When Leona Guenette comes down with a bad case of bronchitis, she knows exactly what antibiotics she needs.
Normally for Guenette, the pension and benefits administrator of the Sagkeeng First Nation, that meant scheduling an appointment with her local doctor to get a prescription. But as of June 2020, when Sagkeeng and 350 other First Nations across Canada got access to Teladoc Health Inc.’s telemedicine platform through their benefits provider, CINUP, she can get her prescription through a consultation in a matter of minutes, and pop out to the pharmacy to pick it up.
For Sagkeeng, a community located about an hour northeast of Winnipeg that has roughly 400 local government employees, virtual care has had numerous benefits. Residents and employees typically need to travel to Winnipeg to see a doctor — something that presents a safety risk in Manitoba’s harsh winters and also during the pandemic. The vast majority of the province’s coronavirus cases have occurred in the capital city.
“For people having to go in for a doctor’s appointment for basic reasons, they’re risking themselves and the community,” Guenette says. “We have a lot of elders that simply don’t drive. The health centre will arrange for a drive, [but] when they’re taking a group of people in a small enclosed area, again, it’s a COVID issue.”
Beyond that, virtual care helps Sagkeeng meet its goals for overall employee health and well-being. “What we want to do as a First Nation is to keep people off disability. If you’re discouraged [from] seeing a doctor [because of the inconvenience], what do you do? You wait until the point of no return.”
Sagkeeng is just one of many employers across the country that made virtual care available to employees in the last year. The service was already a growing trend in employee benefits prior to the pandemic, with 45 per cent of plan members saying in 2019 they would use virtual care if it was offered as a benefit, according to the Sanofi Canada health-care survey from that year. But the pandemic has accelerated a significant attitude shift.
According to a November 2020 survey by Environics and Dialogue, 82 per cent of Canadians believe it should be available as an employee benefit and 66 per cent said they would likely use it if it was available through their benefits. Meanwhile, an International Foundation of Employee Benefit Plans survey from July 2020 found 19 per cent of Canadian employers had added telehealth services during the pandemic and another 17 per cent were considering doing so.
However, the pandemic has made clear that while private virtual care providers have driven innovation in the space and are thriving during the crisis, publicly insured offerings are inconsistent and technically behind — something that experts say needs to be remedied to ensure all Canadians have equal access to the health-care system.
Improving employee health
Providing virtual care is “definitely attached to a lot of the goals of what a benefits program is meant to provide,” says Ryan Weiss, vice-president of product and experience for group customers at Canada Life, which started offering virtual care as an optional benefit in 2017, in partnership with Dialogue. It made its Consult+ service a standard offering for groups under 400 lives as of March 2020.
For employees, it gives them the ability to get help with a minor injury, diagnose new symptoms or a fill a prescription within minutes and at their own convenience — whether it’s in the middle of the night or on their lunch break. For employers, it ensures staff are healthy and don’t have to spend hours away from their desks, waiting at their family doctor’s, a walk-in clinic or an emergency room.
Despite advances in virtual care, Canadians still often face a challenge of access to timely health care. According to the November survey from Dialogue and Environics, while 86 per cent of Canadians have a family doctor, close to half (46 per cent) said it would typically take four or more days to see a health-care professional for a minor health concern. Another 22 per cent said it would take more than a week. Canadians waited a median of 3.2 hours in the emergency department per visit, reported the Canadian Institute for Health Information in 2019.
“From an employer perspective, it makes scheduling very difficult . . . and it’s not really good for health outcomes. The longer you wait for these things, the longer it means people might be suffering,” says Weiss, pointing out that putting off a minor injury now could snowball to something major down the line — which comes with associated mental-health or medication costs and possibly disability claims. “There’s a lot of vested interest in employers helping people get the right care quickly as well as advancing their physical and mental wellness.”
As well, says Christy Prada, vice-president of business development for Maple, private virtual-care models sponsored by employers create the opportunity for more proactive care. “We can not only onboard [plan members] but make sure that we’re keeping them engaged. Really, that level of . . . support actually allows employees to shift it from being a reactive-type model of care to actually using it to proactively improve their health.”
The value became even clearer during the pandemic, when these services helped plan members stay at home and away from a public system trying to manage a highly contagious disease.
Public sector challenges
The public system, meanwhile, was left somewhat flat-footed in the face of the pandemic when it came to virtual care, with the majority of provinces needing to quickly create fee codes to ensure physicians could actually treat patients at a remove. While more than half (60 per cent) of visits with primary physicians at the onset of the pandemic were conducted virtually, according to a Canada Health Infoway survey in September 2020, many physicians were doing so for the first time.
That’s something that Marc Robin, chief medical officer at Dialogue, says is a problem. “We firmly believe virtual care is a specialty in primary care, and if you want to be best-in-class you have to commit to advanced training,” he says, adding that doctors shouldn’t be “improvising in virtual care what [they] do in [their] office.”
Ewan Affleck, a member of a task force created by the Canadian Medical Association, Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada that examined how to scale up publicly insured virtual medical care, agrees. “It’s unfortunate the pandemic had to bring attention [to virtual care] — it’s an important modality of care we’ve been behind in.”
The report Affleck co-authored, released in February 2020 right before the World Health Organization declared the coronavirus to be a global pandemic on March 11, 2020, said there was still a “long way to go” to provide quality publicly-insured virtual care across Canada —despite the technology being around for decades and an “explosion” of interest in pursuing digital health strategies, driven by consumer demand and the challenge of timely and convenient access to health care.
The task force identified several issues with existing public virtual care: there were no standards for patient health information access; physicians need proper training to offer such services; and provincial fee standards for virtual services are inconsistent among various modalities and in comparison to in-person visits.
Filling a need
In the face of those challenges and an already stretched health-care system, private players offer a valuable complement, says David Willows, executive vice-president of digital, innovation and brand experience at Green Shield Canada, which undertook a four-month pilot project with Maple in November 2020 to give plan members four free consultations through the app.
“We think it’s filling a need that doesn’t necessarily exist in-system right now,” he says. “[When] somebody has the choice to navigate a walk-in clinic or an emergency room, the ability to get care in a number of minutes [virtually] for these smaller acute illnesses certainly makes a lot of sense.”
But there’s more to quality health care than just access, says Affleck: “The problem is, [access] comes at a big cost. . . . There’s study after study that shows continuity of care improves outcomes. Simply [having] access to many [doctors] may not help and may drive substantive costs. The likelihood of error or unsafe care increases, the likelihood of redundant tests and health activity increases. It’s driving all-system costs.”
Virtual-care providers disagree that they’re hindering continuity of care. Prada points out that Maple users can upload their own medical history into the app and some have even requested files from their doctors. They can also access the records of any call through the platform to share with their doctor and Maple itself can also transfer records from the platform to a patient’s family physician. Dialogue, too, sends users a record of their consultations to “empower” them to share the information with their doctor.
At the moment, privacy legislation stops private providers from consistently sharing information without extensive permissions, Prada adds. “A lot of our privacy legislation was written before digital and didn’t consider what it means if you are able to technologically transfer data back and forth.”
She says the company intentionally prevents patients from requesting the same doctor: seeing different physicians within the app means they can be seen more quickly. As well, “we don’t want to take away relationships that patients have with their family doctors.”
When it comes to how virtual care is paid for, Prada says, “this is where it gets really complicated.”
Virtual care lives in somewhat of a policy vacuum. Because health care is a provincial and territorial responsibility in Canada’s public health-care system, each of the provinces have taken their own approaches, with some covering some modalities of virtual care and others, prior to the pandemic, offering no coverage at all. For example, while British Columbia covers video and telephone consultations, Ontario only began offering temporary billing codes for such services in March 2020. None of the provinces cover text-based interactions.
For doctors in the public system, this means there were services they simply wouldn’t offer. For individual consumers using private apps, it means they could be billed directly for services, depending on the place they live or the way they prefer to be treated, creating a system that medical experts say means only those who can afford to pay can be treated quickly.
Willows doesn’t see this as inherently problematic. Before its recent pilot with Maple, Green Shield Canada offered plan sponsors the option to add the app to their plans in 2019 and a discounted fee for plan members whose employers didn’t do so. “There are different pockets of the system where [paying for health care] certainly exists and people are voting with their pocketbook,” he says. “Allowing people to make that choice, it may be more cost-efficient for them not to miss work.”
So where do employers fit in? It depends on the providers. Maple, for example, integrates provincial fee codes into its service and employers pay for things that aren’t covered publicly — including the technology it takes to run the service. Morneau Shepell Ltd.’s new Lifeworks Telemedicine program completely removes itself from the public system, says Matthew McCreary, vice-president of product management, with on-staff nurse practitioners. Dialogue, which offers its services exclusively to employers and insurers, operates much the same way, with many of its health-care professionals working on salary.
“There’s never a financial transaction between a physician and a patient or a province,” Robin says. “[That way], there’s no benefit of seeing or not seeing or seeing more often; the idea is that [our] team’s goal is to get you better faster and there’s no incentive to do otherwise.”
The pandemic demonstrated virtual care’s value proposition to employees and governments alike. Now that the dust is starting to settle, provinces are thinking about how to permanently expand the use of publicly insured virtual care in a sustainable way. Any provincial developments will naturally impact private players, who are deeply intertwined with the public system. But insurers and providers think employers and private virtual-care companies will still have a meaningful role in any future system.
For one, McCreary says, private sector innovation can be helpful as the provinces develop their own tools and expand public coverage. “It’s the idea that a rising tide lifts all boats. If we can do well, invest in innovation and figure out the next best thing to help people, ultimately it’s a matter of time before that serves the public system.”
It’s not uncommon for employers to contribute to health costs in a way that supplements what’s covered provincially, Prada adds, pointing to employer drug plans. “We can have certain types of services funded by the government and then things that are not funded by the government, that’s where private pay can pick up the rest of the buck.”
And an expansion of publicly insured virtual care won’t actually increase the capacity of the public system, Robin says.
“If we see 1,500 patients a day, these are people who are not going to the emergency room or the walk-in clinic. All Canadians benefit from that — employers do, because their employees are at work, and governments do because it takes pressure off the public health-care system.”
Kelsey Rolfe is a freelance journalist.