OTTAWA — The new agreement covering the Ontario government’s relationship with its doctors slashes funding for drop-in online medical appointments and has providers of those services rethinking their businesses.

Although the Physician Services Agreement between the Ontario government and the Ontario Medical Association covers about $16 billion in annual public spending, it isn’t public. The Logic obtained a copy from a source.

The government issued a news release about it, but Alexandra Hilkene, the press secretary for Health Minister Christine Elliott, simply did not respond to several of The Logic’s requests to see the agreement after the province’s doctors ratified it.

The OMA said it couldn’t share a copy without the government’s permission, and the government had not given it.

“We had a lot of exciting plans to offer a lot more publicly covered services to Ontarians,” said Dr. Brett Belchetz, the co-founder and CEO of Maple, which offers video appointments mainly covered by private insurance plans or patients’ own out-of-pocket payments. “In particular, the Ontarians who benefit most from a service like ours are the nearly two million Ontarians who don’t have a family doctor—these are the people that desperately need more help.

“Our hope had been really that we could actually expand our service on a publicly funded basis to help those people. And the implication of the changes from this agreement is that we’re not going to be able to do that.”

In an interview with The Logic, Dr. Sheldon Elman, whose startup KixCare offers a virtual health platform focused on pediatrics, was more blunt: “It’s an ass-backwards kind of approach.”

The agreement creates two classes of virtual-care appointments. In a nutshell, doctors who have ongoing relationships with patients but choose to have particular appointments by video get paid at the same rate as in-person appointments. The publicly insured rate for a routine family doctor appointment in Ontario is $84.45.

Services provided “outside of an existing/ongoing physician-patient relationship” will be covered by a new fee code.

Once the temporary codes expire, the rate for the same appointment with a doctor on the roster of a virtual-care platform will be $20. For a phone appointment, the fee will be $15.

“Most likely, when you speak to physicians, at [the new] rates, they’d rather have a few hours off than to actually do more work at those kinds of rates of pay,” Belchetz said. Maple advertises general-practitioner appointments starting at $49 for a single session, for patients willing and able to pay directly.

Virtual appointments were not common in Canada’s publicly funded health system before the COVID-19 pandemic, but in March 2020, provinces rushed to enable them. Ontario created temporary billing codes for doctors in the public system so video and telephone appointments could be covered like in-person appointments. Under the new agreement, those temporary codes end Sept. 30.

The government acknowledges in the new agreement that virtual care can be valuable: “Virtual care will allow physicians to offer new modalities of service delivery that can optimize care for patients and allow for appropriate and timely access,” the document says.

The health ministry will rely on doctors’ judgment “in striking the appropriate clinical balance between providing in-person and virtual care, always mindful of the principles that guide medical practice and the needs of the people we serve.”

Answering an inquiry after The Logic got a copy of the new agreement, ministry spokesperson Bill Campbell said by email that “all medically necessary virtual-care services will continue to be insured under the Ontario Health Insurance Plan when the necessary requirements have been met, regardless of whether or not the patient has a family physician.”

He did not address the difference in how much the province will pay for those insured services, depending on how they’re provided. But Campbell emphasized that under Ontario law, if a health service is covered by the province, it’s illegal to provide it for private payment.

(Officially, providers like Maple offer only “general-practitioner services that are not covered by provincial governments.”)

Several provinces, including British Columbia, Ontario and Quebec, began nudging doctors back toward in-person appointments last year, saying that the pandemic conditions behind the initial rush to virtual visits had changed.

Alberta has gone the other way, adding to the services its doctors can bill for in association with virtual appointments. Nova Scotia has actually contracted Maple for patients who don’t have family doctors—as has Prince Edward Island, though it says the arrangement is temporary.

In-person appointments are fine for people who have ready access, both Belchetz and Elman said, though virtual visits can be much more convenient even for them.

“Much of this then ends up becoming an employee benefit, delivered by a private insurance company, in order to drive this for employees. But what about a mom who’s not an employee?” Elman said.

He said to expect a spike in emergency-room visits in Ontario in the fall. “I would say more than 70 or 75 per cent of emergency-room visits should be handled or could be handled virtually, within certain guidelines.”

The Logic also put questions to Telus Health (which operates virtual services similar to Maple’s, mainly through benefits plans) and Rocket Doctor (which is similar to KixCare, though for all ages) about what the new agreement means for them; neither responded.

Maple had been expecting that Ontario would make the temporary arrangement permanent, but it held back on expanding into publicly funded appointments until it knew for sure, so its current operations aren’t profoundly affected, he said. Some services Maple already offers, primarily as a partner with other health-care organizations such as hospitals, might have to be curtailed.

“We haven’t done enough analysis yet to fully understand the repercussions on our existing services,” Belchetz said.