PCPs could counter virtual plans by increasing telehealth visits [PODCAST]

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“If PCPs want to meet the new competition from virtual primary care plans, I suggest that they gradually increase the percentage of their visits that they do through telehealth. Now that payers are reimbursing those visits at the same level as in-person visits, they have nothing to lose financially. Of course, there are some ancillary services that might be performed in their offices, such as lab tests, X-rays or bone density scans. But PCPs could order some of these when patients came in for visits, and they could also reduce their spending on staff and office space if they saw fewer patients in-house.

Such a move would represent a big change for PCPs. But they’ve already adopted telehealth to a much greater extent than ever before. A fuller embrace of the technology could help them survive financially, and it might even improve chronic disease care if virtual follow-ups were combined with regular office visits.”

Ken Terry is a journalist and author of Physician-Led Health Care Reform: A New Approach to Medicare for All.

He shares his story and discusses his KevinMD article, “PCPs could counter virtual plans by increasing telehealth visits.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we welcome back Ken Terry. He’s a journalist and the author of Physician-Led Healthcare Reform: A New Approach to Medicare for All. His most recent article on KevinMD is titled “PCPs could counter virtual plans by increasing telehealth visits.” Ken, welcome back to the show.

Ken Terry: Thanks for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, for those who didn’t listen to your first podcast, can you briefly share your story and journey to where you are today?

Ken Terry: I’ve been a writer my whole life, and for more than 25 years, I’ve been covering the health care space, first for Medical Economics and later for a variety of other publications. I’ve been a freelance writer since about 2008, and during the last dozen years, I’ve published two books on health care reform, and you’ve already mentioned the title of my latest one.

Kevin Pho: All right. So I’m certainly interested in hearing your perspectives in terms of what’s going to happen after the pandemic ends in terms of virtual health and telehealth. Let’s get into your KevinMD article, and it’s titled “PCPs could counter virtual plans by increasing telehealth visits.” Now, for those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Ken Terry: Yeah. This is actually an outgrowth of a piece that I wrote for Medscape Business of Medicine recently, and I interviewed a number of primary care physicians about their take on these new virtual primary care plans. They’re coming from major health insurers. The latest one is from UnitedHealthcare, which is partnered with a telehealth service called Amwell, and there are similar plans that came out earlier from Humana with Doctor On Demand and from Cigna with MDLive, both telehealth services. The basic idea is that they offer these plans, usually at a lower cost, to employers, and the priority is on having people do telehealth visits with doctors employed by these telehealth services.

Now, this is not new. Insurance companies have taken up this banner in the past, but mainly for urgent care visits. Now their idea is to try to get people who lack a primary care physician paired with one through telehealth, and that doctor would be able to handle a large number of not only their acute care complaints but also preventive and chronic care.

The thesis of my article is that primary care physicians, even though they’re now getting paid as much for telehealth visits as for in-person visits, still have something to be concerned about with these new virtual primary care plans. I mean, aside from the fact that it’s probably not the best way to provide primary care, at least in their opinion, there could also be some serious business competition if some of their own patients, particularly younger patients, decided to go to one of these virtual plans that then offer convenience, access, and very little cost share. So my article says that in order for primary care physicians to meet this new competition, they should consider gradually increasing the percentage of their visits that are conducted virtually, from the average 9 percent for adult primary care today to a higher percentage that, in a recent survey, many primary care doctors said was doable.

Kevin Pho: So I want to clarify some details about these virtual primary care plans. If an employer offers these plans to a patient, for instance, and a patient sees a virtual primary care clinician, is that the only clinician that they’ll see for primary care purposes? Do they have an option of seeing an in-person physician for things that can’t be handled virtually?

Ken Terry: Yeah, I’m sure that the health plan wouldn’t prevent people from seeing another primary care doctor, and you could probably have some sort of combination of those two things. But patients aren’t necessarily going to do that. Some patients may say, “Fine, I have a virtual doctor. That’s good enough for me.” And then, if they did need to be seen in person, there would be nobody who they could see unless they were referred to urgent care or an ER, or perhaps to a specialist. That was one of the things that some primary care doctors pointed out to me was a defect of this approach.

Kevin Pho: Tell me specifically, for those who aren’t versed in how primary care is reimbursed, what is the exact threat to current primary care doctors if more and more patients utilize these virtual plans?

Ken Terry: Well, essentially, they would have fewer patients. Now, of course, that might not be a big problem in some areas where there’s a primary care shortage, but that’s not the case everywhere in the country. I think that they would also feel that they were competing with people who patients were only seeing online, whereas they know that they could provide better service through a combination of telehealth and in-person visits.

Kevin Pho: Now, to give you an idea of context in terms of the penetration of these plans, you mentioned a couple of insurance plans offering these virtual plans, but how common actually are they as we speak now? I think we’re speaking in the middle of March now.

Ken Terry: OK. Well, I mean, besides the three I mentioned, Harvard Pilgrim is also doing this with Doctor On Demand. Some of the telehealth services say that they have deals with other insurance companies. I don’t think any study has been done yet to see how common they are.

There’s one other thing, too, which is that the telehealth service named Teladoc recently acquired an online chronic disease care company named Livongo, and they’re starting to offer a wide range of preventive and chronic care services online. Some of the retail clinics in major drugstore chains are also beginning to expand into chronic care from the minor acute care that had been offered by nurse practitioners. So this thing is definitely expanding in a number of different directions. Virtual primary care plans are only part of the overall picture.

Kevin Pho: Now, you mentioned one way to address this potential threat to current primary doctors is simply to increase their own telehealth and virtual visits. How easy is it for them to do that? And currently, most plans pay for virtual visits, but there’s no guarantee of that continuing after the pandemic finishes. How do you envision that to play out?

Ken Terry: Those are really two questions. In terms of whether or not health plans and Medicare will continue paying for telemedicine at the same rate as in-person visits after the crisis has passed, there’s really no guarantee, and I’d say a lot of doctors are skeptical. But there is a serious movement afoot in Congress to pass a law extending the wide-ranging coverage of telehealth in Medicare after the pandemic, and the private insurers often follow Medicare. That’s one thing. In addition, to me it’s clear that if the private insurers see that they can save some money somehow with these virtual primary care plans, then the chances of them continuing to pay doctors in their primary care networks the same amount going forward are pretty good. So I’m optimistic about that, which is a good thing for doctors.

In terms of how they expand, already a lot of practices have 15 to 20 percent virtual visits. Some of that is because we’re not out of the pandemic yet, but I think that they’ve gotten used to doing that. Their doctors are more trained in it, and they feel more comfortable doing virtual business than they did before. If you have the technology to do it, the expansion is not a problem, although you may want to introduce some more features, like a virtual waiting room, or however you’d like to do it. There are a lot of options.

Kevin Pho: So from your research and talking to other primary care doctors for your article, what’s the ideal proportion of virtual or televisits that current primary care physicians should be shooting for to ward off the threat from these virtual plans?

Ken Terry: All right, well, I’ll give you a couple of reference points. In a recent survey by the Urban Institute and Robert Wood Johnson Foundation, the physicians said that between 20 percent and 70 percent of primary care could be done virtually. One experienced internist I spoke to said that he thought 40 to 50 percent could be done, although he said, in his opinion, it wouldn’t be done as well as it would be if patients came into the office. So I don’t really have a recommended percentage, but if the average is now 9 percent, I’d say there still could be room to increase that. Perhaps for some practices, it might be 15 or 20 percent. For some practices, it could be 30, whatever you feel comfortable with.

But as Dr. Peter Basch, who is an advisor to the American College of Physicians, told me, in terms of caring for chronic conditions, you want to have some good balance between seeing people for follow-ups through telehealth and having to come in periodically to make sure that they’re being properly taken care of. To me, that makes a lot of sense.

Kevin Pho: We’re talking to Ken Terry. He’s a journalist, and he’s the author of the book Physician-Led Healthcare Reform: A New Approach to Medicare for All, and he most recently wrote the KevinMD article “PCPs could counter virtual plans by increasing telehealth visits.” Ken, you’ve done a lot of research, clearly, in the space. So what are your predictions for the next six or 12 months as it relates to the penetration of these virtual plans, and just future trends when it comes to telehealth in primary care in general?

Ken Terry: Yeah, I think that these plans will continue to grow as they sell them to more and more employers. UnitedHealthcare is starting off with 11 states, and they plan to go to more states next year. So I don’t think it’s going to be like a sudden jump, where suddenly everybody is joining virtual primary care plans, but I do see over the next few years that it could become a considerable portion of the population. So that’s something that I think the primary care physician should pay attention to.

As for what will happen after the pandemic, as I said, the crisis has accelerated the use of not only telemedicine but all types of health IT that was still fairly at a low simmer before the pandemic. A good example of that is hospital at home, which was pretty much in the experimental stages, or it had already been shown to be as safe and effective for certain conditions as inpatient care, but very few health systems had been experimenting with it. Then, during the pandemic, a number of leading health systems began trying it out in order to take some of the burden off of their inpatient wards as more and more COVID patients came in. There was one health system, Atrium Health, down in the Southeast, that took some of those COVID patients away and gave them to the hospital-at-home program. There are other systems that have experimented with just taking other kinds of patients and putting them in hospital at home.

Unlike the old version of this technology, which involved having doctors and nurses visit the patient at home and check on their systems, now it can be done via telehealth, and it can be done through remote monitoring systems that feed into the hospital, where hospitals can be seeing what’s going on with the patient. The other thing that is happening is that there seems to be a transition from hospital at home into post-acute care without the patient leaving their home, so they’re not going to be going to a rehab facility necessarily after they’ve had a hospital stay.

So these things initially are more important to hospital-based physicians, who will continue to be caring for these patients, assuming that this technology expands its reach, which I believe, no other reason than it’s less expensive than caring for patients within a hospital. But in addition to that, I think that office-based physicians will be starting to see that they’re going to be called upon to do more of the work, the continuity of care and care coordination work involved with these patients who are recovering at home, because they won’t be in an institution anymore. Of course, that remains to be seen, but it’s certainly something to be considered.

Overall, I think we’re going to be seeing an increase in the amount of remote monitoring done at home, and office-based doctors looking at carefully curated data from those monitoring devices to ensure that they’re staying in touch with patients, particularly those who have chronic conditions, over time. I think this will be very valuable, but it also is a whole new way of caring for patients. You’re going to have to look at some of that monitoring data before you consult with them, either virtually or in the office. For example, there may be a new standard of care involved in making sure that you’re on top of changing vital signs. You’ll be responsible, perhaps, for ensuring that somebody looks in on a patient or the patient goes to the emergency room. There are going to be a lot of changes in medicine that I think are going to grow out of these technologies, and we’ve only begun to see the beginning of them.

Kevin Pho: And my final question, Ken, what’s your take-home message that you want to leave with the KevinMD audience?

Ken Terry: Just as physicians have always been expected to keep up with changes in medicine, new studies, new ways of treating patients, they’re also increasingly going to be called upon to keep up with changes in information technology, as the modes of diagnosing and treating patients change. So that’s something that they should welcome and embrace rather than fear, because I think that it will lead to better care delivery methods and better outcomes for patients.

Kevin Pho: Well, thanks again for coming back on the show. Thanks again for your time and insight.

Ken Terry: Well, you’re very welcome on all counts.

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