Why Rocket Doctor and other online health sites in Ontario are about to come crashing down to earth

The emergency department at Georgian Bay General Hospital was using the system to see patients virtually, which caught the notice of the Ontario Medical Association’s magazine, which intended to write a story.

And, more recently, the company’s founder, Dr. Bill Cherniak, was outfitting two London pharmacies with virtual stations that would allow a doctor, anywhere in the province, to see a patient’s inner ear.

But on Dec. 1, when the new fee codes for virtual appointments come into existence, Rocket Doctor will come crashing down to earth.

The company’s virtual model won’t be economically sustainable after Nov. 30, when OHIP decreases the amount doctors are being paid to see patients by phone or video for one-off virtual appointments.

OHIP will pay $20 for a video appointment, and $15 if it’s by phone, when a patient sees a doctor through a virtual-only website — about half of what a physician could typically bill for an appointment during the pandemic, when the virtual and in-person payments were on par.

“We’ve surveyed MDs who provide emergency and primary care services on our platform and most have said that they intend to stop seeing (virtual) patients after Dec. 1 if the fee codes remain unchanged,” Cherniak said in an email.

“This remains the same for pediatricians who see patients on our platform on a walk-in basis, which is really too bad, given the current flu season we’re in.”

Rocket Doctor could be just one of many online sites that fold in the wake of the pandemic. Either that, or the sites could begin charging patients instead of OHIP.

Appletree Medical Group, for example, has physical clinics and will continue to offer virtual appointments to its patients, but will no longer offer virtual-only appointments to anyone as it did during the pandemic.

Another site, VirtualDr.ca, is no longer taking patients covered by OHIP.

And companies such as Maple Corp. continue to charge patients for its largely chat-based medical care, a technology not covered by OHIP.

Why the change is happening

Many experts agree with the government’s position that virtual care is best when it’s part of the overall comprehensive medical care that a patients receives from a family doctor they continue to see over time. And that the new low fees for virtual-only medical care are a reflection of what they’re worth.

The new fees are part of a Physician Services Agreement between the government and the Ontario Medical Association, which was ratified by doctors in March. It’s the first PSA to include specific fee codes for virtual care.

Family physicians who have seen a patient in the last 24 months will be able to bill in full for a video appointment, and at 85 per cent of the full rate (which varies according to type of appointment) if by phone. The same is true for patients who are rostered, or enrolled, with a doctor or clinic.

“What it looks to me that they’re trying to do is they’re trying to prioritize, incentivize comprehensive care,” says Ibukun Abejirinde, a scientist at Women’s College Hospital Institute for Health System Solutions and Virtual Care.

“We do know that comprehensive health care, wraparound care with this therapeutic alliance between your primary care provider, is actually more beneficial,” says Abejirinde, who is also an assistant professor at U of T’s Dalla Lana School of Public Health.

Critics of the virtual sites also say that the doctors who work there, like the ones in physical walk-in clinics, don’t typically have access to a patient’s medical record, which could lead to problems with prescriptions, such as duplication.

“When a patient is seeing, for example, multiple specialists who may be prescribing different things, you want to make sure you’re getting reports from the specialist,” says Dr. Rashaad Bhyat, a clinician leader for Canada Health Infoway, a non-profit organization with federal funding to improve the use of digital solutions in health care. “And right now, that’s very challenging in our current environment because of the siloing of (electronic medical records).”

Different systems are used by family physicians, specialists and hospitals, among others says Bhyat, who is also a family physician in Brampton.

“You can sort of extrapolate that if there is a proliferation of these virtual walk-in clinics, it may not necessarily be contributing to good continuity of care,” says Bhyat, a concern which he says was raised by many medical associations and organizations, right across the country, during the pandemic.

The family doctor question

However the “elephant in the room,” as Abejirinde put it, is the estimated 1.8 million people in Ontario without a family doctor.

And for those and many other patients, the repercussions of the fee changes could be big.

One hospital clinic in London where doctors provide services to homeless people with HIV and hepatitis C by phone, and very seldom see patients in person, will now be paid $15 an appointment. That amount is less than a quarter of what they could bill even before the pandemic, when they used a different fee code because virtual codes didn’t exist.

Connect-Clinic, a virtual-only clinic that helps people from across the province get gender-affirming hormones and surgery, says the low fees will make it impossible to add patients to its wait list, or even help the 2,000 patients already on it. The clinic, which was founded in 2019 and has always been virtual, could eventually close.

Specialists and other doctors are also very concerned that prioritizing video over phone will force elderly patients or other patients without a computer or reliable internet, to travel long distances for in-person appointments, because phone appointments are either not allowed in some instances, or they are paid at a reduced rate.

Meanwhile, patients without family doctors who turn to emergency departments will be faced with record-high wait times.

With a Dec. 1 deadline looming, Cherniak is looking for a way to save his company, which he and others believed had such promise at the start.

“We surveyed patients after every appointment,” asking “what would you have done if Rocket Doctor hadn’t been here?” Cherniak said.

“And consistently, 33 per cent say they’d have gone to the emergency department,” he said. “Another 50 per cent would have gone to walk-in clinics. So very few people using us would have had a family doctor or waited for one anyways.”

Correction — Nov. 24, 2022: As of Dec. 1, doctors who provide one-off virtual appointments by phone or video — meaning there is no pre-existing or ongoing doctor-patient relationship — can bill OHIP about half of what they typically billed for an appointment during the pandemic. A previous version misstated how much less doctors can bill.