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B.C. telehealth visits absolutely ballooned at height of pandemic

While telehealth can be convenient, a B.C. doctor says investing in primary care is strongly needed.

B.C. government-provided data shows virtual physician visits jumped almost 2,000% at the height of the COVID-19 pandemic.

Figures provided to Glacier Media by B.C.’s Ministry of Health shows virtual physician visits in the province have been steadily increasing since 2014, with 29,268 visits recorded in 2014-15.

By 2019-20, virtual care services reached 684,059. This number jumped to 13,946,806 in 2020-21 when COVID-19 restrictions were in place — a 1,938 per cent increase from pre-pandemic times. For comparison, there were 5,735,883 in-person visits in 2020-21.

For Vancouver-based family physician Dr. Melissa Lem, telehealth is just one piece of British Columbia’s health-care puzzle.

One problem with the rise in telehealth, she says, is that it can further fracture the “longitudinal relationship” between primary care providers and patients.  

“I totally get that we have a primary care crisis in B.C. right now. But if more and more resources are plowed into virtual care, not in the setting of actual longitudinal primary care relationships, this is going to make the overall state of health care within B.C. worse," Lem says.

A statement from the health ministry notes telehealth companies are not “covered” by MSP and are not able to bill to MSP; rather, physicians bill to MSP.

“Physicians can assign their MSP billings to companies they work with; however, they are still bound by the terms of the Medicare Protection Act which prohibits charging MSP-insured patients for MSP-eligible services,” a spokesperson wrote.

The statement notes telehealth companies are registered corporations and follow the same process that all corporations do to seek registration. 

“Although telehealth companies do not register with the ministry, the ministry identified less than 10 telehealth companies providing virtual care under a model like Telus in 2020-21,” the ministry said, noting that this accounted for less than 0.7% of total fee-for-service medicine.

The benefits and shortcomings of digital health care

Lem notes that virtual care helps to save time on the patient's end such as "getting to the appointments, waiting in the waiting room and having to wait for their turn." It can also be a great alternative to people, physicians and patients, who are immunocompromised.

And for doctors who might have mobility or health issues, virtual care allows them to practice medicine in a safer setting. But to be a virtual care provider, Lem says that "you have to be backed up by a brick and mortar team" so that the patient can get a timely exam or access to in-person care when necessary.

"Because then, it can just become like a phone triage service like, 'Oh, I don't know what's going on. OK, go to this higher level of care.'"

And while virtual care can be convenient for things that don’t require exams or getting prescription refills, the family physician says it shouldn't replace in-person care.

She notes since virtual care has entered mainstream health services, she believes the government is realizing that virtual care isn't enough on its own.

"You actually have to be connected to on-the-ground clinics. It is important to be able to lay hands on a patient sometimes, and not to just kind of defer care to someone else not related to your own virtual care clinic,” she says.

Not paid enough

Nearly one million British Columbians do not have a family doctor.

In order to address the shortage, Health Minister Adrian Dix announced this week incentives to about 175 new family practice resident graduates. They include student loan forgiveness, lucrative contracts, and $25,000 signing bonuses if they sign on by September. 

One of the issues with the lack of family physicians in B.C. is because doctors don't have interdisciplinary support, says Lem.

"So a lot of the tasks that nurses or dieticians or pharmacists could do really well, but that doctors don't necessarily need to be using their specific skills on. I think that can lead to sort of a feeling like we're not supported. Like we're getting overburdened with all kinds of tasks."

Another reason for the primary care crisis, according to Lem, is the lack of pay for their specialty, which she argues is a specialty because family doctors focus on longitudinal care and relationship building, as well as being knowledge keepers about their patients' medical histories.

On average, B.C. family physicians are paid $221,000 in gross payments, where medical and surgical specialists are paid $338,000 and $487,000, respectively, according to a 2019 report from the Canadian Institute for Health Information.

"It's not as well remunerated as other areas of practice, and unfortunately, economics are a major consideration for people everywhere," says Lem. 

"If you go to medical school, and you come out with a six-figure debt, and you're thinking, 'How am I going to pay off my debt, and practice?' And then you look at the cost of living in some of Canada's major cities, and especially in Vancouver, and you think, 'I'm not going to be making all that as a family doctor. Why would I go into that specialty?'"  

A pyramid of complexity

B.C.'s family medicine model is fee for service, which means that doctors who work for telehealth companies like Telus are paid the same as family physicians who provide virtual care in addition to an in-person clinic.

"If I see you in-person, I do a whole exam, a whole assessment. I write you a prescription or give you a list of counselling or whatever, it's paid the same as a 45-second visit from a telehealth doctor, and unfortunately, the system that we're in incentivizes volume, because you get paid per patient," explains Lem.

She also notes that one valid complaint among traditional family practice and walk-in clinics has been that "telehealth [is] kind of siphoning off the easiest visits."

"The least complex people get dealt with on the phone. And then, next step is walk-in clinic, next step is family practice clinic. The average patient who's sent to me from a virtual clinic who can't assess them takes more time because they're not easy. And they actually require an exam and a more detailed history and workup," says the doctor.

This is why Lem argues that both services need to exist together.

"I think it's really important to have all these virtual clinics, paired with fast access in-person assessment because then it levels out the playing field."

Ultimately, Lem says investing in primary care is strongly needed.

"It saves money, it saves lives. It saves hospital admissions when patients actually have primary care, like a family doctor or a nurse practitioner. It's actually a good investment. We actually save more money than we cost," she says.

And better health outcomes is what physicians like her want.

"A health-care system that functions in primary care is the central hub of that. And virtual care can both contribute to that if provided in a careful and thoughtful way, but it can also detract from it. So we have to be really careful how we move forward."

With files from Cindy E. Harnett, Times Colonist