Anita Dickson recently saw the kind of primary health care one corporate provider is delivering in British Columbia. And it scared her.
Dickson is past president of the Licensed Practical Nurses Association of BC, an organization that dissolved in April and merged into the Association of Nurses and Nurse Practitioners of BC.* She has worked everywhere from emergency rooms to hospices and knows the kind of attention that goes into providing careful, personalized health care.
Not long ago she was with a family member who was using Babylon, a service that Telus offers through its health division. “See a doctor from your phone,” Telus promises, with the cost covered by the province’s medicare plan.
Dickson could see that the service was convenient. But she was concerned about what she witnessed — and the risks to patients.
“There’s no connection. It’s just being able to call up and get a prescription, and that’s how [the patient] sees it, and that’s the scary part,” Dickson said.
“What I saw was this female doctor gave a prescription for several months of birth control — not knowing [the patient] hadn’t taken her IUD out,” Dickson said. The patient wanted to alter her menstrual cycle and didn’t tell the truth when asked key questions about the IUD. The pill and some types of IUDs both affect hormone levels; using both could create risks for the patient.
A doctor who had been providing care to the patient for some time would likely have identified the risk. But it would be difficult, if not impossible, for a doctor dealing with the patient for the first time, on the phone, to recognize the complication.
“They don’t know your medical history,” said Dickson. “I didn’t see a full assessment. She asked several questions for sure, but it was ‘Sure, OK, that sounds right, that sounds good.’ And that’s the scary part for me as a nurse.”
Telus, a publicly traded Vancouver-based company worth $29 billion, was making inroads into health care before the COVID-19 pandemic began. It’s moving more heavily into primary care, traditionally provided by generalist family doctors who are patients’ first point of contact with the health-care system. They look after day-to-day concerns and also provide a co-ordinating role when people need ongoing care or to see a specialist.
Besides Babylon, which is available in B.C., Alberta, Saskatchewan and Ontario, Telus offers a similar service nationally called Akira that it promotes through employers.
Telus has bought clinics operating under the Copeman and Medisys brands, both of which operate in a “legal grey area,” charging patients annual fees in the thousands of dollars while still billing provincial health plans.
And it provides electronic medical records services to some 26,000 doctors and clinics, which it says makes it Canada’s biggest digital health-care provider.
The corporation’s investment in the health sector — more than $2.5 billion so far — was seen as a way for the telecommunications company to differentiate itself from competitors BCE and Rogers.
The Globe and Mail in June quoted Telus executive vice-president Francois Gratton, group president of Telus Health and Telus Quebec, saying, “We decided that a big differentiator for Telus would be the health-care sector... that health would be our ‘content strategy,’ if you will, as others were focusing on content, sports and entertainment.”
When the pandemic hit and many people sought virtual appointments to avoid waiting rooms, Telus and other corporate health-care providers advertised aggressively and attracted new patients.
Problems in primary care aren’t new
Once, Canadians had family doctors who cared for them and their children. Now corporations are moving in, delivering primary health care by phone or through a chain of branded clinics.
Critics say that’s the direct result of long-term problems in primary care delivery and governments’ failure to support better ways of improving access.
They worry about the quality of care corporations will provide, and conflicts between the corporate need to increase profits and patients’ need for care that puts their interests first.
The underlying issues are long-standing, some going back to the founding of Canadian public health care. But they’ve been heightened in the pandemic, as physicians and patients have turned to virtual care provided by phone or over the internet.
Telus was positioned to capitalize on the shift.
“Telus has really got the jump start in terms of the outreach, the advertising,” said Marcy Cohen, who has researched issues around primary care and community care for two decades.
“We’ve never seen anything like it in terms of the massive advertising that goes on from Telus and the extent to which they’re overselling, over-promising in terms of what they say they can offer through virtual care.”
Cohen said regulatory systems and governing bodies aren’t set up to address the new models of primary care being launched by Telus and others. There’s a system to respond to complaints about individual care, she said, but “not a proactive regulatory mechanism that can look at issues like conflict of interest or unsafe care and inadequate care.”
Nobody from Telus was available for an interview. The company instead referred the request to a public relations company that answered questions by email.
There’s no doubt the COVID-19 pandemic had been a catalyst for change, they said. “It’s dramatically driven up adoption of virtual care and removed many of the barriers that limited access to these innovative solutions.”
The public relations person wrote that Canadians have long wanted virtual care and the demand for Telus’s services during the pandemic has demonstrated they will use it. The use of the company’s virtual services had increased 10-fold, they said.
“While not intended to replace in-person care, we believe that virtual care is here to stay, as a complementary way for patients to access care, while similarly offering health-care providers another tool to effectively connect and engage with patients,” the statement said.
In a quarterly report, Telus said that while the temporary closure of its Copeman and Medisys clinics during the pandemic was a negative, the increased demand for virtual services was a bright spot.
The company was also pitching its home health monitoring platform as a way to provide remote care to people with COVID-19. Projects in B.C. and Saskatchewan were designed to enable “clinicians to remotely manage, track and care for people diagnosed with or exposed to COVID-19, relieving pressure from hospitals, driving efficiencies and decreasing exposure to the virus,” it said.
Further pilots were starting in Alberta, Ontario and Quebec, Telus said.
Telus said every province was now allowing doctors to bill for remote visits. Some 26,000 doctors using the company’s electronic medical records service had access to its newly launched video visit platform, it said. That could decrease the need for unnecessary visits to emergency rooms and leave hospitals with more capacity to respond to the COVID-19 outbreak, the company said.
“We are also seeing increased demand for our one-on-one virtual health solutions, with increased adoption of Akira by Telus Health by provincial and business customers as well as increased demand for Babylon by Telus Health,” it said. “This increased demand has accelerated the adoption of these virtual care solutions.” The services take pressure off the in-person health-care system, the company added.
The need for better access to primary care has been clear for years. According to the most recent figures from Statistics Canada’s Community Health Survey, about 4.3 million Canadians, 15 per cent of the population, had no regular family physician in 2013.
The provincial government says 760,000 British Columbians don’t have a family doctor, about one out of seven people.
Statistics Canada figures show the number of people in B.C. without a family doctor nearly doubled between 2005 and 2013, the most recent year for which figures are available.
Telus argues its services help address that need and notes many patients would otherwise seek help in walk-in clinics and emergency rooms.
“Our virtual care solutions are intended to complement existing health services and support those who have a difficult time accessing primary care,” the spokesperson said, adding the services are available on evenings and weekends when many clinics are closed.
“Through our Babylon by Telus Health and Akira by Telus Health services, British Columbians can have a one-to-one virtual consultation with a locally-licensed family doctor, often within minutes, and receive prescriptions, test requisitions and referrals as appropriate,” they said.
While that kind of speedy response is exactly the kind of care that worries Dickson, the spokesperson for Telus argues that it has its place within the system.
Telus agrees it’s beneficial for patients to have a long-term relationship with a family doctor, the company’s statement said. “The virtual care services we offer have been designed to ensure the delivery of quality care and high patient satisfaction. Every aspect of the model has been built around putting the patient first.”
But criticizing Telus for providing episodic care without providing a consistent patient-doctor relationship is a distraction, it says. Instead the focus should be “on how to improve access to quality health care to help all patients versus a debate on episodic care.”
Many physicians and their representatives disagree and raise concerns about the care Telus and other companies provide.
‘Fast food’ version of health care
Toye Oyelese, a family doctor in West Kelowna, said he believes an increase in corporate primary care is inevitable. But it will disrupt the traditional doctor-patient relationship and mean more patients are getting worse care, he said.
“It’s going to be fast food, because that’s what corporations do.”
The BC Family Doctors, which represents doctors providing primary care, recently released a statement urging caution in the adoption of telemedicine and calling for closer scrutiny of the involvement of corporate care providers.
“The encroachment of private, for-profit telemedicine needs to be regulated and controlled,” the statement said. “BC Family Doctors calls on the B.C. government to regulate and control the expansion of private, commercial interests in for-profit telemedicine in B.C.”
The statement argues that telemedicine is best when used as a tool within a long-term patient-doctor relationship. One-off episodic services “should only be provided as an intermittent and infrequent alternative to a patient’s family doctor,” it says.
Corporatization was pushing care in the other direction, it said, with a growing number of British Columbians using telemedicine and losing continuity of care.
The doctors’ group also said private companies should be required to meet the same conflict of interest standards accepted by family physicians and other regulated health professionals. It warned, for example, that pharmacies shouldn’t be allowed to gain by entering partnerships with telemedicine providers that agree to drive patients to them.
“These changes are necessary in order to provide for the protection and safety of patients,” it said.
Some worry the government will be reluctant to take steps that would hamper Telus’s business.
The Vancouver-based company is closely tied to the provincial government and provides it with various services. The public accounts listing core government spending show B.C. ministries spent almost $111 million last year with Telus Communications Inc., Telus Communications Co., Telus Corp., Telus Mobility and Telus Health Solutions Inc.
Between 2005 and 2017 when the current government limited corporate and union political donations, Telus, through various entities, gave more than $631,000 to B.C. political parties. More than 90 per cent of the money went to the BC Liberals, who held power from 2001 to 2017. Notably, however, Telus gave $20,000 to the NDP on May 8, 2017, the day before voting began in the last provincial election.
There’s money to be made in health care. The B.C. government alone will spend more than $22 billion on it this year. Payments to physicians providing primary care are mainly made through the Medical Services Commission, spending that added up to more than $4.3 billion last year.
As companies including Telus take an increasing share of that public money, there’s no shortage of suggestions for how to improve the care they provide and the overall system.
Dickson of the Licensed Practical Nurses Association said it would help if Telus tracked whether the people using its Babylon service are attached to other primary care, made sure the care they are receiving isn’t fragmented and provided information to the person’s family doctor if they have one.
“I think Babylon has a huge need to say, ‘We have this person who calls us quite frequently, do you know that as their family doctor?’” By doing so the company could make sure the patient gets a continuum of care where somebody who knows them has the big picture on how they are and the care they’re getting.
According to the public relations company working for Telus, about 40 per cent of Babylon users report they don’t have a family physician.
“Should a user need to have another virtual consultation, they can also request an appointment with the same Babylon by Telus Health physician they spoke to previously,” it said. “We also ensure that patients without a family doctor and/or who require an in-person appointment have a smooth transition from virtual care to in-person care at a local clinic.”
Even for those who are already attached to a primary care provider, Babylon fills a need, the company said. Half of those patients “said they typically wait more than a week to see their own family doctor and eight to 12 per cent said that had they not received care through our service, they would have sought care at a hospital emergency room.
“Our virtual care service may have prevented users from delaying care and having their conditions worsen.”
Patients who have a family physician can choose to have the notes from their consultation sent to the physician’s office. “We always encourage users to reconnect with their regular physicians when they can as we support the benefits of a patient medical home,” they said.
But others say that in the worst cases, Telus’s service adds inefficiency and costs to the system.
Burnaby family doctor Baldev Sanghera gives the example of a patient of his who got in touch with a doctor through Babylon about a wart. Not being able to remove the wart virtually, the Babylon doctor sent a note to Sanghera who ended up seeing the patient and removing the wart.
It’s unfair if Telus can bill $30 for a two-minute phone call when the person doing the actual wart removal gets paid the same for a procedure that takes 15 minutes, he said. But it also means the public is paying more than it should for the care.
“Now the system is going to get billed twice for dealing with one problem,” Sanghera said. “That shouldn’t be happening.”
A related issue is that while the government records and publicly reports billings by physicians, it has no way to track whether they are working for a corporation, themselves or a clinic. That leaves the government and researchers unable to answer key questions about how the method of delivery affects patient care and things like visits to emergency rooms, hospitalizations and patient outcomes.
Underlying the rise in corporate care is a longer-term issue with how primary care is managed, despite decades of discussion around how to make it better.
“I personally think [corporate care] is significant, and I feel there should be concern about the real risk it has to further fragment health care in the province,” said Jeanette Boyd, president of the BC College of Family Physicians. “Absolutely they are filling a vacuum, but it’s a vacuum I feel is artificial and can be addressed in other ways.”
*Story updated on Sept. 11 at 9:58 a.m. to note that the Licensed Practical Nurses Association of BC is no longer an active organization.
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