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The question

I have a skin problem and did a Google search to see if I could figure out what it is. I found a website called DermaGo.ca where Canadian dermatologists will provide a diagnosis and even a prescription – for a fee. I didn’t think our doctors could charge for providing basic medical care. Is this legit?

The answer

It is indeed a “legit” website. But you are also correct in assuming that Canadian doctors can’t charge for services that would usually be covered under our publicly funded health-care system. Normally, doctors have to treat a patient in person to receive a payment under the various provincial and territorial health insurance plans. But the fact that an online dermatology consultation isn’t on the list of insured “medically-necessary” services means they can charge patients a fee.

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DermaGo isn’t the only Canadian-based website that is now offering health services directly to paying patients, and this emerging trend is worrying some experts who are concerned it’s a step toward two-tiered medicine, in which those who can afford to pay get quicker access to care.

DermaGo, which was launched in Quebec in December, 2017, has a total of six dermatologists offering advice online – three in Quebec, two in Ontario and one in Alberta - and is expanding across Canada.

“Obviously there is a demand for our service,” says Dr. Marc-André Doré, a dermatologist in Quebec City and co-founder of DermaGo. Part of that demand, he says, is being fuelled by long wait times to see a dermatologist.

It’s fairly easy for patients to use DermaGo. They create a file through the website and use a smartphone to take and upload photos of their troubling skin conditions. A dermatologist replies with a written message and, if it’s needed, sends the patient a prescription for medication.

It costs $179.99 to get an answer within 72 hours, and $249.99 for a 24-hour response. (These prices are higher than what doctors are usually paid in the public health-care system.)

Doré say the online service is best suited for skin conditions involving acne, psoriasis, eczema and hair loss. “These are problems that can be diagnosed easily on the web platform,” he explains.

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Even so, a few patients have sent images of lesions that looked suspiciously like melanoma – a potentially deadly form of skin cancer. The only way to accurately diagnose melanoma is through a biopsy in which a small skin sample is removed and examined under a microscope.

In these cases, the patients happened to be in Quebec and lived relatively close to the offices of the doctors involved with the website. So each patient was directed to the nearest office of a DermaGo dermatologist where a biopsy was performed, and melanoma confirmed.

“Some of them actually had already been waiting to see a dermatologist for a couple of months,” Doré says. “I am not saying we saved their lives, but we certainly helped them.”

Buying medical services in this way does raise questions about who is ultimately responsible for the patient’s ongoing care, says Dr. Joel DeKoven, a dermatologist at Sunnybrook Health Sciences Centre in Toronto. "Once a physician-patient contact has been made, one might expect that there is a duty of care for the online physician to provide subsequent in-office care if requested by the patient."

Dr. Danielle Martin, a family physician and vice-president at Women’s College Hospital in Toronto, says problems of fragmented care might arise when the patient’s family doctor has been sidestepped. “If something is identified as being an important part of a person’s medical history, how will that person’s primary-care provider ever learn about it?”

But Doré defends his direct-to-consumer website, saying that patients have some responsibility to keep their family physicians in the loop. He points out that patients can print their files from the DermaGo platform. “So, if they want, they can just drop them off at their doctor’s office.”

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Despite the controversy created by the sale of medical services, there’s general agreement that providing virtual health care online can be extremely convenient for patients.

“This could be part of the solution to how we make the health-care system more efficient and sustainable,” Martin says. “But it should be offered to people on the basis of need – not the ability to pay.”

Paul Taylor is a Patient Navigation Advisor at Sunnybrook Health Sciences Centre. He is a former Health Editor of The Globe and Mail. Find him on Twitter @epaultaylor and online at Sunnybrook’s Your Health Matters.

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