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?
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.
However, the dermatologists get around this restriction by giving their advice online. Normally, doctors have to treat a patient in person to receive a payment under the various provincial and territorial health insurance plans. And the fact that an online dermatology consultation isn’t on the list of insured “medically necessary” services means they can do it.
What you also need to know is that DermaGo isn’t the only Canadian-based website that’s now offering health services directly to paying patients. For instance, getmaple.ca will connect patients to doctors through their phones, tablets or computers 24/7. “Skip the waiting room!” the website beckons.
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.
“It has the potential to undermine the universal health care system,” warns Dr. Danielle Martin, vice-president of medical affairs and health-system solutions at Women’s College Hospital in Toronto.
Meanwhile, DermaGo, which was launched in Quebec in December 2017, is moving forward with plans to expand nationally. A total of six dermatologists are now offering their expert advice online—three in Quebec, two in Ontario and one in Alberta. Efforts are underway to recruit more dermatologists 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, which can vary from a few weeks to several months to see a dermatologist.
Doré says he was inspired to set up DermaGo because of the success of similar websites in the United States.
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. An Ontario dermatologist, for instance, gets $72.15 for a patient consultation.)
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.
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,” says Doré. “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.”
Furthermore, Dr. Danielle Martin believes 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?” Under the traditional approach, she explains, the family doctor makes the referral to the specialist who then sends back a report about the patient.
But Dr. Marc-André Doré defends his direct-to-consumer website, saying that patients have some responsibility to keep their family physicians in the loop. He notes 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.”
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.
In fact, the value of “virtual” care has been well established by Ontario Telemedicine Network (OTN), a not-for-profit organization that operates within the health care system but is funded separately from the Ontario Health Insurance Plan (OHIP).
OTN has created a video-conferencing network that enables Ontario patients who live in remote locations to have virtual doctor appointments in their own communities.
In some respects the arrival of websites dispensing medical diagnoses and prescriptions is a natural evolution of virtual medicine.
“This could be part of the solution to how we make the health care system more efficient and sustainable,” says Martin.
“I would like to see lots of virtual visits happening with specialists as well as with family physicians,” she adds.
“But it should be offered to people on the basis of need, not the ability to pay.”
Sunnybrook’s Patient Navigation Advisor provides advice and answers questions from patients and their families. This article was originally published on Sunnybrook’s Your Health Matters, and it is reprinted on Healthy Debate with permission. Follow Paul on Twitter @epaultaylor.
If you have a question about your doctor, hospital or how to navigate the health care system, email AskPaul@Sunnybrook.ca