In November of 2021, Michael Mort’s doctor in Victoria retired without finding anyone to take over his practice. Michael, 82, has complex medical needs and requires nine prescriptions to manage his health. He and his wife, Janet, worried about what this change would mean for him. By the time his doctor stopped practising, Michael was regularly overcome with crippling pain in his lower belly. He needed to urinate so frequently that the couple no longer felt comfortable driving 15 minutes from their home. They worried he might have cancer.
Janet is a former superintendent of innovation for B.C.’s ministry of education. With the focus of someone accustomed to cutting through bureaucratic red tape, she took on the task of finding her husband a new doctor. She cold-called 20 clinics across Victoria and then broadened her search to include rural communities. No one had room for Michael. Clinic staff advised her to try urgent-care centres, which are designed for patients who lack a family doctor. Every morning, at 8:45, she would sit down with a coffee and her phone and dial urgent-care centres in the hope of getting Michael on a wait list. Each time, she would get a busy signal. After 30 minutes, her call would go through to a recording saying that the centre was fully booked for the day.
Before Michael’s doctor retired, he told the couple that if they were ever in a bind, they could get medical care through online walk-in clinics. Telus Health, a division of Canada’s privately owned telecom giant, connects patients to doctors affiliated with the company, but the visits are funded by the provincial health-care system. With nowhere else to turn, the couple signed up for an appointment to see a physician over a phone screen.
A doctor appeared immediately, agreed that something seemed off with Michael’s health and ordered blood tests. Two weeks later, the Morts got a message saying that the results were in. At their next Telus Health appointment, a different physician came up on screen. She asked what she could do to help, and they told her that they’d come for Michael’s results. The doctor seemed surprised. She told them there were no results available for them. After keeping the couple on hold for 20 minutes, the doctor finally located Michael’s results, which showed high levels of prostate-specific antigen—a finding that can indicate a number of health problems, including prostate cancer. The doctor ordered an ultrasound. Eventually, a third Telus Health physician told them that the results were inconclusive.
By this point, Janet couldn’t sleep. She’d pace at night, convinced that her husband needed to be examined by a physician. She’d been searching for eight months, and the only doctors she could find—the ones on a screen—couldn’t help her.
In every province and territory, health systems are hanging on by a thread. Nearly six million Canadians do not have a family physician. Even people with life-threatening diseases can’t access timely care. In December, a man in his 70s died of a heart attack in the waiting room of a hospital in Edmundston, N.B., while the ER was overrun with patients. At Calgary’s Children’s Hospital, families wait up to 18 hours to see a doctor, while, outside, others receive care in a heated trailer. In 2021, Canadians experienced the longest-ever emergency-room wait times—a record that’s likely to be broken when 2022 data is available.
Meanwhile, the federal and provincial governments have spent years locked in a showdown over health funding: The provinces are demanding money with no strings attached, while the feds insist on guarantees about how funds will be used. The parties are moving toward a new health-care funding deal, but not with the urgency required.
In the midst of this chaos, private virtual clinics have become a booming business, offering care via phone, text and screen. At least two dozen companies have set up shop in the virtual-care space in Canada over the past few years; major players include Maple, Telus Health, Dialogue, PC Health, Felix, Rocket Doctor, MD Connected, KixCare and Cura. They offer services in primary care, mental health and specialty medicine. Some will probably start popping up on your social-media feeds as soon as you read this story—the advertising is aggressive.
Virtual walk-in clinics are the easiest way for many Canadians to access immediate non-urgent medical care. The attraction is the guaranteed visit, no waiting required—a luxury unheard of in a country where waits are typically measured in hours, months or even years. Most of these companies have a hybrid business model where publicly covered services are billed to the province while all other care is paid out of pocket. What’s covered in virtual care depends on where a patient lives and what they need. In some provinces, the public system includes all virtual walk-in care for residents without a family physician. In Ontario, the provincial reimbursements for physicians who provide these services were recently cut so dramatically that companies are shifting to a business model where patients pay privately to be seen by nurse practitioners. Meanwhile, many third-party insurers cover virtual visits as part of employee benefits.
At virtual clinics, patients can get last-minute prescription refills or have unusual rashes assessed. They offer fast appointments for people who want to talk to a doctor but don’t want to wait to see one. When Alison Forde, a biologist in Mississauga, Ont., developed intense shoulder pain in January of 2022, she couldn’t get time with her family physician, even over the phone, within two weeks. She got a same-day appointment at Telus Health, during which the doctor referred her for an X-ray. In a time frame shorter than what it would take to get a phone appointment with her own physician, Forde had talked to a doctor, had imaging done and received the results. “I thought, ‘Wow, that’s fantastic,’” she says.
There is no single Canadian health system: The provinces and feds have shared jurisdiction. As a result, rules vary from province to province. However, the federal government has huge sway when it comes to health delivery. The Canada Health Act sets out what the feds are responsible for funding, and a foundation of the act is that medical care covered within the public system cannot be offered as a private-pay service.
For public services, like ER visits, the act requires provinces and territories to meet a number of criteria—including universality and accessibility—in order to receive their full federal funding. There must be no extra billing or user charges for patients who are insured for these services.
But there are massive and contentious grey areas. For instance, some primary-care clinics charge new patients a membership fee, which, ostensibly, is meant for non-insured services but also provides faster access to a family doctor. Some surgical centres offer orthopaedic operations that patients can pay for privately to circumvent long waits in the public system.
At the same time, there’s a host of medical care that the public system clearly does not cover. This is where Canadians are expected to pay themselves or where their insurance can step in. Nearly 30 per cent of health-care spending in this country is paid privately. This includes services like sick notes, eye care and, until Covid, many kinds of virtual care. Pre-pandemic, medical care by app or text was not listed by any province as a service that would be publicly funded. It was wide open to the private market.
In 2016, Brett Belchetz, an Ontario ER physician, launched Maple, one of the country’s first virtual-health-care clinics. The idea came to him one weekend after he diagnosed illnesses for three friends and family members via text; they’d all messaged him rather than going to see a physician in person. People craved rapid medical advice for simple things, he realized.
From its launch, Maple provided a service that no one in the public system could match, offering consults via an app. It charged $49 for a weekday virtual visit, $99 for an overnight call and $79 for a weekend appointment and offered memberships ranging between $359 and $579. After paying, patients could record their symptoms on the app, which would match them in five minutes or less to a physician or nurse practitioner who could address their concerns. The first months were slow going. Canadians were not clamouring to text with a doctor, especially when the cost for it was coming out of their own pocket. A physician colleague told Belchetz: “Keep dreaming—nobody will ever pay for this.”
After the sluggish start, Belchetz hired a PR firm and ramped up advertising. The company gained steam, helped along by corporations that signed on to provide coverage en masse for their employees. By March of 2018, Maple had approximately 100 licensed Canadian doctors on the platform who’d cared for nearly 20,000 patients. A year and a half later, it had raised $14.5 million from investors like VC firm Acton Capital and the Royal Bank of Canada.
Once Canadians got used to the idea of virtual care, they liked having a doctor at the press of a few keys, says Belchetz. They didn’t have to wait for an appointment or take time off work. But virtual walk-in care was still just a drop in the bucket of health care in Canada. By 2018, as little as two per cent of all physician visits in Canada were conducted remotely.
When it comes to modernizing health care in Canada, there is always plenty of heel dragging. Faxes, for example, bizarrely remained a primary means of communication for two-thirds of Canadian doctors as late as 2018, and many clinics still kept medical records in hard copy. By this point, in the real world, the general population was relying on cellphones for almost everything; there were more Canadians with cellphones than with landlines. And yet governments continued to preferentially cover in-person medical care rather than visits over the phone or computer.
This left the door wide open for private companies to step in, says Will Falk, an executive-in-residence at Rotman School of Management at the University of Toronto and a senior fellow at the C.D. Howe Institute. “Every time governments say ‘No, that’s not covered,’ guess what happens?” says Falk. “Private business steps in and offers that thing.”
Despite the government’s predilections, there was a healthy appetite for virtual visits, even paid ones. After all, the hours that patients spend in hospitals and clinics waiting to see a health provider come at a cost, even if they never get a bill for it. A study from Canada Health Infoway, a federal-government-funded corporation tasked with moving health care into a more digital realm, found that the average in-person medical visit in Canada cost patients about $99 when things like time off work, child care and parking were factored in. These costs are especially high for hourly wage or freelance earners, families who need to hire child care, people who live in remote communities and must travel a long distance for a medical visit and those seeking care in cities where parking costs are high. “That $99 hits different groups differently,” explains Falk. “If you’re going to lose $100 of income to go get your meds prescribed, you’re going to be quite happy to pay $25 to do that by email.”
Falk doesn’t understand why patients should have to come to an office if their medical needs can be addressed virtually. In a world that’s increasingly reliant on phones and computers, the requirement that provider and patient be in the same room for an act of medical care to occur is outdated, he says. “Care is care.”
Falk is an investor in and board member at multiple virtual-health-care companies. Even so, he says he’d like all virtual health care to fall under the public system, even if it’s privately delivered. “I worry that the public system isn’t moving fast enough to expand coverage for stuff Canadians clearly want,” he says.
In 2020, a new virus made governments quickly scramble to adopt telemedicine within the public system. Covid-19 was a watershed moment for virtual health care around the world. Globally, investment in the industry skyrocketed almost overnight, with three times the level of venture-capital investment in 2020 compared to 2017. In the U.S., virtual visits grew by more than 3,000 per cent during the first waves of the pandemic, with 150 million telehealth claims in less than two years. Physicians who’d long said that they couldn’t provide care remotely suddenly found themselves “seeing” patients via phone and computer.
The pattern was the same in Canada. As the country shut down in the spring of 2020, provinces finally adjusted physician-fee schedules so that doctors would be reimbursed for phone calls and video visits. In a matter of weeks, virtual visits in Canada—via either private apps like Maple or family clinics— accounted for 70 per cent of primary health care. (It has now stabilized at closer to 30 per cent.) Two months after the pandemic started, Justin Trudeau announced investments of $240.5 million into expanding virtual and mental health care to Canadians through the public system.
The private virtual-care system, meanwhile, after years of trucking along, exploded. Many visits were suddenly publicly funded, even if the services were provided through private companies like Maple. Days after the WHO declared a pandemic, new players jumped into the telemedicine market.
One of them was William Cherniak, an emergency physician who worked in Toronto and northern Ontario. After finishing his medical training, Cherniak set his sights on improving global health outcomes, first completing a master’s in public health at Johns Hopkins and then a fellowship in global cancer at the National Institutes of Health. He founded a charity, Bridge to Health Medical and Dental, to improve health services in villages in sub-Saharan Africa.
He returned to Canada in 2019, just in time for an unusually rough flu season. In the ER, Cherniak treated many children with respiratory illnesses. Some were sick but not sick enough to be in the hospital; they came because their parents were worried and had nowhere else to turn. He thought that a virtual-care clinic would help keep people out of the emergency room. Patients could be assessed remotely, and parents could be advised to bring them in or treat them at home. And yet pre-pandemic, there was no way to make a virtual clinic available as a publicly funded service.
That changed in 2020, when governments revised their policies. Cherniak started a virtual walk-in clinic called Rocket Doctor, which connects patients with family doctors, pediatricians, substance-use specialists and other physicians through video consultation or text chat and operates in Ontario, Alberta and British Columbia as well as California. He wanted to operate within the publicly funded system—physicians would see patients online and bill the visit to the province using new virtual billing codes. Even Rocket Doctor’s California branch functions in the American public system as a virtual-care service through the government insurers Medicare and Medi-Cal. Cherniak says he wants to provide good care without charging patients. Revenues come mostly from physicians, clinics or payers who choose to license Rocket Doctor’s software, he says.
For companies that were already offering telemedicine prior to the pandemic, Covid kicked off a massive growth spurt. “It was all hands on deck, really, just to keep the lights on and be able to fulfill the level of demand that was coming in,” says Maple’s Belchetz. In the fall of 2020, Loblaw, through its subsidiary Shoppers Drug Mart, invested $75 million in Maple, which was by then facilitating prescriptions for more than 160 pharmacies in B.C. Over the next two years, the governments of Prince Edward Island, Nova Scotia and New Brunswick contracted Maple to provide publicly funded online visits for residents without a family physician. In Nova Scotia alone, that covers more than 10 per cent of the population. By the end of 2022, about 100,000 people were using Maple each month—90 per cent more than pre-pandemic levels.
Dialogue, a publicly traded telemedicine company founded in 2016, grew by 1,596 per cent over the pandemic, earning it a spot as one of Canada’s fastest-growing companies in 2022. “I would say the pandemic accelerated our growth by five years,” says Dialogue’s COO Jean-Nicolas Guillemette. The group, based in Montreal, sells its services directly to employers, who can then send their workers to an app where they will be connected to a multidisciplinary team of doctors, nurses and psychologists. “It’s the first time in decades that there’s been a new money injection into the health-care system, and that is coming from employers,” said Guillemette.
“Every time governments say ‘No, that’s not covered,’ guess what happens? Private business steps in and offers that thing”
Telecom giant Telus, which consistently ranks among Canada’s 30 largest companies, had been making inroads into e-health since 2008. Its long-time CEO Darren Entwistle has said that his grief over the loss of his father—who died from an allergic reaction after receiving penicillin for an infection—inspired him to expand into the space. By 2018, Telus had developed a $2-billion unit focused on health-related technology.
The spending spree continued into the pandemic: Telus Health partnered with Babylon Health, a provider in the U.K., to launch a virtual-care mobile app. It eventually bought Babylon’s Canadian operation, rebranding it as Telus Health MyCare after Babylon garnered negative press in the U.K. for providing expensive care within the cash-strapped National Health Service. Telus declined interview requests for this story, but the company’s communications department often cites the stats that someone in Canada downloads the Telus MyCare app every 30 seconds, and a patient sees a doctor via the app every 90 seconds.
Three years into the pandemic, the global digital-heath industry, of which virtual walk-in care is only a small part, has reached $20 billion. Many Canadians appreciate that they can finally get long-sought health care at the touch of a button. Noah Richardson, a 26-year-old television news producer in Ottawa, has ongoing medical issues. Despite putting their names on a wait list for a physician and calling around to a dozen local clinics, he and his partner have been without doctors since they finished university and graduated out of the student health-care system. Richardson has used Rocket Doctor 20 to 30 times since March of 2020. “Having access to telemedicine was a godsend, especially during the pandemic,” he says.
Despite its lightning-quick expansion, the virtual-health-care system remains plagued by criticisms. Some have voiced concerns about Canadians being asked to pay privately for services that are supposed to be covered in the public system. Telus, for example, is under investigation for fees it allegedly charged patients at one of its in-person clinics.
Lorian Hardcastle, an associate professor in law and medicine at the University of Calgary, signed up for the Telus app two years ago for research purposes. “I still get emails all the time trying to sell me stuff,” she says. Users are invited to sync their accounts to their wearable health-tech devices. “These companies are in the business of big data in a way that your walk-in clinic down the street is not.”
Two of Telus Health’s medical-service providers (the Medisys Health Group and Copeman Healthcare, which operate in-person clinics and telemedicine) ended up paying an unspecified ransom to retrieve 60,000 clients’ personal information after a data breach in the summer of 2020. The next year, Alberta’s privacy commissioner found that Telus had ignored health-information privacy laws when it launched the Babylon app in 2020. “There’s no active oversight,” says Sheryl Spithoff, an assistant professor of family medicine at the University of Toronto. She says her research indicates that digital-health companies also share de-identified user information with third parties like Google or Facebook.
Many virtual clinics specialize in walk-in-style care—which means there’s no long-term follow-up, preventive care or ongoing management of chronic disease. Cherniak says that Rocket Doctor patients can request to see doctors they’ve seen previously, thereby maintaining some continuity of care. But physicians and nurses at virtual clinics do not always have access to a patient’s medical records outside the virtual system. This raises the possibility of inappropriate care. Patients could receive a prescription for a drug that interacts dangerously with something they’ve been prescribed elsewhere, or a vital part of their medical history could be missed. Critics argue that these clinics order tests unnecessarily and bill them to the public system in lieu of being able to examine the patient.
“These companies are in the business of big data in a way that your walk-in clinic down the street is not”
Lauren Lapointe-Shaw, an assistant professor of medicine and an internal-medicine doctor at the University of Toronto, argues that there will be times when it’s dangerous for someone not to have an in-person assessment. She studied patients and physicians at 13 virtual-care walk-in clinics in Ontario during the pandemic and found that patients who saw a physician at a virtual walk-in clinic were more likely to return within a month, compared to patients who had virtual visits with their own family physician. They were also more likely than other patients to go to the emergency department within a month. But despite her own reservations about virtual walk-in care, Lapointe-Shaw knows why patients turn to these clinics. “It’s hard to resist how easy it is,” she says.
One argument against these services is that they can exacerbate workforce shortages by drawing physicians and nurses out of real-life practice—where they have to deal with high overhead costs, such as office space, staff and equipment—and into the virtual stream. Lapointe-Shaw’s work has shown that in Ontario, online walk-in clinics tend to be staffed by younger physicians who are billing fee-for-service, which could indicate that these physicians do not have large patient panels at comprehensive bricks-and-mortar family practices. Virtual-care companies are big employers; on average, Telus lists job openings for nurses every other day.
People who run virtual walk-in services say they’re adding capacity, not taking away. At Dialogue, Guillemette says the services offered are “complementary” to the public health system—designed to provide help that people can’t readily get elsewhere. Most doctors in Dialogue’s physician workforce also work in the public system, putting in, on average, eight hours per week for the private company. At KixCare, a virtual clinic offering pediatric care, the physicians and nurses who work with the clinic do so in their free time, says CEO Darren Sacks. And some physicians interviewed for this story said they are working at in-person clinics and providing virtual walk-in care.
After nearly three years of rapid growth in virtual walk-in care, the Ontario government is now testing the brakes in a move that will dramatically affect the smaller players in the market. In December, the Ontario government chopped fees for physicians at virtual walk-in clinics. Reimbursements for first-time visits dropped to $15 for phone calls and $20 for video sessions, down from $37 and $60, respectively. And physicians are leaving in droves. Rocket Doctor’s physician count is down to 15 per cent of what it was in November. As a result, only 50 patients a day—down from 500—can see a doctor, says Cherniak. Patients like Noah Richardson have once again found themselves without access to a physician. In December, he spent seven hours in an urgent-care clinic waiting for a prescription refill. Next time, he says, he’ll just pay out of pocket to see someone virtually. “It just boggles the mind. This was a system that I and many other people benefited from.”
KixCare, where visits used to be fully covered by the public system, switched to a private model in which families pay a $29 monthly subscription to connect with pediatric nurses and pediatric nurse practitioners. Parents and caregivers are furious. In Ottawa, new mom Leah Littlepage used the service last year after waiting 30 hours for a callback from the provincial telemedicine line when her infant daughter, who has allergies and respiratory issues, was struggling. She came to rely on it for medical care. “I’m so angry,” she says. “It’s fundamentally wrong that this service would disappear.” When she visited a hospital with her daughter in early December, she saw the staff being hammered with patients, some of whom were struggling to breathe. Others might have been taken care of virtually, but instead they were waiting in the hospital.
“I worry that the public system isn’t moving fast enough to expand coverage for stuff Canadians clearly want”
Aviva Lowe, a pediatrician who worked one four-hour shift a week for KixCare before the fee change took effect, says the new rules have created two classes of patients. Those who have a primary-care doctor will continue to have a virtual option with their physician. Those who don’t have a family doctor, however, will have trouble accessing virtual care because so many doctors have left the private space. “It’s baffling,” she says. Will Falk, too, says the cuts are the wrong decision at the wrong time. “Anything that takes capacity out of the system right now, when our emergency departments are full, is probably a policy mistake,” he says.
In medicine, doctors often talk about the gold standard—the benchmark for the best care under reasonable conditions. In Canada, the gold standard for primary care ought to be a properly funded full-service system where patients can see doctors in person or virtually without a wait. But patients are experiencing care that is the opposite of that standard. They don’t have family doctors; even when they do, they have to wait. Private virtual-health-care companies have stepped in and remain one of the most efficient ways for Canadians to access medical care. As long as governments continue to downplay the value of virtual health care, they leave it open for private pay.
Janet Mort decided to take matters into her own hands when she couldn’t find a doctor for her husband and turned to a medium that predates the internet. She took out a large ad in the local paper saying she was looking for a physician for Michael. A doctor responded and accepted him as a patient. Examinations revealed that Michael has a bleeding lesion as well as an enlarged prostate and irregularities in his bladder. He underwent multiple biopsies in late 2022. As of January, the couple were still waiting for results.
This article appears in print in the winter 2023 issue of Canadian Business magazine. Buy the issue for $7.99 or better yet, subscribe to the quarterly print magazine for just $40.