Sheryl Spithoff is a family physician and an assistant professor at the University of Toronto.
Tara Kiran is the Fidani Chair in Improvement and Innovation and an associate professor at the University of Toronto and a family physician at the St. Michael’s Hospital Academic Family Health Team.
The health care system’s pivot to virtual care during the pandemic has sparked a corporate stampede into primary care.
Every corporation – from telecom giants to technology startups – seems to want a piece of the pie. Just within the past year, Loblaw purchased a minority stake in a telemedicine platform and launched a health and wellness app that offers reward points at its grocery stores. The goal? To become the “front door of health care.”
Virtual care services are appealing – especially to the millions of Canadians who don’t have a family doctor or who struggle to get a timely appointment with the doctor they do have. Who doesn’t like the idea of chatting with a doctor in your pajamas or skipping the waiting room?
But this shift to corporate-driven care also has a dark side. We need to be wary of the consequences.
It creates a system that is driven by profit – one where care is designed to maximize revenue, not health outcomes, and where your health data is viewed as a financial asset. Instead, we need to find ways to improve access and incorporate new technologies in a primary care system that prioritizes patient health.
Over the past decade, corporations have slowly expanded into primary care by acquiring a range of health care products and services – clinics, pharmacies, virtual care platforms, wellness apps, electronic medical record systems and artificial intelligence companies.
In 2013, Telus purchased an electronic medical record company with the largest market share in Canada. More recently, it acquired a virtual care platform, a chatbot symptom checker and a chain of 30 primary care clinics.
When the pandemic hit, doctors needed to minimize in-office visits. So provincial governments introduced fee codes that paid for phone and video visits, making them publicly covered. Some provinces, such as Ontario, British Columbia and Alberta, also fund virtual “walk-in” services. These are standalone services where patients log into a commercial platform and receive care from a health care provider with whom they do not have a continuing relationship.
Virtual care is attractive to corporations because it offers better margins than in-person care. Companies save by running fewer bricks-and-mortar clinics and using virtual scheduling assistants instead of receptionists.
It also offers companies other revenue streams. According to Ontario’s auditor-general, many companies bill patients for services such as “medical advice, prescriptions, medical notes and lab work requisitions,” items that would usually be provided free of charge during an in-person visit.
But there are also other financial opportunities driving corporate interest in primary care.
One is partnerships with pharmaceutical companies. CloudMD – a Canadian health technology company – is incorporating a marketing platform into its electronic medical record system, Juno.
The platform permits pharmaceutical companies “to advertise directly to [health care providers] and their patients inside the exam room – keeping your brand top of mind at treatment decision-making time AND at home.” Juno is used by more than 376 clinics in eight provinces.
Health data are also a potential revenue generator. MCI Onehealth – a technology company that owns 25 primary care clinics – states that it intends to create one of the largest databases of de-identified primary care records in Canada, and unlock “the clinical and commercial potential.” It estimates that each de-identified electronic health record is worth $35 to $330.
These business strategies don’t just mean more profit – they drive up health system costs, pose risks to privacy and fragment care.
Numerous studies show that direct pharmaceutical advertising – like ads within the electronic medical record – leads doctors to prescribe medication that is less appropriate and almost always more costly than alternatives.
The commercialization of patient data is also worrisome. Privacy loss is one risk, but commercial uses of the de-identified patient data can also cause harm. In Canada, patient data is often used by pharmaceutical sale representatives to identify the right physicians to target with visits to promote their drugs. Like pharma ads, this kind of marketing leads doctors to prescribe less appropriately.
The type of virtual care offered is another concern.
Many companies offer standalone virtual care with no option to be seen in-person by any doctor, let alone the one you connect with virtually. This results in fragmented care that drives up cost with unneeded and duplicative services.
Let’s take an example of a patient who contacts the virtual walk-in service because of dizziness. Dizziness is almost impossible to diagnose safely by phone or video. So, chances are a virtual walk-in doctor would suggest the patient see their family doctor or go to the emergency department. That means two visits when the system could have had one. For problems such as ear pain, it may also increase the chances that a patient is prescribed an antibiotic they don’t need.
Standalone virtual care services also don’t provide Pap tests or immunizations that keep you well. Nor are they designed to manage continuing complex chronic conditions. They are no substitute to finding a family doctor who can look after all of your health needs and prevent health problems from happening in the first place.
And although timely appointments are important, decades of research show that an ongoing relationship with one family doctor is just as or more important. Continuous care with one physician has been shown time and again to improve health and reduce health system costs.
And then there’s the question of who is using the standalone virtual care services, particularly since some of them charge fees for services.
People who don’t speak English, those with sensory impairment and those with limited financial means have obvious barriers to accessing care through an app. Instead, these virtual services are targeted at the young, affluent, able and articulate – the opposite of who needs more care.
All of this comes at additional financial cost – some paid out of pocket but much of it from the provincial government courtesy of new virtual billing codes.
It doesn’t have to be this way. Instead, we could use public funds to invest in primary care models that incorporate new technologies in a way that improves timeliness and convenience but also enhances care continuity, reduces costs and ensures all people in Canada have access to high-quality primary care.
One solution would be to expand not-for-profit models – where family doctors work in groups with other team members like social workers, nurses and pharmacists and have accountability for providing after-hours care. These models have been linked to better care and lower health system use but are still a rarity in Canada. As a condition of expansion, these team-based models could be accountable for unattached patients in their neighbourhood.
We need to integrate virtual care in a way that enhances access, continuity and appropriateness. That means rejigging virtual billing codes. It also means doing more to integrate secure video and messaging options in regular offices, for example, by having governments require that companies include these features within electronic medical record systems.
At the same time as we reform the public delivery system, we need to change the rules to make it harder to profit off patients.
We need regulation to protect de-identified patient data collected during the provision of health care – whether through an in-person visit or a virtual care platform. Governments should prohibit advertising to physicians in the electronic medical record systems. This would help ensure that patient care is not biased by pharmaceutical company influence.
Embracing profit-driven care is not the only way to improve access to a family doctor – and it’s a path that has the potential for more harm than good. We should use public dollars to strengthen the existing front door of health care, not to support the corporate bottom line.
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