When Ontario declared its first COVID-19 state of emergency in March 2020, its healthcare sector faced an urgent challenge: how to continue care while minimizing virus exposure. The solution? A swift and widespread adoption of virtual healthcare. Once a niche option, virtual consultations became a lifeline, replacing crowded waiting rooms with screens and phone calls – all from the comfort and safety of home. The indispensable service not only safeguarded patients and providers but opened new doors for the future of medical care.

Four years later, as the dust from the pandemic continues to settle, the question lingers: will this digital health revolution endure and thrive in the province, or will we return to old practices?

Intrigued by the swift shift to a "digital first" approach in healthcare, Ivey Associate Professor Laurel Austin, along with Marisa L. Kfrerer (Health Sciences PhD candidate) and Kelly Zhang  Zheng (Ivey HBA/MSc 2023), investigated the evolution of virtual healthcare in Ontario. Their research, titled From 0-50 in Pandemic, and Then Back? A Case Study of Virtual Care in Ontario Pre–COVID-19, During, and Post–COVID-19, forecasts the prognosis for virtual care – and the outlook isn’t positive.

The birth of virtual care

Though virtual healthcare seems modern, its roots in Ontario go back nearly 50 years. Introduced as “telemedicine” in the late 1970s, it aimed to serve remote, underserved patients, who traveled to host sites for video consultations. By the late 2010s, advancements in technology allowed patients across the province to access virtual video visits from home by Ontario Telehealth Network (OTN) registered providers.

“In Ontario, until just a few years ago, virtual care was primarily thought of as a way to provide care to people in rural areas who did not have access to local care,” said Austin. “Only approved technologies could be used, requiring the provider and patient to have access to, and understand, specific technologies.”

In November 2019, Ontario’s Ministry of Health announced the "Digital First for Health" strategy. The plan aimed to expand virtual tools for physicians; implement online appointment booking; increase patient access to health data; and redesign electronic medical records. With an overall goal to end hallway health care and streamline digital health delivery, the program incentivized physicians to offer video consultations via approved video technologies, even to local patients.

Yet, despite this ambitious strategy, by 2020, fewer than one per cent of family physician consultations and all physician services were provided virtually. But that would soon change.

From 0 to 50

While some programs grow slowly, others are executed under pressure. Such was the case for virtual healthcare during the COVID-19 pandemic. Driven by overwhelming patient demand and government-mandated lockdowns, virtual consultations surged from less than one percent to about 50 percent of all medical consultations by April 2020. Despite fluctuations during the pandemic and stay-at-home orders, the rapid implementation of the virtual model proved to be a success. It enabled doctors to care for patients seamlessly without exposure risk and – of crucial significance – to offer services to those without a family doctor through virtual walk-in clinics.

So how did a 50-year-old niche program suddenly achieve rapid, wide implementation? Austin and team outline that a key driver was the province's decision to allow video and telephone care for OHIP-insured patients, without specific technology or OTN-registration requirements. The integration of phone care was a game-changer, with an early study indicating over 91 per cent of virtual care was provided by telephone – likely due to convenience and ease of use.

Additional enablers included temporary billing codes (K-codes) that allowed physicians to bill for virtual care at rates equivalent to in-person visits. Further, private-pay virtual platforms in Canada were also highly active, with providers able to bill OHIP using K-codes.

Given these positive results, one might expect virtual care to remain a priority for the province. But Austin’s research indicates the opposite.

The long-term prognosis

As public health measures gradually eased in 2022, so did the enhanced use of virtual care. By December, the province introduced a new funding framework that reshaped everything. Physicians could now bill for video visits at 100 per cent of the in-person rate, but only if using a verified virtual visit solution. Similarly, telephone visits are now billed at 85 per cent of the in-person rate, but only for enrolled patients who have used specific services, or had been seen in person or via a video consultation within the last 24 months. For walk-in patients or those without a family doctor, physicians received $20 for video visits and $15 for phone calls. The rationale for this shift? Emphasizing a continuing physician-patient relationship seems to be what drove the changes.

The new funding framework spells trouble for the future of virtual care, according to Austin and her team. The researchers predictive model suggests the changes will not support continued high provision of virtual care, but reduce it, especially for the estimated 2.2 to 4.6 million people in Ontario without a primary care doctor.

“There are hopes that virtual care might reduce some inequities in health care by making access to care easier for those who have difficulty getting to a clinic, or difficulty finding a brick-and-mortar walk-in clinic. I’m concerned that these changes risk introducing a new kind of inequity into our health care system, by improving access to care for some but not for others,” said Austin.

Austin elaborates that without equal compensation and a strong emphasis on technology by policymakers, the program will never achieve its full potential. “It’s clear from what happened during the pandemic that billing policies have very real impacts on provision of care. Researchers will continue to study the effects of policy changes during the pandemic. My hope is that as we gather and synthesize that evidence, policy makers will use it for future decisions and policies.”  

Research in progress…

Austin and her team are already working on the next phase of their research. Her team is currently analyzing interviews conducted with Ontario residents and physicians to understand their experiences and perceptions of COVID-19 digital self-triage tools and virtual care during the pandemic.

Austin said: “From our interviews, we are hearing varying opinions on virtual care. On the positive side, we heard from some residents that receiving care virtually means only having to take a few minutes off work for a call, rather than taking time to drive round-trip to a clinic, making care more accessible. There of course are limitations as well. In interviews we heard that some physicians experienced more missed appointments, while others experienced fewer missed appointments. And of course, some patients strongly prefer being seen in person. It will require further study to determine what works as well, better, or not as well when care is virtual to really figure out how to ideally mix virtual and in-person care.”

Full details of From 0-50 in Pandemic, and Then Back? A Case Study of Virtual Care in Ontario Pre–COVID-19, During, and Post–COVID-19 can be found online through Science Direct

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