🩺 Startups are Privatizing Health, Policymakers Let Them

harms on the horizon

Trying out a longer form piece, as a follow up to #16.

The tech economy is  coming for our cherished public health care system, and it might be policymakers’ fault.  

Celebrated startup Maple, a virtual healthcare platform, has raised more than $14M USD to charge people [~$49] to see a doctor online. In fact, Maple employs shrewd second-degree pricing that varies by the time of day and specialty, unlocking near-instant digital access to medical professionals for a price.

On other, similar online platforms like KumoCare or TiaHealth, virtual care - also referred to as “telemedicine” -  is totally free. That’s because it is covered under OHIP. Access to health care is protected by the Health Insurance Act and Commitment to the Future of Medicare Act, and yet physicians and dentists are not necessarily paid on par with in person care for services delivered via phone or video. This inconsistent regulation of billing is creating space for a private marketplace to steadily grow and become a key part of the healthcare system.  

Virtual care is not new but it has been improving. EQ Care has been offering virtual care in Canada for more than 30 years now. There are a range of sophisticated platforms and companies that facilitate online consultation, like Appletree (clinic specific), GoEVisit, or the Ontario Virtual Care Clinic. Ask the Doctor is an email Q&A service where you can ask a doctor a question and wait for a reply for a fee. The province of Ontario has its own mobile application - Ontario Telemedicine Network (OTN) - which is part of our publicly-funded healthcare system, and their website provides numerous virtual care options at no charge to the patient. 

While a lot of these web-based and mobile apps are - appropriately - free for the user, companies like Maple represent a dangerous creep toward a two-tier system. This evolution is being helped along by the inertia of provincial policymakers, who are failing to address a critical regulatory gap in a reasonable amount of time.

In March, pushed by the pandemic, the provincial government agreed to cover *some* forms of virtual medical care, issuing new temporary billing codes for a variety of services delivered by phone or video. Given that physicians in Ontario previously could not even bill for an online visit because the associated billing code just didn’t exist, it’s easy to see why they might be enticed to participate on an online platform that will actually pay them for their work. 

So some people are willing to pay out of pocket for access - is that really a huge problem? The growth of these kinds of companies is significant because we know that tech media can inadvertently help entrench negative aspects of technology.  When we unquestioningly celebrate the growth of  startups, we may wind up normalizing disregard for our policy frameworks -- in this instance the core principles that underpin public health. 

That said, the sector seems to be somewhat aware of billing code discrepancies. In February of 2020, the Virtual Care Task Force — a collaboration of the Canadian Medical Association, and the regulatory bodies of family doctors and specialists — released its recommendations for expanding the implementation of virtual care in Canada. One of the  key recommendations was new fee schedules. 

Sometimes regulatory realities are a  source of opportunity, rather than a constraint. A pending, more permanent update to provincial billing codes is likely to constrain Maple's growth as physicians will be able to charge patients for virtual care. However, their reach could have further expanded by then, and the potential for a superior service offering is likely to preserve their earned customer base.  

There is also a great deal that the public health system could learn from Maple and companies like it. The firm is solving for a matching and access gap, offering immediacy. A 2019 study found that about half of medical practices in Canada had arrangements to see a patient when the practice is closed. Sometimes all people need is a prescription renewed, and that platform can save you time. It’s also simple to use; especially for digital natives more accustomed to administering their lives online. 

While Maple could directly lobby for this modest loophole to be consistently closed - i.e. some doctors are disincentivized to see you online, we've created a platform where you can connect online and the doctor will get paid a *modest* fee while we work towards more meaningful policy change - it’s not exactly in their business interest to do so; unless they aspire to become “the” platform of choice for the Ontario government. 

As we continue to work remotely and the primacy of geography erodes, it will become more advantageous to connect people to a doctor online. Those delivering health care have much to learn from the matching and immediacy that Maple is able to provide. Nudging people towards telemedicine alternatives can reduce wait times and minimize emergency room visits. However, when accessing a doctor or specialist through these kinds of platforms requires that a patient pay out-of-pocket, this inequity limits accessibility and essentially downloads a policy failure to the insured person. 

We need to demand more scrutiny of the implications of these new services early and often. We also need policymakers to be more responsive and stand up for public health before it’s too late.

*NYT - Is Telemedicine Here to Stay? August 3rd, 2020.