Contributed by Dylan Yan
Introduction
The COVID-19 pandemic has caused a drastic shift in Canadian healthcare. Since the onset of the pandemic, several new digital technologies, medical licensing schemes and privatized services were introduced into the Canadian healthcare ecosystem, each altering the way Canadians receive healthcare. Since the first wave of COVID infections, one of the greatest changes has been inpatient care, which has since shifted from in-person visits to virtual services, with over half of all Canadian healthcare being delivered virtually. This is a stark contrast to pre-pandemic averages, with less than 1 in 10 Canadians polled reporting use of virtual healthcare. While this virtual shift is necessary to slow the spread of the virus and save Canadian lives, it also bring about new problems like higher prices, uninsured payments and gaps in coverage that our legislature must address.
This article seeks to outline the growing privatization of virtual healthcare and elucidate how Canada’s health laws must adapt to these novel challenges.
The Expansion of Virtual Healthcare
During the COVID-19 pandemic, physician home-care visits have dropped, in-person hospital screenings have declined, and fewer patients are visiting their doctor’s office. Even the volume of emergency department visits have declined. So where are Canadians getting their healthcare?
This decline of inpatient care has been offset by a surge of activity in new healthcare media; more Canadians are following the increasing trend towards using virtual services. Family doctors can now be booked for a phone consult. Dermatologists can be found online. Even specialized conditions, like musculoskeletal disorders, can have preliminary assessments completed virtually.
This digital shift of healthcare has created new technological interfaces: individualized portals for patient records, electronic prescription transmission and self-assessment tools. As patients adapt, so must healthcare practitioners. Provinces like Ontario have created new billing regimes specific to virtual care. Private companies like the Maple Corporation have created online platforms on which physicians can provide care.
These changes have clear advantages. Virtual care increases the accessibility of patient services, allowing treatment to be readily provided in remote areas, across borders and to those with mobility concerns. Online platforms are also incredibly convenient; Canadians can easily access test results, schedule appointments and refill prescriptions on their smartphone or personal computer. Most significantly, virtual services prevent the transmission of COVID-19, avoiding physical contact and allowing the patient to be treated from the safety of their home.
Even specialized conditions, like musculoskeletal disorders, can have preliminary assessments completed virtually.|| (Source: pixabay // mohamed_hassan)
Public Latency and Private Expansion
Despite the massive benefits of virtual healthcare, public virtual infrastructure in Canada remains limited. Those services that do exist, like Ontario’s Telehealth Network, are suboptimal, suffering from long wait times and devastating system crashes.
To make matters worse, very little legislation covers virtual healthcare. While provinces like Ontario have legislated some areas of virtual care, and others have implemented strategies to combat perceived issues in virtual healthcare, many jurisdictions have inadequate laws regarding virtual services. Provinces like Quebec have been slow to adapt to match the requirements of this evolving landscape, creating “holes” of unregulated healthcare policy.
In this policy vacuum, with little public competition, privatized healthcare has flourished. A rush of virtual private providers, including Maple Corporation and Dialogue Health Technologies have seen rapid growth and massive profits. In the year following the onset of the COVID pandemic, Maple Corporation went from taking a few hundred appointments per day to several thousand and saw its profits quadruple. Dialogue has recently gone public with its company shares, resulting in gross proceeds of roughly 100 million dollars.
Validating Critiques of Private Virtual Care
The growing privatization of virtual healthcare has created a new set of problems and drawbacks for Canadians. Private providers frequently have patients pay out-of-pocket for their virtual appointments. Other private services write extensive warrantees that release the company from responsibility for the quality of healthcare services rendered on their own platform. Critics of these private processes argue that the industry operates in a legislative “gaps” and “violat[es] the core tenets of medicare in Canada” by making Canadians pay for medical necessities that are covered by provincial health insurance.
How is it possible for Canadians to be charged for healthcare that is already covered? Provincial insurances (like RAMQ in Quebec and OHIP in Ontario) have general provisions that pay out public healthcare professionals directly. “Non-participating healthcare professionals” operating in the private sector are not covered. Thus, a patient using private virtual services cannot claim for reimbursement with RAMQ. They either need to pay out-of-pocket or file a claim with private insurance. Ultimately, many Canadians who want virtual care are forced to balance the inaccessibility and long wait times of the public sector with the costly timeliness of the private services.
Even creative solutions for virtual healthcare oversight, like Ontario’s new billable coding system which covers phone and online healthcare, have gaps in coverage. The system only regulates phone-call appointments and certain types of online care, leaving several virtual tools unregulated – including text message, Facetime and Skype. This allows private providers like Maple to skirt billing restrictions by offering expensive services in unregulated formats, such as pricey text-message appointments.
How accurate are these concerns? A report by the Canadian Medical Association in 2019 raised many issues similar to those of contemporary critics. Findings in the report advocate for restrictions on privatized virtual care: a pressing need for regulatory framework that ensures the affordability and quality of virtual services, a comprehensive increase to bodies that regulate virtual physician licensing, and restrictive caps on as-of-yet unregulated billable processes, like text-message appointments.
Private Billing Models and the Principles of Canadian Healthcare
Cofounder and CEO of Dialogue Cherif Habib defends the integrity of his company’s billing policy by pointing out that Dialogue operates only through group and employer insurance. In other words, the patient must access Dialogue through previously-compatible private insurance plan, and are not billed by Dialogue directly. However, Dialogue is the only private healthcare service in Canada to follow this insurance-billing model. The rest of the private industry still allows for out-of-pocket payments. Furthermore, by Dialogue’s own terms of service, patients are still responsible to pay for “services that are not included in your [private insurance] plan.”
Most importantly, these private insurance plans are still paid for by the patient. By providing a publicly-available healthcare service on private insurance, the patient to pay twice: once in taxes and again for private coverage. The operation of privatized healthcare providers like Dialogue in practice appears to be at odds with the preamble of the Canada Health Act, which aspires to “continued access to quality healthcare without financial or other barriers.”
Conclusion: Filling in the Gaps
The transition to virtual healthcare is inevitable, especially with the advent of COVID-19. Virtual care presents clear benefits in terms of accessibility, convenience and safety. However, Canada’s limited public virtual care and lack of legislative coverage has allowed privatized actors to flourish in the field. While these actors provide necessary and desired services, these services come at the direct expense of Canadians. This for-profit model of healthcare is fundamentally at odds with the ethos of the public healthcare system. Canada’s public healthcare policymakers need to address these service and policy oversights in a timely manner, or they risk having more of the public system usurped by further privatization.
Canada’s public healthcare policymakers need to address these service and policy oversights in a timely manner, or they risk having more of the public system usurped by further privatization.|| (Source: flickr // bastamanography)
Although such a Canadian framework would be uniquely adapted to solve Canadian healthcare concerns, policymakers can look to other countries with universal healthcare for inspiration. For example, the National Healthcare Service of the United Kingdom created a long-term plan that includes a massive virtual overhaul of healthcare platforms. France and Australia have also both enacted comprehensive legislative reforms for digitized care. It is up to Canada to follow the same path.
Dylan Yan is a Junior Online Editor for the McGill Journal of Law and Health. Dylan is a recent transfer BCL/JD student at McGill University’s Faculty of Law.
Previously, Dylan studied law at Osgoode Hall Law School, where he was awarded the Ivan Cleveland Rand Prize and the Samuel Rubinoff Prize for Legal Research and Writing. During his time at Osgoode, Dylan was a student caseworker for Mahdi Weinstock LLP and Community Legal Aid Service Providers, focusing on immigration and refugee practice.
Dylan also attended McGill’s Faculty of Science, in which he holds a bachelor’s degree in Microbiology and Immunology and the J.W. McConnell Entrance Scholarship. During his undergraduate studies, Dylan conducted research as part of the Lady Davis Institute. His efforts there focused on HIV enzymes, characterizing the effects of HIV drugs in order to optimize combination HIV therapies.
McGill Journal of Law and Health 