By Jocelyn Keegan, Senior Consultant
Many payers, providers and pharmacies are banking on virtual visits in which patients receive remote diagnosis and treatment to improve quality care, reduce costs and increase patient access to medical care. These can be done through a variety of arrangements, including kiosks at pharmacies connected to some of the nation’s finest medical centers or video visits at home from specialists through use of computers or mobile phones.
Sometimes known as telehealth visits, virtual visits are not new. Whatever you call them, their use is accelerating beyond connecting to a limited number of patients in rural areas. Major payers, including Anthem, Aetna and UnitedHealth Group, pay for virtual visits for traditional medical care. Early adopters of virtual medicine, like Kaiser Permanente, are now seeing more patients remotely than in brick-and-mortar offices. In the public sector, the Department of Veterans Affairs (VA) is leading the way with one of the nation’s largest virtual visit programs, which served 700,000 veterans in 2016. Through VA Telehealth, veterans can virtually access some 50 clinical specialties, from dermatology to intensive care. Both public and private payers are looking to virtual visits to increase access to mental health services.
Drivers for virtual visits. There are many reasons why virtual visits have become so popular. They include:
• Costs of care. The average virtual visit costs around $40, in contrast to $125 for an in-person office visit. In addition, virtual visits are expected to reduce costs of care, hospitalizations and emergency room (ER) visits for chronic illnesses, especially diabetes. Diabetes is one of the most common chronic illnesses, with treatment costs significantly higher than other diseases. Moreover, government statistics show that complications from diabetes result in 7.1 million hospitalizations and 14.2 million emergency department visits each year. The vast majority are considered preventable.
• Scarcity of physicians. The doctor shortage is real. The United States could lack between 46,000 and 90,000 physicians by 2025. The biggest gap is for primary care doctors. There also is an inequitable geographic distribution of physicians (particularly specialists), with rural areas hit the hardest.
• Strategic adoption by pharmacies. Pharmacies are ramping up use of virtual visits as part of a strategic move to offer more direct patient care in clinics and pharmacies. For example, New York-Presbyterian (NYP) and Walgreens are teaming up to provide remote access to NYP physicians on Walgreens’ website and kiosks at certain Duane Reade drugstores in New York City. CVS similarly is exploring direct-to-consumer virtual visit opportunities. Virtual visits are perceived as a way to create competitive advantage as well as bring patients into stores.
• Physician payment penalties. Because many hospitalizations and ER visits are preventable, payers — particularly Medicare — are reducing reimbursement for readmissions. This is driving providers to adopt virtual visits to prevent readmissions and related payment penalties. In addition, the move toward value-based care also can negatively affect reimbursement if providers do not meet outcomes and other quality targets. Providers are responding, with over half investing in virtual visits to improve patient outcomes.
• Expanded access to care. The explosion in electronic technologies has created a wide availability of options for virtual visits. Now virtual visits can be done just about anywhere and anytime through kiosks, tablets, mobile devices and other applications. Virtual visits also can add expert capacity across health care systems and individual providers.
Moving forward with virtual visits. Despite the enthusiasm for virtual visits, a number of considerations must be addressed to ensure a smooth transition. For example:
• Payers. Payers must consider which services will be covered, where and under what circumstances, as well as what individual states allow. Will coverage include just basic diagnostic visits for limited needs, such as dermatology, or run the gamut, including follow-up care, maternity and mental health? Will coverage extend beyond physician visits to those provided by such other practitioners as physician assistants and registered dieticians? Payment structures will have to be revisited and often depend on individual states. Will special copays be instituted? The proposed bipartisan Medicare Telehealth Parity Act would significantly expand Medicare payment for virtual visits. If enacted, the bill would modernize how Medicare pays for telehealth care, which could affect how private payers provide benefits and reimbursement for virtual visits.
• Patients. The jury is out whether patients will understand virtual visits and use them. Certainly payers, providers and pharmacies are making substantial bets that they will. However, critics, including the Medicare Payment Advisory Commission, wonder if consumer enthusiasm will materialize at sustainable levels.
• Providers. Practices and integrated delivery networks will need to take stock of how to fully integrate virtual visits into their existing support services. What technology model will work best for their organization? Is integration with the electronic health record possible? Which patients, services and appointment types will work best, given locale and patient mix? Will current staff be used or will they be augmented with external resources? Issues such as reimbursement, cost, and clinical resistance also need resolution to increase provider adoption.
• Legal issues. There are still many legal barriers that must be resolved by the states, which regulate insurance and various aspects of medical practice. A very basic issue is what constitutes telehealth or virtual visits. The definition varies across states and will need to be updated to address changes in technology and medical practice. Another issue is malpractice coverage across state lines, which not all states and insurers allow. Then there are varying credentialing and privilege laws and regulations across the states. These are gradually changing in favor of licensure compacts, which allow licensure portability or reciprocity across state lines. About half the states have enacted or proposed such legislation for physicians and a handful have done so for nurses. A new proposed rule from the VA could help things along, given the size and scope of its system. This rule would allow doctors anywhere in the VA system to see patients regardless of location as well as remove licensing barriers. The Federation of State Medical Boards, representing the 70 state and territorial medical and osteopathic boards, is behind compact arrangements and has developed model language.
It is clear that virtual visits are rapidly becoming part of the new health care landscape. Point-of-Care Partners has done a deep dive on what that looks like, as well as opportunities and gaps. Let me know if you want to learn more. You can reach me at jocelyn.keegan@pocp.com.
