When Cherif Habib co-founded Dialogue, a virtual health care and wellness platform, in 2016, the concept of seeing a care provider on the other end of a screen was still a relative novelty.
Thanks to three years of COVID, public health restrictions, and overloaded provincial health care systems careening well past burnout, telehealth is now a synonym for the doctor’s office.
Dialogue is far from the only virtual health-care provider in Canada these days. Private companies like Maple connect users with doctors or counsellors for a fee, while not-for-profit organizations like the Ontario Telemedicine Network set up virtual visits to provincial providers. But Dialogue doesn’t work directly with patients.
Instead, the provider offers benefits plans to organizations or to insurance companies. These clients, in turn, pay for subscriptions. This model isn’t unique to Dialogue — other employer-focused telehealth firms in Canada operate along similar lines — but the Montreal-based company says it has taken a somewhat different tack from the rest of the virtual health care industry.
Instead of competing with the Canadian health care system for patients and doctors, Habib says Dialogue tries to complement it.
He spoke to the Star in mid-January:
Dialogue was involved in telehealth way before the COVID-19 pandemic began. What did people think about the idea of a telehealth company when you launched?
When COVID-19 started, it really accelerated a telehealth trend that was already happening. It changed people’s attitudes toward virtual care, both among employers and patients, but also health care providers. All of a sudden, if you were a physician working in a clinic, you were forced to adapt and learn about virtual care.
The pandemic was obviously a very interesting three years, but if you’re asking the one thing it did, it was changing people’s attitudes toward virtual care. People just got used to this new modality.
Are there specific industries that are really overrepresented among the clients you serve? I imagine tech companies are more interested in Dialogue than, say, a manufacturing facility.
That’s actually one of the positive surprises we’ve had as we were building this company. When we started, we thought our clients would include a lot of tech companies, professional services, lawyers, bankers, et cetera. Our first clients were from those industries.
But five or six years later, every industry in Canada is well-represented. White-collar companies, blue-collar companies — manufacturing, distribution, grocery chains — all of them are clients of ours. That’s because the benefits we provide to these employers really transcend industry lines. Every employer wants to be a good employer and support the health of their employees.
Do you employ medical professionals directly? Or do your professionals do other things and Dialogue is something they do on the side?
That’s a really important differentiator between different players in this market. We decided to employ health care workers on a full-time basis as much as we can. We have 12 professionals on our platform, and most are full-time employees — whether they’re care co-ordinators, nurses, mental health specialists, or something else.
The only type of provider on our platform who is not a full-time employee are our physicians. That’s just because physicians in Canada are generally independent contractors. We don’t operate an Uber model where they can sign on any time they want and pick up a patient. We really believe in having a very stable and recurring provider base. We believe it gives a better quality of care.
From a continuity of care perspective, it makes a big difference. If you were to consult three times with Dialogue over the span of six weeks — we can ensure you’re seeing the same provider who knows your story.
A lot of medical professionals are leaving the mainstream health care system. They’re simply burned out. Given that Dialogue is trying to employ full-time health care professionals — have you had trouble?
Another hypothesis we were wrong about in the beginning is that hiring health care professionals would have been one of the biggest challenges of running this business. After looking back over the last six years it has not been one of the main challenges. It’s amazing to see how people are drawn to our model. People like the flexibility of Dialogue, of working on their own conditions at the time and place of their choosing.
Now, health care professionals can work after they’ve put their kids to bed at night. They can work at their cottage. They can work on weekends. By allowing this very high degree of flexibility, we believe we’re increasing the supply of available physician hours in the system. We’re a complement to the health care system, not in competition with it. That’s really important to us. We want to be a good partner to the health care system.
Was there a change in the types of mental health cases Dialogue staff saw after the pandemic, versus before?
Currently, 44 per cent of all our physician’s time is spent on mental health issues. They represent 30 per cent of overall consultations. The difference in the number of cases we’re seeing now is an order of magnitude higher than before the pandemic. I don’t think we’ve seen a big change in the types of mental health issues we see, but the overall volume of cases just exploded.
What about the wellness side of Dialogue’s business? How did that change before versus after the pandemic?
Actually, we did not have a wellness product before the pandemic began. During the pandemic, everybody was trying to get healthier and move more. One of the challenges of remote work is that people have decreased the amount of walking they’re doing every week. We wanted to make a philosophical shift in the mindset of the company. Today, you call Dialogue when you’re sick — we thought it would be nice if we prevented that.
We analyzed 150 different wellness companies around the world, and we found one that we really liked in the U.K. called Tictrac. We acquired this company and integrated it into our platform. Now, on the very same application, you can watch a yoga video and you can speak to a physician about an issue.
That’s been really helpful. 80 per cent of the members using our wellness program are achieving 150 minutes of activity per week, which is what the World Health Organization recommends. The sedentary segment of that population saw a 75 per cent increase in their daily activity. We’ve been really encouraged by that.
The global recession we’ve been talking about for a year now is creeping up on us. Are you worried Dialogue’s clients are going to cut your services to save money?
It’s a question we think about every day. We can’t predict the future. But what we do know, for example, is that at the beginning of the pandemic, a lot of companies were struggling. Some of our top clients were facing bankruptcy challenges. What we discovered was that virtual care and supporting the physical and mental health of their employees was the last thing they cut. We were really encouraged by that.
Again, I can’t predict what’s going to happen in the future, but we believe that employers are going to first cut more frivolous expenses as opposed to something like the health and wellness of their employees. We don’t think we’re going to be the first on the chopping block.
Some virtual mental health providers aren’t willing to help patients with complex issues like schizophrenia. How does Dialogue address cases that are complex and maybe not so easy to resolve virtually?
We handle everything that we feel is appropriate. At some point, our providers may feel like their patients need a different kind of help, and we can guide those patients to the right place. A really important distinction here is that we don’t pay our providers per case. In different environments, these complex cases are not welcome because — for argument’s sake — if a provider is making $50 per consultation, they would much rather take a 10-minute consultation than an hour-long consultation.
In our system, we don’t pay per case, we pay our providers per hour. So there’s really no incentive for our providers to choose easy cases, or to work fast. We want the patient to be treated. We want to help them. So we’ve developed our compensation system to prioritize spending all the time that is needed on the patient, and not going fast.
What are Dialogue’s parameters as to what issues it is or isn’t willing to treat? Can you give me any examples?
If someone calls Dialogue and says their left shoulder is hurting and they have chest pain — and it’s obvious they are having a stroke or heart attack — we will call 911 and stay on the line with the patient. That is not a virtual care-appropriate case. We always look for red flags and issues that would make it unsafe for us to discharge somebody.
Our patients, when they come to us, expect a very high level of safety and security. If we tell them to go to the ER, at least they know they’re not going to waste their time there.
Dialogue only works with organizations or insurance companies. It doesn’t work with individuals. Do you ever see that changing in the future?
No. We’ve really committed to a business model and a care model that is focused on employers and on insurance companies. From a health care regulations point of view, that is the safest way to stay within the confines of the Canada Health Care Act, and for us to be good partners to the health care system. That is not going to change. A patient never uses their credit card to pay for health care service, which we don’t think is part of the Canadian value system.
This interview has been edited for length and clarity.
Brennan Doherty is a former staff reporter for Star Calgary and the Star’s 24-hour radio room in Toronto. He is now a freelance contributor.