Changes to virtual care billing in Ontario raise concerns over health care access

Some Ontario physicians are concerned pending changes to virtual care will make it difficult for a wide swath of patients to access a health provider, adding to continuing challenges facing the province’s health system.

The province is restricting payment for telephone-based doctor visits later this year and requiring physicians to be able to see patients in person if necessary, which would make it impossible for virtual-only clinics to operate.

There have been growing concerns throughout the pandemic that some doctors are leaning too heavily on virtual care and refusing to see patients in person or using virtual clinics to see patients on a one-off basis, which is linked to poorer health outcomes. The changes are, in part, designed to encourage face-to-face interaction and reduce the frequency of one-off calls with patients.

As of Dec. 1, Ontario’s health insurance plan will no longer fund initial telephone visits between new patients and their physician. Only video calls will be eligible for payment under the new permanent virtual care funding model.

Follow-up phone calls between patients and doctors will only be eligible for 85 per cent of the fee doctors can bill for video calls or in-person visits.

And the plan will only pay $15 for one-off phone consultations and $20 for one-off video consults.

Richard Davies, an Ottawa cardiologist and board member of the Ontario Association of Cardiologists, said the elimination of coverage for phone-based new patient visits will make it difficult for vulnerable patients to access virtual care. For instance, Dr. Davies said he sees many elderly patients who live outside of Ottawa who aren’t able to use technology for video calls, leaving them to travel lengthy distances for a visit that could have been done over the phone.

The changes will make it harder for people who live in parts of Ontario that don’t have high-speed internet or people who can’t afford the technology to access virtual care, he said.

“It becomes an accessibility barrier,” Dr. Davies said.

The Ontario Association of Cardiologists also argues that cutting payments for follow-up phone consultations makes telephone-based virtual care unsustainable in the long term.

In a statement, the Ontario Medical Association said it’s important for physicians to see patients face-to-face to get information that otherwise could be missed.

“In many cases, a video visit allows a physician to provide the same medical assessment as an in-person visit but the same may not be true for a telephone visit,” the statement said.

One of the reasons new patient telephone visits will no longer be covered is to discourage the growth of virtual walk-in clinics, which became popular during the pandemic. A new study, currently available as a non-peer-reviewed preprint, found that people in Ontario who used virtual walk-in clinics were more likely to visit an emergency department the following month compared with those who had a virtual family physician visit.

Tara Kiran, a family physician at St. Michael’s Hospital in Toronto who led the study, said many people who use virtual walk-in clinics will never see that physician again, which is linked to poorer health outcomes. It makes sense to adjust the virtual care coverage system to encourage continuity of care between patients and providers, Dr. Kiran said.

“These reforms were really designed to limit that kind of practice, which we know isn’t in keeping with high-quality care,” she said.

Sumeet Sadana, a consultant pediatrician in Ottawa who has also been seeing patients on KixCare, a virtual-only clinic for children and adolescents, said the restrictions will cut off the only access point many families have to the health system.

“I think it will compel that small percentage of physicians who are only offering virtual to basically get back to practising,” Dr. Sadana said. “But that way you’re going to alienate and marginalize a larger and growing group of people who have no other option.”

Dr. Sadana said the province needs to have rules in place to prevent abuse of virtual-only clinics and ensure patients are getting the help they need on those platforms. He sees a variety of patients on KixCare. He often counsels parents on whether a feverish child warrants an hours-long wait in the emergency room or helps families get connected to specialists or other resources to deal with developmental or mental-health concerns. Many of the patients he sees have no family care provider.

“We don’t have enough medical accessibility to physicians to meet the demands of the public,” he said.

While it’s important to ensure providers are operating at a high standard, Dr. Sadana said the pending changes would swing too far in the other direction, making virtual care too hard to reach for many who have nowhere else to go but the emergency room.

In its statement, the Ontario Medical Association said virtual care will continue to be ramped up and that there will be continued focus on how to make it accessible to everyone in the province.