Virtual Care in Primary Practice

The Dawn of a New Era

Virtual care and telemedicine have drastically shifted the way healthcare is delivered. Virtual care has tremendous potential to improve the rigid and technologically archaic industry of medicine. However, there is a risk that the same technological innovation could lead to exploitation of our healthcare systems. These systems may be ill-prepared against the pressures of rapid change. It is inevitable that virtual care is a tool that will advance the healthcare industry, but its integration requires both thoughtful regulation and well-intentioned design. 
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People who have worked in the medical field will largely agree that the technology and processes used day-to-day are incredibly outdated. As a physician, I remember still using pagers during my residency training that ran on batteries oftentimes held in place by scotch tape. I would chart in the hospital using software that looked older than myself and then return to my comparably futuristic home where my personal PC ran on Windows 10 and the entirety of the pager device could exist merely as a tiny app in my smartphone.
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Classical Remuneration

The compensation structure for healthcare providers also felt incredibly out-dated. For Ontario family physicians, the predominant billing code for any office issue was an A007 which pays approximately 37 dollars. Whether you treated a simple UTI for a young, healthy patient on no medications who already came to clinic correctly knowing their own diagnosis and management plan or managed an ill-defined complaint like “weakness” in a frail elderly patient who can’t provide a reliable history nor recall what medications they’re on; the compensation would be the same. Under a fee-for- service model, family physicians that manage the so-called undifferentiated patient essentially had one fee for an incredibly broad scope of services.
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The problem with a fee-for-service model is that it financially incentivises episodic care and a “one-issue-per-visit” policy. Important components of patient-centered care such as patient education, counselling, and prevention were ill-suited for this system. The time pressures in this practice environment, sometimes described as “revolving-door” medicine, also make it difficult to offer multimodal management plans at all. When pressured to see as many patients as possible in a day, there may only be enough time to write a prescription and move on to the next.
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The Capitated Compensation Model

Personally, I think Ontario is far ahead of some other healthcare systems by having a capitated or patient enrollment model. British Columbia has just recently followed suit and now Alberta is trialling it in a limited capacity. In this model, a physician’s earnings come from having a patient on the roster, and theoretically, high-quality comprehensive care could mean the patient visits their family doctor less. Such a model is ideal for older, more complex patients who benefit from having a main provider that collates all the specialist reports, imaging tests, and comes up with a personalized medical plan with the holistic perspective emblematic of a primary care provider.
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Having providers compensated for quality of care instead of quantity of office visits gives physicians the comfort to provide care for complex patients. Removing rigid fee-for-service incentives allows physicians to provide high-value patient access such as medical updates via phone and allowing for sufficient time during appointments to address multiple or more complex medical issues. Patient convenience and satisfaction are achieved through physicians being compensated for the tremendous work done behind-the-scenes outside the boundaries of the office visit.
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Where Should Virtual Care Fit?

Virtual care makes it easier for physicians to provide comprehensive family medicine. . The introduction of billing codes for virtual assessments now recognises and compensates physicians for the direct patient interactions taking place  outside of a traditional in-person appointment. It gives recognition that when physicians provided medical services to patients and chose to save them a trip to the office, that they should be compensated for it. Furthermore, if in such calls the patient uses the opportunity to bring up new medical issues, providers can decide whether to address it then and there instead of using additional time to have a separate appointment arranged. Much of the unpaid work that burdens primary care providers can be captured and compensated which can further incentivize physicians to improve their practices to be more accessible. Society also benefits economically from the fact that patients with full-time jobs no longer need to take significant time off work travelling to-and-from appointments. This also reduces the likelihood that patients delay timely medical assessments with their physician in an effort to  avoid missing work. Virtual care dismantles many of the barriers to care for both patients and providers.
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How Accessible is Too Accessible

The first widely used virtual codes in Ontario were developed as an emergency response to the COVID-19 pandemic. Nearly overnight, the barrier of having to see physicians in-person to get assessed was completely lifted. With these emergency codes, a patient could call a physician anywhere in Ontario any time of day for essentially any reason and the bill would go to taxpayers. 
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This iteration of virtual care offered unprecedented levels of patient convenience which is not compatible with a publicly funded health care system that has very limited resources. In this system where surgeries and specialist wait times exceed  a year, it would seem counterproductive that access to a virtual doctor assessment to get a lifestyle drug prescription could be arranged within an hour.
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Unlike a system with limitless resources, a provider in the public system has the difficult and important task of triaging and conserving scarce resources. As a physician born and raised in this system, I think the limitations train us to rely on and cultivate stronger clinical skills. 
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Although wait-times are long for elective, non-urgent and lifestyle medical issues, from my experience patients with truly urgent issues such as newly diagnosed cancer would never be delayed. The reality is that the public system cannot sustain itself without sacrificing some patient convenience of non-urgent matters to maintain reliability to those needing it most.
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Wait times aren’t ideal,  but I’ve come to accept that moderate wait times and mild inconvenience are inescapable to a functioning public system. Soft barriers to entry such as dealing with office phone pre-recorded messages and needing to drive to a physician’s office, prompted some degree of patient investment prior to having an appointment. Access to specialists and most medical testing requires authorization from a provider which indirectly shifts responsibility of reducing healthcare spending onto primary care providers.
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Therein lies the potential pitfall of virtual care – it can open the floodgates to unrestricted patient demand for convenience, incentivized by the profitability and scalability of digital technology all at the cost of taxpayers in a public system. Our provincial health plan funds medical appointments only when medically necessary. However, without reliable standards or regulation towards what constitutes medical necessity, the public healthcare system pays indiscriminately for any service that involves a phone call between an Ontarian and a provincially licensed physician. In this environment of episodic, consumer demand-based access, we risk dismantling the primary care model that has served Ontarians so well.
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In theory, episodic virtual care could fill in an important care gap for unattached patients  but 60% of users already have an established primary care provider.  These virtual visits could be redundant, and patients may find the level of care is less preferred in comparison to the comprehensiveness and rapport they have with their regular physician. In fact, the Ontario Medical Association’s stance has consistently been in support of virtual care when it is in the setting of an ongoing physician-patient relationship.
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December 2022 introduced changes to Ontario billing codes that placed  strict measures on episodic virtual care and two conflicting narratives emerged reflecting on its impact on healthcare during the pandemic. Episodic virtual care providers purport high levels of patient satisfaction with their services and argue that these visits would have reduced potential emergency room visits. However, a recent study by University Health Network, demonstrated instead, that patients using virtual walk-ins are twice as likely to still end up going to the emergency room within 30 days.
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Patient satisfaction and convenience are important health measures but can be at direct odds with other important measures such as quality of care and equity. A common example such as patients requesting medications for inappropriate medical indications (such as antibiotics for viral infections) would be difficult to moderate if patients could shop between multiple virtual providers until they get a prescription. Physicians exclusively working through virtual care companies may be unable to provide care for patients who aren’t as computer-literate.

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Virtual Care has an Identity Crisis. 

Without any regulation, virtual care could lead to excess and unnecessary public healthcare spending. With too much regulation, the public system will simply abandon virtual care, paving the path to a two-tiered healthcare system where only private payers can benefit. Some balance will be needed because virtual care certainly is not going away.
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Left unchecked, virtual care can accelerate the commoditization of healthcare but at the same time, virtual care can be the  tool for physicians to  steer the healthcare system from its current dismal state. It is up to creative and thoughtful physicians to apply these tools to bridge otherwise unsurmountable healthcare gaps. Virtual care is an immediate remedy to healthcare access in rural communities and for patients that have barriers to attending clinics in person. Taken further, there is much untapped potential in utilising virtual care to extend a physician’s reach and provide more high-value care in less time by automating large amounts of administrative work that contributes to physician burnout. Virtual care can connect practising family physicians with ancillary resources to create a true primary care home; this is a logical next step to what the province had already built towards with family health teams.
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I believe the virtual care revolution will undoubtedly help address the family medicine crisis. Patients can have better access to their provider, clinics can run more efficiently and physicians can feel adequately compensated for good comprehensive medicine. In its early stages, some wrong turns may be taken but with time and proper regulation it will eventually find itself indispensable to and likely at the center of a modernized healthcare landscape. When it does, virtual care will be effective and cost-saving while still being equitable. It will be convenient and desirable but never superfluous. It will address and solve pre-existing healthcare problems without merely deferring them or producing new ones. In this healthcare landscape, the MD will not only be participatory, but instead, essential.
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For up-to-date listings of virtual care and remote physician jobs in Canada don’t miss Cherry Health’s telehealth jobs index.

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