for their patients where it’s not necessary to see them in person.” He points out that this could also allow plan members to access providers they wouldn’t otherwise be able to see, such as a specialist in a particular type of mental-health care who isn’t located in their city.

By the Numbers

67% of working Canadians said they’d use a video chat, web portal or telephone to consult with a mental-health practitioner, up 17% since 2019.The percentage of working Canadians who said they’d use video and telephone counselling is also growing, rising to 60% in 2020, way up from a mere 15%in 2019.

Source: October 2020 RBC Insurance survey

As well, McClenahan says, virtual services allow plan members to stretch their annual coverage maximums, because such platforms are often less expensive than in-person practitioners.

But with employees wanting to return to normal, virtual-care providers will need to prove their worth after the pandemic. “I think the challenge is going to be can the providers . . . [extend their] value proposition substantively beyond remote access? COVID provides a window for them, but I think if they rely too much on that remote access piece, they’ll probably see customer behaviour slip back.”

Focus on mental health

Before this once-in-a-century global crisis, one in five Canadians experienced a mental health issue in any given year, and, according to the Mental Health Commission of Canada, nearly half a million Canadians missed work each week because of mental-health challenges.

Read: Shifting workplace norms causing mental distress for Canadian workers: report

“There was already a crisis pre-COVID, and then you layer on top of that a global pandemic where . . . 60 per cent of Canadians are saying their mental health is negatively impacted,” says Côté. “We don’t believe this is something that will resolve itself quickly, or in the foreseeable future, because there were underlying issues to start with.”

It’s no wonder that employers have amped up their mental-health offerings, requesting higher annual maximums for practitioners such as psychologists and social workers, or expanding the list of covered practitioners to include clinical counsellors, family and marriage therapists, psychotherapists and analysts and more. Some employers have also expanded coverage for virtual mental-health sessions, internet-based cognitive behavioural therapy and even sleep assistance programs, says Potvin.

In December 2020, Quebec City-based software-as-a-service company Coveo Solutions Inc. expanded its employee assistance program through Dialogue Health Technologies Inc. to a full package with counselling about family and relationship issues, child and elder-care challenges, work and career needs and even legal and financial assistance. It was previously a “hotline” for employees to use when they had an urgent issue and Coveo would pick up the fee, says Isabelle Dumont-Gagnon, human resources business partner at the company.

She says the upgrade was due to a change in thinking: after starting the pandemic in “survival mode” when it came to employees’ mental-health needs, Coveo wanted to prioritize proactive and long-term employee well-being.

Read: Stigma preventing employees from seeking mental-health help: report

Since the start of this year, when the platform launched, there have been more than 40 consults. “It’s awesome because people are taking care of themselves, they are making sure they are doing well and working around the COVID situation. It’s a great starting point for us.”

Insurers have also responded to this new reality. At Sun Life, Côté says the company aimed to target plan members who wouldn’t seek treatment for their mental-health challenges by launching a mental-health coach that could connect them with the right solution, taking into consideration what’s available in their benefits plan and other factors.It also created a free digital mental-health strategy toolkit for employers.

MacDonald says he believes the pandemic will herald a fundamental shift in how employers deal with employee mental health, prompting some “upward pressure” on the annual limits for those practitioners and changing the culture around discussing it.

“I think we have been breaking barriers and reducing the stigma of mental health over the course of the past five to 10 years . . . but I think the pandemic changed things for everybody. I don’t know one person who would put their hand up and say, ‘This pandemic has not impacted me at all.’”

Eyes on claims trends

While some paramedical and traditional benefits practitioners were able to bring their services online, many were not — and claims data indicates plan members saw in-person providers like massage therapists, chiropractors and dentists less frequently than in previous years.

A September 2020 report from insurance comparison platform found Canadians avoided a range of health providers during the first wave of the pandemic, leading to a 71 per cent drop in private health insurance payouts over the first six months of 2020. Optical and dental care appointments dropped more than 90 per cent in the first half of 2020 compared to the same time period in 2018, and appointments with specialists dropped 73 per cent.

Read: Head to head: Should employers allow staff to carry over their annual paramedical coverage?

MacDonald says he’s skeptical this could lead to a spike in claims once more Canadians are vaccinated. “Once things are safe again and people are vaccinated and feel much more comfortable, I think they’ll go back. There might be a bit of immediate pent-up demand, but I don’t see it being huge.”

He says plan sponsors could see employees turning more to paramedical practitioners such as massage therapists, chiropractors and physiotherapists post-pandemic, in order to deal with the impacts of more than a year spent working at home in ad hoc setups. According to an April 2020 Facebook Inc. survey from the American Chiropractic Association, of 213 respondent chiropractors, 92 per cent said patients had reported more neck pain, back pain or other musculoskeletal issues a mere month into the pandemic. And a November 2020 study found 72 per cent of 1,000 surveyed Americans had worked remotely from their bed during the pandemic.

Potvin, meanwhile, expects higher demand for dental in particular, as many plan members have likely postponed required treatment or their yearly check-up, and have annual limits on those benefits that they’ll want to use.

Côté says Sun Life is keeping an eye on the pandemic’s impact on mental-health claims, both for service providers and short- and long-term disability. “Before the pandemic, mental-health conditions were the number one cause of long-term disability by quite a lot. We haven’t yet identified new trends in our 2020 claims, it’s hard in the disability space to attribute cause and effect without looking at a large scale. We want to give ourselves more time, but we don’t imagine the situation is any better than that. . . . We know that it’s a crisis.”

Kelsey Rolfe is a freelance writer.