Health+Benefits Vital Signs the October 2021 issue

Virtual First

Q&A with Carrie Kincaid, VP, Individual Markets, Priority Health, and Paul Bartosic, VP, Connecticut Market, Point32Health (Harvard Pilgrim Health and Tufts Health Plan)
By Tammy Worth Posted on October 1, 2021
The pandemic dramatically hastened the uptake of virtual healthcare. Was that the motivation for these virtual-first plans?

Kincaid: The pandemic accelerated the use of virtual health, but we had started studying it back in 2019. In April 2019, one of every 1,000 visits was virtual. When the pandemic hit, one out of five was through telehealth.

Through our research, we found that about one third of people were not regularly interacting with a primary care doctor. This was happening because many people were having accessibility issues. In our market, there are two key pockets of people in this situation: some are early retirees who buy individual insurance products and then travel a lot. Because of this, they can’t touch base with brick-and-mortar primary care providers. The second group is hourly workers and those who have individual insurance working the day shift. They aren’t able to break away for an hour and a half to go to a doctor’s office. But we knew they did have scheduled lunch breaks where they could sit in their car for 15 minutes and take care of their healthcare needs virtually.

Bartosic: We were already anticipating large increases in telemedicine—we had been planning the product before the pandemic hit in 2020. The industry was ripe, and there was a lot of interest in virtual-first products. Then from February to April of 2020, the use of telehealth tools saw an increase of well over 1,000%, so it solidified for us that we were making the right decision to roll it out. We released SimplyVirtual in our Connecticut market on Jan. 1 with large employers with workforces of more than 51. Then we rolled out our Virtual Choice plans in Maine and New Hampshire. We were the first group health plan in New England to launch these kinds of products.

A New England Journal of Medicine article from April reported numbers from three different nonprofit virtual-first plans. According to the data, Harvard Pilgrim sold one group account out of every 60 employer groups that were given the option. In 2021, Priority Health enrolled 5,000 members in its telehealth PCP plan.

Kaiser Permanente’s Mid-Atlantic plan (offered in Washington, Maryland and Virginia) charged midsize and large employer groups between 15% and 20% less for its Virtual Forward plan than the cost of its traditional insurance options. Video health visits grew from about 50,000 in 2019 to nearly 800,000 in 2020, according to the data.

How does virtual-first work?

Bartosic: With our SimplyVirtual plan, when an employer chooses it, they pick Doctor On Demand as their primary care provider. It’s an HMO plan design, with the primary care doctor acting as a gatekeeper for the enrollee. Doctor On Demand is able to treat well over 95% of all primary care that members need. If they need to go into a brick-and-mortar facility for something like an X-ray or other procedure that is hands-on, their primary care physician then refers them to one of the providers throughout our New England network.

With Doctor On Demand, they can see whatever doctor is available when they need an appointment. If they want the same provider on a continual basis, they can do that as well. There may be some wait time to see a specific physician, but it’s usually pretty short.

Telehealth tends to be known as a model for urgent care and, increasingly, behavioral health. How does this work for people with chronic conditions or who need other kinds of care?

Kincaid: It does have a long history of urgent care, but in our research, what popped up were other things as well. We have an area here we call “up north,” where people have to travel a long way to get to a behavioral health provider because of lack of physicians. Then in the cities, there are a lot more doctors, but people tend to have long wait times. Telehealth can increase access for both of these groups.

With this product, you can make a match with a primary care doctor, and that’s your provider you can keep consistently. The providers can manage chronic conditions, but it won’t matter where they are located and people don’t have to drive to the doctor’s office. So enrollees can have visits from the comfort of their own home. If someone is asthmatic or diabetic and needs treatment, they are matched with someone who specializes in that space. Or, if a person needs urgent care, they can call and get someone quickly—usually within five to 15 minutes.

How does the cost compare to traditional models?

Kincaid: We’ve been able to lower premium rates six to eight points in the first year, and we expect potential premium reductions in the future. The plan design is the same as a traditional brick-and-mortar plan; enrollees pay $30 for primary care visits and have the same deductible and out-of-pocket maximum. They are saving because they are seeing a reduction through their premiums.

Bartosic: Our enrollees are seeing savings of roughly 8% on average.

How are you able to reduce premiums with these plans?

Kincaid: The providers don’t have traditional practices, so they are able to deliver their solution at a lower price. Offering primary care isn’t necessarily the innovative thing here, but the way it is delivered is. There is greater accessibility with the 24-hour nature of it to offer care outside of the traditional 8-to-5 model.

These plans are also focused on true population health management. The providers’ specialty is chronic condition management where they are looking at how each member is unique versus applying a peanut butter spread to everyone.

There is also more accessibility for everyone because a doctor’s appointment can fit into someone’s lifestyle. People are working virtually more and traveling, but patients can keep that relationship going with their doctor, which is quite crucial if they need care for chronic conditions.

This model reduces ER visits by 20% throughout the year in aggregate because people can get to urgent care anytime and then can be redirected if they have to go somewhere else. There is a huge cost differential between urgent care and emergency care.

Bartosic: The cost savings is partly from the primary care model and an HMO model. We also see significantly lower fees in Doctor On Demand and lower no-show rates. You get a lot of no-shows in a brick-and-mortar office. Having less of those can improve care quality.

Any other benefits to virtual-first plans?
Kincaid: We know there is going to be a greater shortage of doctors in the coming years. And, generally speaking, once members try virtual care, they really love it, particularly in the behavioral health space. Six in every 10 visits gets reviewed by members, so we are getting consistent feedback. In aggregate, our doctors get 4.9 reviews across the board.
Do you do anything with these reviews? Can they be used to improve care or track physicians who aren’t faring as well with patients?

Kincaid: We keep a close eye on them and review the feedback monthly. Doctor On Demand uses it as well.

Bartosic: In each of the states where we have plans, we have worked with local physician groups where doctors can refer directly into those provider groups in New England. This is data we can share with Doctor On Demand, and we can use those referrals to see the full picture of the health of a patient.

Are there any populations this kind of product wouldn’t work for?

Kincaid: If someone has a strong relationship with their brick-and-mortar doctor, it probably wouldn’t work for them.

Bartosic: Everyone might not want to use Doctor On Demand, which is why we have Virtual Choice plans. In those, people can split: like my wife could choose virtual, but I might want to continue seeing my local primary care doctor.

It’s important to work with employers so, as a health plan, we can educate members as they choose a plan. We have had some employers ask if they can have the virtual-first as their only plan design. We recommend having it as part of several choices so employees can choose the product that best fits their needs. We’ve been working with employers to make sure employees fully understand the plans as they make informed decisions. Some HR professionals weren’t sure employees would be comfortable with telehealth, especially in large groups, but people were already using it, at least from an urgent care perspective. Continued communication is important with members and employers during enrollment in any organization.

Mental health conditions are by far the most frequent issue where telehealth is currently being used, accounting for 60% of the claims in May 2021, according to a monthly telehealth regional tracker provided by Fair Health. The most common visit is a 60-minute psychotherapy session, and the two top conditions being treated are generalized anxiety disorders and major depressive disorders. The report also found that telehealth usage declined in May of 2021 for the third month in a row. After dropping in February, telehealth visits continued on a downward slant: 12.5% from March to April and 12.5% in May. Usage declined nationwide, with the greatest decrease in the South.

Another industry report by Trilliant Health found:

  • Women ages 30 to 39 are the most consistent users of telehealth.
  • Telehealth use has fallen 37% from early in the pandemic to March 2021.
  • About 38 million U.S. adults conducted 96 million telehealth visits last year, the majority of all telehealth visits in that time frame.
  • Eighty percent of Americans reported a willingness to try some kind of home care model if it were covered by their insurance.
Tammy Worth Healthcare Editor Read More

More in Health+Benefits

Human Capital Risk Is a Business Risk
Health+Benefits Human Capital Risk Is a Business Risk
Five questions for the incoming CEBE chair.
Health+Benefits Pool Party
More brokerages and carriers are diving into pooled employer plans for retiremen...
The Mouth Is the Gateway to the Body
Health+Benefits The Mouth Is the Gateway to the Body
Q&A with Sarah Chavarria, CEO and President, Delta Dental of California and Affi...