Virtual Care Moves Toward the Frontline of Provider-Patient Relationships

Virtual care, once on the fringes for providers and patients alike, is becoming more of a reality, and is increasingly used for low-acuity needs.

Kaiser Permanente and UnitedHealthcare are among the big names using such settings for primary care appointments and quick patient consultations.

Backers of virtual care say it holds potential to improve quality, cut costs and improve accessibility to specialty services.

“Virtual care has great promise,” said David Harlow, principal at a healthcare law and consulting company and author of HealthBlawg. Still, he warned against over-reliance.​

“It is not a panacea. We need a different system-level mindset to achieve long-term improvements in outcome and reductions in cost,” Harlow told Healthcare Dive.

And it’s not like an episode of “The Jetsons” either. It doesn’t replace in-person healthcare. Instead, virtual care integrates video, phone, email and messaging into a person’s healthcare.

Providers are selling the idea as a means of convenience and efficiency:  Patients might not have to take off work, find a babysitter and drive to an appointment. Instead, virtual care lets patients decide — when clinically appropriate — whether an in-person visit is necessary.

Patients seem to like the idea even if they haven’t tried it yet.

A recent Accenture report said about 70% of consumers are interested in virtual healthcare. Only 20% have actually received such care. “Virtual care offers what consumers really want: a variety of health and care service available to any location at any time, crossing the spectrum from health and wellness to episodic injury and illness to ongoing condition management,” the report said.

The shift may be sped up amid the shift from volume to value in payment models. Virtual care can become part of value-based care if there isn’t a worry for providers about not getting paid for a virtual visit, the case now in a fee-for-service payment system.

More than half of Kaiser Permanente’s patient visits are virtual care

Some health systems are already putting virtual care at the forefront. Kaiser has grown virtual care to slightly more than half of their more than 100 million patient encounters.

One benefit KP has over other health systems is that it’s integrated and offers physicians capitation. Providers are paid a monthly member fee to care for the whole patient. That helps Kaiser by avoiding potential payer/provider issues involving insurers paying physicians for volume. About 95% of its 11.7 million members are covered through a capitated payment system.

That makes engaging physicians less of a challenge than it might be for providers reimbursed by volume.

KP offers non-emergency consultations via video behind a VPN firewall, secure email, messaging and telephone. Patients can have virtual visits for non-emergency urgent care, and routine and follow-up care with primary care and specialists, including in the areas of dermatology, mental health and podiatry.

Pat Conolly, executive vice president of information technology and chief information officer at The Permanente Federation, told Healthcare Dive that the type of virtual care, whether video or phone, that is most popular varies by area.

In Hawaii, where a body of water may separate patients from doctors on another island, telephone appointments are especially popular.SIGN UP

Video doesn’t just help physicians; patients like to be able to see their doctor, Conolly said. “That adds to the experience rather than just being on the phone,” he said. Rather than replacing in-person services, virtual care creates more touch-points between physicians and patients, he said.

In a New England Journal of Medicine commentary in 2017, Robert Pearl, then with The Permanente Medical Group, estimated 80% of calls to KP’s nurse advice center can be resolved by phone. Of the remaining 20%, video can handle about 60% of those patients, which avoids emergency room visits.

Pearl said telehealth costs are similar to traditional care. He added there are savings associated with virtual care, including on capital, transportation, parking and time away from work.

Payers see benefits of virtual care

Payers are also showing interest. UnitedHealthcare provides a network of remote doctors through its Virtual Visits program. Physicians are with either Amwell or Doctor on Demand and offer 24/7 visits via mobile device or computer without an appointment.

UnitedHealthcare promotes the cost savings and time savings associated with using a remote physician. The payer said a virtual care visit compared to an in-person doctor visit saves the patient an average of 106 minutes. Most virtual visits in the program take 10-15 minutes. Plus, the cost is between $50 and $75 rather than a potentially hefty emergency room bill,according to UnitedHealthcare.

The insurer suggests to patients that virtual visits are the right option when a primary care doctor isn’t available or instead of visiting an emergency room for a non-emergency. The payer also tells patients the Virtual Visits program is not for anything that might need an exam or test, chronic conditions on injuries like broken bones.

In a similar agreement, Aetna works with Teledoc to offer virtual care. The program has more than 3,600 licensed healthcare professionals. Aetna said Teledoc has provided more than 2 million virtual visits for non-emergency health issues. Visits cost members $45. Caregivers share consult summaries with primary care physicians and other providers.  Aetna said the virtual program resolved 92% of health issues presented.

Could virtual care become the primary way patients receive care?

A recent perspective published in the NEJM re-imagined a system where patients would consult with their provider first and make in-person physician visits a last resort.

“For patients with the most healthcare needs — the 5% that account for 50% of costs — an ‘in-person as last resort’ system should aim to bring as much of the necessary care and social support into the patient’s home as possible,” authors Sean Duffy and Thomas H. Lee wrote.

“Ultimately, we believe such a model will result in a level of trust that furthers collaborative, honest, supportive care,” the wrote. “Organizations that adopt this mindset may gain a competitive advantage since the required investments should lead to operational efficiencies and increased patient loyalty. Viewing in-person physician visits as a last resort sounds radical, but it just represents a deepened commitment to patient-centered care.”

Future of virtual care

Conolly expects video consultations will increase in the coming years as more providers invest in the technology.

One specialty where Conolly expects virtual care to expand is pediatrics, especially outside of business hours. A virtual visit could mean parents won’t have to take off work for a routine pediatric visit.

Some people, however, will want to know they can see a doctor in person, and that will still be the case. “There are people who need to be reassured. They need to have contact with a person to be reassured. I don’t see that totally going away,” he said.

In the long run, Harlow said it could also mean less need for brick-and-mortar in healthcare. The industry has already lost inpatient hospital beds and healthcare continues to move more care to the least costly, appropriate setting possible.

Though the future is bright for virtual care, there are still barriers and concerns. For example, providers will need to make sure virtual care doesn’t affect the personal connection between patients and healthcare professionals. That would be negative for both of them.

Harlow said there are laws and regulations in place that may make it hard for healthcare systems to use virtual care across state lines because they need licenses for multiple states. About 30 states have laws requiring payers to pay for telemedicine on par with payments for in-person care. That helps push providers to invest in virtual care. However, the federal government generally requires that a patient is in a healthcare facility to access telemedicine, Harlow said.

Plus, there are the infrastructure costs associated with virtual care for a smaller practice. Harlow said infrastructure can be expensive at the outset, but he believes the move to a value-based system will push more healthcare companies to expand virtual care.

“If a payer offers a bundled payment for care of a certain patient and will not pay for re-admissions, it is in the interest of the provider organization to provide the best care to the patient in the most cost-effective manner possible,” Harlow said.