How Should Healthcare be Delivered?

By Matt Fisher, General Counsel, Carium
Twitter: @matt_r_fisher
Twitter: @cariumcares
Host of Healthcare de Jure#HCdeJure

How should patients be able to access healthcare services? The question is becoming more nuanced given the growth and expansion of telehealth. Prior to COVID-19 driving the implementation of telehealth, access to healthcare services had largely been the same for years. Access focused on patients going to a physician’s office, a hospital, or other facility. The common thread was physically going somewhere.

With telehealth now an increased presence within healthcare, as should be recognized, it enables access to care by patients from almost any location. The ability to access some type of care through a variety of devices arguably removes some barriers to access along with presumably faster access.

Health Insurance Promotion of Telehealth

The trend of telehealth seems to be catching on especially with the health insurance market. Plans are considering or rolling out virtual first plans for beneficiaries in rising numbers. The virtual first plans seek to have telehealth be the initial means of accessing care at all points. Enrollees in the virtual first plans select a primary physician who provides services online, which emphasizes the virtual component. The selection of an online physician replaces the traditional model of finding a primary care physician near the enrollee. The only limitation, if it can be described as such, is finding a physician who has sufficient state licenses to see patients in a variety of locations.

Once the online physician is selected, the enrollee will initiate services virtually in all instances. The remote evaluation may then seek to resolve the issue being presented or referred to an appropriate in-person clinician. Some insurers will provide kits to enrollees to help enhance the remote assessment capabilities of the physicians, which kits can include blood pressure cuffs, thermometers, or other vetted devices. The telehealth component, therefore, is almost a gating visit to assess where care should be provided. A question arises whether that just adds another visit to the process that an enrollee must follow that could increase time spent and potentially add to out of pocket costs.

Aside from promoting convenience and access, virtual first plans may also try to focus on reduced premiums. The cost to enrollees may be lower because there is less need to support in person practices. However, the push to virtual could also be reinforced with higher copay or deductible obligations, meaning more out of pock costs to the enrollee, when accessing in person care. The economic pressure could best be considered an indirect means of driving care virtually. The economics of a virtual first plan may not be readily apparent when first viewing the details, especially when considering that it can often be hard even for well-versed individuals to make heads or tails of what a plan does.

Quality of Care Concerns

As would be expected, pushing virtual first care raises questions as to the quality of care. Not all healthcare issues can (or should) be addressed remotely. In person care is an absolute necessity. However, if care must first be obtained remotely, will there be pressure, whether direct or indirect, for the remote physicians or clinicians to keep care virtual and minimize utilization of in person services. That tension could end up being quite real since the health insurance plan in many instances retains the telehealth firms to staff the virtual care component. If the company paying the price of the virtual care has a vested interest in encouraging care in that direction, then it could reasonably be expected to increase in that direction.

Given the newness of telehealth playing such a prominent role in healthcare, the scope of services that are suited to a virtual first approach is still being worked out. While more services can be provided virtually than initially expected, it is also clear that many things need the in-person element.

Additionally, the ability to detect issues without being able to take advantage of a physical presence together is being worked out. It will take time to develop evidence and assess the data of how virtual care impacts outcomes or potential delays in diagnosis. There is honestly just not enough information on those fronts to effectively know the answer.

Beyond the increased diagnostic capabilities of being in person, virtual first can also put more of a burden on the enrollee. If the enrollee receives certain devices from the plan with the aim of helping the remote clinician make an assessment, then the enrollee must become versed in how to utilize the devices. If the devices are only taken out during a visit, there could be time spent on education and skepticism about the accuracy of what is being done. The repetition of use found among clinical staff is important in obtaining clinically useful information. How many individuals want to be responsible for those actions? That is something that will need to be determined, especially as individuals many not be aware of the requirement when signing up for a virtual first plan.

Establishing the Best Continuum

Promoting virtual first plans may be an instance of entrenching a distinction between traditional, in person healthcare and telehealth. The distinction is a bit of a misnomer though. Regardless of where healthcare services are provided, it is still healthcare. If the distinction between in person and telehealth is removed, meaning that all services regardless of location or modality should be viewed as healthcare.

If all services, whether in person or virtual, are viewed as healthcare, then it becomes a bit more possible to establish an appropriate continuum of care. In this instance, continuum of care means determining when it is appropriate to access care in different means and how to ensure a smooth flow of patients to the right interaction. Establishing that continuum certainly requires real world evidence and not just speculation or guessing as to what to do. That is where the benefit of the pandemic driven experiences becomes more important.

Instead of driving to an extreme of saying everything should be virtual first, time should be taken to establish a good flow. A good flow will recognize the benefits, efficiencies, and opportunities from each modality of delivering care. Avoiding a knee jerk move from one extreme to the other can also improve the ability of minimizing more extreme reactions down the road. Using best efforts to chart an even keeled path would prove helpful to everyone whether it be enrollees (patients), clinicians, insurers, and others.

What will it take to create the continuum though? First, evidence of outcomes and limitations of care in all forms is needed. The evidence should largely be available for in person care, but now it is essential to get the same base for virtual care. That evidence is starting to come in and will keep increasing along with ongoing use. However, patience will be necessary because the evidence will take time to be refined.

Once evidence is obtained, involving all impacted parties in the discussion of how to establish the continuum will be important. Clinicians can bring professional expertise by showing their understanding of diagnostic capabilities and opportunities. Enrollees must be at the table too as their views of access, convenience, and real world impact should inform what is done to avoid entrenching options that will not be used or create frustration. Insurers also have a role from the likely ability to see broader sets of data and longitudinal impacts. The suggestion of what each can bring to the table is not exhaustive, but meant to show that no one can be excluded if a useful and valid continuum will be created.

Where to Now?

The immediate future will likely be choppy as everyone gets used to new workflows and expectations. As suggested though, moving too far in either direction will not create benefits, only frustrations by some or all involved. The most productive immediate change will be assessing available data, starting the development of a justified continuum, and working collaboratively. The current moment is one full of opportunity that should not be squandered by rushing in any direction without due consideration.

This article was originally published on The Pulse blog and is republished here with permission.