Faced with an acute infection, a mental health crisis, or the need for ongoing chronic care, most people sought in-person appointments in physical offices prior to March 2020. The pandemic changed all of that.
Patients embraced virtual care, such as video physician visits, and digital care, such as app-assisted self-care. Providers who previously didn’t offer visits outside of the office moved to virtual platforms. Investors offered digital and virtual care providers new funding and high valuations.
As the pandemic subsides, care delivered without a physical visit is positioned to become an essential and long-lasting feature of health care. The combination of in-person, virtual and digital options creates valuable choices that can bring access to care to those with unmet needs and decrease pressure on the existing system. But balancing the three modalities requires careful planning. It’s expected that leading employers will support each option with navigation and insist on accountability and coordination to fully meet the current and future needs of their members.
Optimizing Your Health Care Portfolio
1. Offer Plan Members Many Different On Ramps to Access Care
Different health plan members have different needs and preferences. A member with an unexpected cancer diagnosis has vastly different needs than someone with a sore shoulder. Some need care after business hours, and others may be traveling far from their usual physicians. Still others may not have any ongoing physician relationships at all.
Employers and health plans have not been successful in requiring patients to use a single front door to access health care because consumers want choice when it’s available. Digital and virtual care offer new on ramps to members so they can obtain care that’s most appropriate and convenient for them in their moment of need. In addition, many office-based providers are now available for virtual visits, which increases patient choice and can promote continuity of care.
2. Provide Members with Navigation Assistance
The new health care freeway will require the equivalent of signage and GPS to help patients navigate to the care that they need. Patients need to know what concerns are appropriate for virtual and digital care, and how to be sure that all their providers coordinate care. Like the freeway itself, navigation support is best when it is accessible to all members and suits their needs and preferences. Plan design, incentives and multi-modal communications help the member to steer toward the best care sources to meet their needs. Quality, cost transparency and triage support tools can help a member figure out where to start. Many health plan members will also benefit from interactive navigation support via apps, websites, portals and coaches.
Research has shown lower adoption of telehealth in less advantaged communities, so employer programs should seek to promote navigation tools for virtual and digital care options to all members. When these tools work best, they provide a means to escalate to more intensive levels of care when necessary, de-escalate when lower levels of care are more appropriate, and steer to the best next step in care.
3. Insist on Data Sharing and Coordination Among Providers
Digital and virtual care could exacerbate the fragmentation of medical care that already plagues the United States. Primary care physicians already report that it’s difficult to get information from specialists who are part of different medical systems, and expert medical opinion services have developed complex operations to collect medical records. The addition of new vendors adds additional challenges.
Recent government regulations requiring patient access to their medical records will help. Employers can include requirements for data sharing and coordination in their requests for proposals from digital and virtual care providers. This can be codified in contractual agreements and incorporated into evaluations and performance guarantees. Employers as purchasers can be certain that their members receive integrated care across all available modalities.
4. Hold Providers Accountable for Quality Outcomes
Digital and virtual providers, just like in-person providers, should be held accountable for quality, patient experience and outcomes. Employers can require timely aggregate reporting from every vendor, which should include care delivered and handoffs or interactions with other providers or vendors. Virtual and digital care can be reported to the carriers and can be correlated in a data warehouse and incorporated in evaluations.
Discerning employers will evaluate the quality of their digital and virtual vendors based on structure, process and outcomes. Structure includes having in place all promised elements, including robust technical infrastructure and well-implemented user interface. Process usually covers utilization, from sign-up, to first use, to persistence for longitudinal programs. Process measures can also incorporate compliance with evidence-based guidelines, such as avoiding antibiotic overuse and screening for depression.
Outcome measures can include member experience, and many contracts for digital and virtual care can include performance guarantees or warranties so that the vendors will be highly focused on improving experience and quality of care for the employer’s population. Evaluation can also include intermediate outcomes (like hemoglobin A1C control in a diabetes program), which are well-correlated with eventual outcome, but measurable in the near term. Some employers might wish to include outcomes like decreased long-term complications from chronic disease. Unfortunately, these outcomes don’t fit well into contractual guarantees as they often happen years after care is delivered and are highly influenced by risks outside of health care delivery.
5. Focus on Total Cost of Care, Rather Than Unit Cost
Employers want to offer members access to a broad array of care modalities. They also want to fully understand the effect on total medical expenditures and optimize the portfolio of options to prevent expenditures that don’t add value. This means understanding impact on both unit cost and utilization across all care modalities.
Employers should be sure that all vendors are billing appropriately and that they understand whether vendors obtain revenue from other sources, such as payments from subcontractors or sale of aggregated data. Vendors should be clear about both population payments, which are usually expressed as “per employee per month,” and fee for service payments by the employer or the member for direct care provision. Vendors also should disclose whether any portion of fee-for-service payment is retained and not passed on to providers.
Employers can ascertain how virtual or digital care will affect utilization of in-person care. The cost per visit is only one component of how virtual and digital care will impact total cost. Will these new modalities substitute for in-person care, or will they be incremental? Lower unit cost for digital or virtual care will only lower total costs if they prevent the need for some in-person care or prevent significant, high-cost events. Consider ancillary costs, too. Digital and virtual care can diminish total costs because they generate fewer laboratory and imaging tests.
During the pandemic, some employer plans eliminated all member cost-sharing for virtual care to ease access to care and to enable people to stay safely at home. As the pandemic recedes, employers will seek to find the right balance. Benefit designs that include modest cost-sharing in proportion to member benefit encourage effective use of virtual and digital care — by the member and the clinician.
6. Support a Stable Regulatory Framework to Enable All Modalities of Care
Prior to the pandemic, Medicare and some states erected serious barriers to virtual care, including requiring initial visits to be in-person and limiting ability to practice across state lines. In response to the pandemic, the federal government alone altered dozens of regulations to ease the transition to remote care, which helped expand access and diminish barriers to entry. This was especially helpful to patients in rural settings; 70% of the counties in the United States have no pediatric psychiatrist. A uniform and consistent regulatory framework can continue to nurture the continued growth of digital and virtual solutions, while creating appropriate standards to coordinate care and protect patient health.
Advocacy may not be a fit for most companies. Nonetheless, there may be opportunities to support regulations that make sense for companies, their employees, families and communities. Indeed, a recent Kaiser Family Foundation/PBGH poll indicated that 85% of executives believe a larger government role is needed in health care.
A New World of Health Care
The pandemic has changed health care delivery dramatically. Just as some employees adjusted to working from home, patients became comfortable seeing their providers on video and enjoyed communicating via chat and text message. Providers discovered they could better scale their efforts and improve their margins. Regulators showed flexibility by easing access to care without a physical visit. Many employers found that offering diverse modalities improved member access and satisfaction.
As we begin the transition to post-pandemic ways of working, health care plans and options must also evolve. Employers can make real strides in improving employee well-being by continuing to offer a diverse portfolio of health care delivery options post-pandemic.
Employees and their families can benefit from a multitude of cost-effective, high-quality on ramps and navigation to help them find appropriate and needed medical care, with clear expectations of what to expect from digital, virtual and in-person providers.
