Primary care physicians already have a lot of competition from retail clinics, urgent care clinics and telehealth services that cater to consumers. Now they’re facing a new threat from the “virtual primary care plans” that insurance companies have launched recently. These are health plans that prioritize virtual visits with doctors hired by telehealth services over in-person visits to primary care doctors. For years, some insurance companies have been offering online urgent care to people who might not have a primary care doctor. In contrast, the new virtual primary care plans also cover preventive and chronic disease care, as well as diagnostic services. Instead of just having a one-off telehealth visit for a minor acute problem with a physician you’ve never met, you can now form an ongoing relationship with a particular telehealth physician or even a “care team.” Some of these plans — which are coupled with traditional coverage of specialists, hospital and post-acute-care — cost employers less than plans based on visits to brick-and-mortar offices. They also cost patients less. In Humana’s virtual primary care plan, for instance, there are no copays for telehealth visits and $5 copays for common lab tests and prescriptions. United Healthcare recently made news when it launched its virtual primary care “service” in 11 states, with plans to expand to more states next year. AmWell, a telehealth service, is providing the doctors for United’s new plan. Similarly, Humana has partnered with Doctor on Demand, and Cigna is working with MDLive on their virtual primary care plans. United also covers virtual preventive and chronic care services provided by the physicians in its local networks. And, like other insurers since the start of the pandemic, it’s reimbursing doctors the same for telehealth and in-person visits. So what’s not to like? Some patients might jump ship The new virtual care plans that use telehealth services will inevitably compete with office-based physicians. Sure, they’ll attract people who don’t have PCPs because of their convenience and low or no copays. But some established patients of primary care doctors might also switch to these plans for the same reasons if their employers offer them. From a clinical perspective, there are inherent drawbacks to a virtual primary care plan. To begin with, a telehealth physician usually doesn’t have a new patient’s records and has to build his or her history from scratch. Also, there are times when a physician “seeing” a patient online believes that he or she needs to come into the office, perhaps because the problem can’t be diagnosed without a physical exam. And fourth, while follow-ups can be done virtually, a physician needs to see a chronic disease patient in person at least once every few months. What happens if you have a telehealth physician who doesn’t live in your area and you need to be seen face to face? Well, based on what the health insurers have given out, you might be referred to a specialist. But as one internist recently told me, the PCP hired by a telehealth service won’t have any idea which specialists in your area are the best. Alternatively, the telehealth doctor can refer the patient to an urgent care center or an ER. But these are costly care settings, and the physicians there generally know little about a patient’s history — unless they’re frequent flyers. In summary, virtual primary care plans might not save money, might provide inferior care, and will almost certainly create more competition for office-based PCPs. Competitive business plan Prior to the pandemic, fairly few primary care doctors were involved in telehealth, partly because they were often paid less for virtual visits than for in-person visits. That has changed during the crisis, and 36 states now require payment parity. Meanwhile, Medicare has dramatically loosened its restrictions on telehealth coverage. While it’s unclear whether that will continue after the pandemic ends, Congress seems likely to codify the new Medicare policies. For primary care doctors, telehealth was a lifeline early in the pandemic, but the percentage of PCP visits that are virtual has sunk to 9 percent for adult primary care. That is still far more than the average before the pandemic, but it means that 90 percent of patient visits continue to be conducted in person, on average. This is far below physician estimates of how much of primary care could be performed virtually, which ranged from 20 percent to 70 percent in a recent survey of PCPs. While many doctors would still prefer to see patients in person whenever possible, this is not always necessary to provide good care. 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. Source
