Virtual Care’s Niche Within the Current American Healthcare Ecosystem

Virtual care offers a technological alternative to deliver healthcare at the same or higher quality, higher patient satisfaction possibly at a lower cost compared to face-to-face encounters. Unfortunately, research publications by mobile health start-up companies have not demonstrated effectiveness consistently across patient populations with some disease burden. Considering the most appropriate combinations of virtual care and existing face-to-face care allows payers to develop the most relevant financial models to help patients receive the most cost-effective care in ways that engage other members of the healthcare community. As technology evolves in the provider’s office and through virtual care, the optimal configuration of these different methods of delivering healthcare services may also change.

There are some research findings to support telemedicine for specific care domains. Shigekawa et al. identified mental health, dermatology and rehabilitation as three specialties when delivered through virtual methods to be equivalent or superior to in-person encounters. Tucker et al. found patients who monitored their own blood pressure with additional co-interventions like systematic medication titration lowered blood pressure just over six millimeters of mercury.

Some clinicians have expressed concerns that virtual care could increase the diagnostic error rate. Diagnostic error accounts for nearly a one-third of all paid malpractice claims. Schoenfeld et al. analyzed nearly 600 telemedicine encounters with standardized patients for six common acute conditions (ankle pain, streptococcal pharyngitis, viral pharyngitis, acute rhinosinusitis, low back pain, and recurrent female urinary tract infection). Over three-quarters of the encounters ended with the correct diagnosis. Siew et al. found similar results with clinicians using telemedicine to assess febrile children. O’Connor et al. demonstrated the equivalence between teledermatology and in-person dermatology for diagnosis in a pediatric practice. With some specialized maneuvers, telemedicine can effectively diagnose diabetic retinopathy.

Once a diagnosis has been made, virtual care may be well-suited to manage chronic conditions in the ambulatory setting with less variation and lower costs than monitoring care across thousands of provider practices. Clinical laboratories and innovative groups are collecting samples from patients in their homes, obviating the need for trips to a lab for blood or urine testing. In addition, virtual care for chronic conditions could increase a provider’s reach among patients struggling to make a face-to-face appointment. Finally, virtual care staffed by nurses, pharmacists or health advocates may be able to deliver protocol-driven therapy that only uses independent ordering providers for protocol deviations. From the ambulatory provider’s point-of-view, these monitoring visits may prevent higher acuity visits or patients with new complaints that may benefit from a face-to-face evaluation.

Since most patients have a relationship with their provider’s office, it would be imperative to have these virtual care groups who manage chronic conditions to connect regularly with the patient’s primary care provider. This coordination would reduce miscommunications between the patient and their primary care provider when managing other conditions. The communications could also reduce any perceived threats from the provider’s office about patients being shifted out of the practice. This co-management approach echoes how patients may be managed by one (or more) consultant(s) along with a primary care provider today in serial face-to-face encounters.

For those clinical entities that can organize additional services like physical therapy, home nursing and home pharmaceutical delivery, virtual care could replace observation encounters, low-acuity hospital encounters and skilled nursing facility visits for eligible patients. The challenges for a physician-based entity to consider delivering these offerings include the perceived higher liability of managing these patients at home, the expectations patients and family members might have around receiving a “hospital-like” or “skilled nursing facility-like” experience at home and having a relationship with a stand-alone urgent care facility (for patients qualifying for observation and inpatient status) or a hospital (for patients qualifying for a skilled nursing facility) who could direct patients to these entities instead.

I would suggest the following sequence of virtual care delivery for physician-owned groups (with a suggested payment model): chronic care monitoring after face-to-face diagnosis (per-member per-month); second opinions for patients who have all of their diagnostic information electronically (per-encounter); urgent care for low-acuity, common acute conditions (per-encounter); alternative for skilled nursing facilities (bundled payment); and, finally, alternative for hospitals for low-acuity inpatient admissions (DRG-like bundled payment). Beyond the challenges to deploy technologies to support these models, interested organizations will have to accept some inefficiencies as patients adjust to the new models. But for those entities that are willing to learn about integrating these approaches into how they currently deliver care will be better-positioned to handle the market’s increasing expectation for healthcare professionals to manage patient populations in a value-based paradigm.