Using Administrative Data to Explore Potentially Aberrant Provision of Virtual Care During COVID-19: Retrospective Cohort Study of Ontario Provincial Data
Authors: Stamenova Vess , Chu Cherry , Pang Andrea , Tadrous Mina , Bhatia R Sacha , Cram Peter 
Published: May 2021

Background
The COVID-19 pandemic has led to a rapid increase in virtual care use across the globe. Many health care systems have responded by creating virtual care billing codes that allow physicians to see their patients over telephone or video. This rapid liberalization of billing requirements, both in Canada and other countries, has led to concerns about potential abuse, but empirical data are limited.

Objective
The objectives of this study were to examine whether there were substantial changes in physicians’ ambulatory visit volumes coinciding with the liberalization of virtual care billing rules and to describe the characteristics of physicians who significantly increased their ambulatory visit volumes during this period. We also sought to describe the relationship between visit volume changes in 2020 and the volumes of virtual care use among individual physicians and across specialties.

Methods
We conducted a population-based, retrospective cohort study using health administrative data from the Ontario Health Insurance Plan, which was linked to the ICES Physician Database. We identified a unique cohort of providers based on physicians’ billings and calculated the ratio of total in-person and virtual ambulatory visits over the period from January to June 2020 (virtual predominating) relative to that over the period from January to June 2019 (in-person predominating) for each physician. Based on these ratios, we then stratified physicians into four groups: low-, same-, high-, and very high–use physicians. We then calculated various demographic and practice characteristics of physicians in each group.

Results
Among 28,383 eligible physicians in 2020, the mean ratio of ambulatory visits in January to June 2020:2019 was 0.99 (SD 2.53; median 0.81, IQR 0.59-1.0). Out of 28,383 physicians, only 2672 (9.4%) fell into the high-use group and only 291 (1.0%) fell into the very high–use group. High-use physicians were younger, more recent graduates, more likely female, and less likely to be international graduates. They also had, on average, lower-volume practices. There was a significant positive correlation between percent virtual care and the 2020:2019 ratio only in the group of physicians who maintained their practice (R=0.35, P<.001). There was also a significant positive correlation between the 2020:2019 ratio and the percent virtual care per specialty (R=0.59, P<.01).

Conclusions
During the early stages of the pandemic, the introduction of virtual care did not lead to significant increases in visit volume. Our results provide reassuring evidence that relaxation of billing requirements early in the COVID-19 pandemic in Ontario were not associated with widespread and aberrant billing behaviors. Furthermore, the strong relationship between the ability to maintain practice volumes and the use of virtual care suggests that the introduction of virtual care allowed for continued access to care for patients.