Health Canada is reiterating that it expects provinces to fund medically necessary health services as one company raises fears of two-tiered health care in Ontario.
Maple, a Loblaw-funded virtual care business based in Toronto, charges $69 per doctor's visit (or $30 per month for 30 visits per year) — a service that would be free in person.
The Canada Health Act requires provincial and territorial health insurance plans to cover "all medically necessary services," Health Canada spokesperson Anne Génier said in a statement.
Charging Ontarians for insured services is banned by provincial legislation in accordance with the Canada Health Act.
Ontario has insured virtual visits under OHIP, but Maple has found a way around the province's insurance.
Instead of connecting an Ontario patient with a doctor in Ontario — which would be covered under OHIP — Maple will set up an appointment with a nurse practitioner or a physician outside of the province. Those appointments aren't covered by OHIP. And before a patient speaks with a health worker, they go through a text-based chat, which is also uninsured by OHIP. Maple works the same way in other provinces.
The practice has some worried about health care privatization — including the federal health ministry.
"Health Canada is always concerned when a patient is charged to access a service that would be insured if provided in person by a physician," Génier said.
She said the feds will work with the provinces and territories to make sure health care keeps up with "modern realities" like virtual visits, "while remaining true to the fundamental principle of medicare, i.e., access based on need."
Those concerns usually come from "a lack of understanding" on the part of provincial and federal health ministries, said Maple CEO Dr. Brett Belchetz, a Toronto emergency room physician.
"Once we make it clear ... that no patients are ever being charged for provincially insured services, that the only charges that are ever being levied are for uninsured services, that is typically a pretty easy conversation," said Belchetz, a former McKinsey & Company management consultant.
Belchetz noted that Maple does provide some OHIP-covered services, like gynecology. But private-pay options like nurse practitioners, text chatting and out-of-province doctors can add capacity to the strained health system, he said.
"I would love to see expanded coverage from OHIP to help cover a lot of these other circumstances that could help patients. But right now, we don't have that full coverage," he said.
Ontario Health Minister Sylvia Jones' office confirmed that Maple is operating within the law. If a patient thinks they've been charged for an OHIP-insured service, they should contact the provincial CFMA program to seek reimbursement, spokesperson Hannah Jensen said.
While Maple may be legally in the clear, "it doesn't feel good," said Liberal health critic Adil Shamji, who is also an ER doctor.
Virtual care exploded in the early days of the pandemic when the province set up a temporary billing code for visits conducted on video platforms such as Skype; before COVID-19, virtual care was only funded on a single provincial platform that was not widely used. But on Dec. 1, 2022, the government cut the rates from $37 to $20 per visit to encourage more face-to-face time between doctors and patients.
There are lots of loopholes in the legislation and that's where companies like Maple operate — by using nurse practitioners and text chats as "barriers" to publicly funded care, he said.
"It does feel as though it’s pay-for-access," he said.
Shamji said he'll speak with health stakeholders and will be "pushing hard" to make sure virtual care is delivered equitably.
University of Toronto epidemiologist Dr. David Fisman is similarly unconvinced.
"The undercutting of OHIP funding for virtual visits is pushing us into the kind of two-tiered health system that those of us who have worked both sides of the border have come to dread," he tweeted about Maple in December.
Belchetz has sung the praises of two-tiered health care in an article for the Fraser Institute, a conservative think tank where he is a senior fellow. Asked about the Ford government's plans to expand private care, he told QP Briefing the "devil is in the details" when it comes to implementation, to avoid cannibalizing public sector health workers.
Saw 3 patients in ER this week for routine pregnancy tests. Cost to system: $300 each. Pregnancy test @ pharmacy: $25. User fees anyone?
— Dr. Brett Belchetz (@brettbel) April 29, 2015
Other virtual health companies, like Rocket Doctor and Tia Health, have had to pivot from OHIP-covered virtual care since Ontario's fee cut. Rocket Doctor now uses a text-based service like Maple's. And to see a doctor through Tia Health, Ontarians have to be added to a "roster" with a family medicine group. Again, this is a quirk of Ontario's billing system — for virtual visits with their regular patients, doctors can still bill OHIP $37, instead of $20.
Getting doctors to do virtual visits has been harder since the virtual fee cut, said Belchetz and Rocket Doctor founder and CEO Dr. William Cherniak.
"The province has said, 'We want to get doctors back in the office,' but actually, this doesn't do that, because family physicians can continue seeing their patients virtually," he said. "But what it does is take away access to care for patients in rural and northern communities, or those folks who don't have a family doctor."
A recent study found that people who used virtual walk-in clinics were more likely to go to the ER than those who saw their family doctors virtually — potentially because family doctors are more likely to schedule in-person follow-ups.
A physician who doesn't know the patient's history might also be more likely to err on the side of caution and tell a patient to go to the ER right away, Shamji said.
"Putting a hand on someone's abdomen to see why they're experiencing pain ... makes a big difference in being able to say whether a patient truly has an acute or critical issue," he said.
Cherniak took issue with that study, noting that it took place during the first wave of COVID when many swabs were being done in ERs.
These days, our data consistently show that ~94% of patients seen virtually were managed virtually, and that ER visits are conclusively prevented through high-quality virtual care. This isn’t speculation on retrospective data, it’s real #s from a real virtual ER with @GBGHMidland
— William Cherniak (@WilliamCherniak) January 13, 2023
In any case, Shamji expects the new-ish virtual care industry to keep evolving.
"I suspect there are many loopholes that exist and need to be found and need to be tightened," he said.