Before the COVID-19 pandemic onset, virtual delivery of physician services in Canada was rare – other than in specific settings, it was not included within publicly funded health services. Soon after the start of the pandemic, 50 per cent of outpatient care was provided through virtual modalities, an astonishing 56-fold increase, comprising 71 per cent of primary-care visits in the first months of the COVID-19 pandemic. This was a welcome change for many patients, who had reported substantial barriers to accessing virtual care in the past.
These changes also impacted accessing mental-health services for many patients, given that primary mental-health care physician services are publicly funded, and therefore free-of-charge to most patients. Our team’s work has demonstrated that anxiety and depression were the most common reason for people consulting family physicians in 2020.
Family doctors are a mainstay of mental-health services in Canada because their services are paid for by provincial and territorial Medicare programs. Billing codes included in the Schedule of Medical Benefits in each province and territory determine the range of services that are publicly funded. The biggest change after the start of the pandemic was that synchronous virtual care (where the physician and patient are interacting in real-time, using video or phone calls) became part of what was publicly funded across the country.
But what is included in this – and the relative compensation – has ebbed and flowed. For example, recent changes in Ontario’s catalogue of billing codes show that the rates physicians can bill for video or phone-based appointments with patients with whom they do not have a longitudinal relationship have fallen dramatically, from about $38 per appointment to $20 and $15, respectively. This has resulted in a substantial disincentive and the closure of virtual-care clinics that were facilitating this type of “virtual walk-in care,” or their switching to operating through a private-pay model. (With 6.5 million Canadians not having access to regular primary care, some form of “walk-in” type service is, for better or worse, an essential part of health service access for millions) For mental-health care, the changes are even more dramatic – a 30-minute “primary care mental-health” visit for someone who does not have an ongoing longitudinal relationship with that provider previously paid $67.75; it has been reduced to either $20 or $15 depending on whether it is provided through video or phone.
Even more troubling is the comparison of services provided by family physicians between provinces.
Where this becomes even more troubling is in comparing services provided by family physicians between provinces. Our team looked at “virtual” billing codes that apply for mental-health services, in British Columbia, Alberta, Manitoba and Ontario. We found that what can be provided in one province doesn’t necessarily exist next door. For example, billing codes in B.C. limit family physicians to a billing maximum of eight mental-health related appointments (either virtual or in person) per year per patient – the first four under a “Telehealth Counselling Fee,” and an additional four under the “Mental Health Management Fee.” To make this even more confusing, before the four “Mental Health Management Fee” visits can be provided, B.C. family physicians have to arrange a specific “Mental Health Planning” visit of at least 30 minutes during which a care plan must be documented. (Changes to family physician billing in B.C. are working toward simplifying this, but those changes only apply to longitudinal family medicine practices, leaving B.C. residents without family doctors at a serious disadvantage to getting mental-health support). Keeping track of this adds to family physicians’ administrative burden, a factor contributing to family doctors leaving their practices and medical students increasingly avoiding it, with more than 100 unfilled residency places in this year’s Canadian residency match – the highest vacancy rate ever.
In Alberta, Ontario and Manitoba, there are essentially no limits on the number of primary virtual mental-health care appointments a patient can have with a family physician. Other nuanced differences can also be found between these provinces. For example, in Alberta, physicians can bill for asynchronous care services, such as emails – but this is the only one of the four provinces we looked at that included emails as an eligible service. In Manitoba, family physicians can email their patients, but they can’t bill for it – they can provide synchronous virtual mental-health care but only to those with whom they have an existing patient-physician relationship. For the hundreds of thousands of Manitobans without a regular family physician, the billing codes disincentivize mental-health support.
The goal of the Canada Health Act is to “…protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” But it is obvious that this principle is not being achieved. Patients in Jasper, Alta., can receive an email from their family physician, but just across the border in Invermere, B.C., they might have to go into clinic to review a document.
The establishment of standardized guidelines – an effort our team is leading, funded by the Canadian Institutes of Health Research – would help to ensure that all Canadians have equal access to virtual primary care services, regardless of where they live. But it will also take political will to look across provincial and territorial borders and work together to make sure that everyone has access to the same high-quality services.
Virtual primary care can be a valuable resource for people who are unable to access in-person care due to geographic barriers, mobility issues or a lack of available physicians in the local community. By offering virtual care services, patients can receive medical advice, treatment and referrals from the comfort of their own homes, reducing the need for in-person visits.
It is unacceptable that virtual physician services are offered haphazardly across different provinces. Where the public health system fails to deliver, for-profit companies follow – and across the country there are examples of virtual services beginning to be offered at extra cost to patients.
For virtual primary care services to be effective and accessible, we must ensure that patients receive the same high-quality care, regardless of where they live from coast to coast to coast, and that physicians are able to provide that care.