Global Lab for Innovation

Audiovisual consultations with primary care

physicians (also known as Virtual Primary Care or

Tele-Outpatient Visits) decrease total cost of care

and help patients avoid more complex interventions.

Studies comparing e-visits with face-to-face care

demonstrated an average or net savings of $19 to

$92 per case.

Application Profiled Here: TelaDoc and Health

Partners’ Virtuwell

What it is

These services offer patients primary care consultations with physicians or nurse practicioners (NPs) through audio-visual tele-communications. Tele-primary care visits are available 24/7 and without appointments to patients who need non-acute care. Consultations are conducted through secure audiovisual connections over computers and smart phones, allowing patients to access care from home, work or other locations.

Problems addressed

• Patients use Emergency Departments (ED) and urgent care clinics –which are much more costly than primary care

visits— for convenience, drop-in care, to avoid commuting to see their doctor, or while they are traveling.

• A shortage of primary care physicians limits the availability of appointments. • Patients with communicable diseases may infect others while visiting the clinic.

• Patients who are ill may not feel well enough to travel to a clinic and instead go untreated.

Summary

Application Profiled: TelaDoc and Health Partners’ Virtuwell Category Documented, Focused Savings Level 2 Access Experience Engagement NR Outcomes Barriers Regulatory Investment $ Training Moderate EMR Integration Favorable Potential for Spread

User Sites <30

Tele-Primary Care Visits

Global Lab

for

Innovation

How it works

Patients visit a website or call an 800 number to describe their problem and request an appointment. Only relatively simple conditions such as respiratory, urinary tract infections, or conjunctivitis are scheduled for virtual consultation. Potentially serious or complex conditions are referred for face to face care.1

Appointments for a consultation with a physician or nurse practitioner are usually made for a time within 30 minutes to several hours of the request. The clinician and patients can communicate through a variety of methods: phone, structured asynchronous online communication, videoconferencing, or a combination. The tele-primary care clinician may give a diagnosis, prescribe antibiotics and other non-controlled scripts, recommend self-management or follow-up care, or refer for a face-to-face appointment. Protocols direct the care given.

Records and payment arrangement vary with the service and are dependent on how integrated the service is in the delivery system. Where the tele-primary care service is offered by a delivery system or by a contractor to the delivery system, a record of the encounter is entered into the patient’s electronic medical record (EMR.) The service is a covered service and patients pay similar co-pay portions as for a face-to-face visit. When the tele-primary care service is offered outside of a delivery system patients typically pay in full with a credit card.

Direct savings are achieved through lower charges per visit than office visits and much lower charges than ED or acute care clinics or other alternative care sites. Where tele primary care visits resolve problems at similar or higher rates than the alternative care, there is no offset from additional follow-up visits.

Longer term, indirect savings may accrue where patients obtain prompter care from tele visits and thus avert need for more complex interventions. Additionally, by directing low acuity conditions to a virtual service, EDs and Urgent Care sites can be decompressed to allow patients that require those face to face visits to see providers in a timely manner.

Innovators

TelaDoc — the first tele-primary care service in the US — began in 2002 with a telephone, direct-to-consumer offering

of consultations with primary care physicians. TelaDoc has since added audio-visual and internet consultations and also contracts nationally with delivery systems and health plans.

In 2010, HealthPartners in Minnesota initiated an “on-line clinic” for their members called Virtuwell. The online clinic is available at all hours and is staffed by NPs who follow specific care protocols. Patients may interact with the NP online or either party may call the other at any point during the consultation.

Other firms offering tele-primry care include:

• _Zipnosis, founded in Minneapolis in 2010, and offering an online survey and response service monitored by primary

care physicians and NPs.

• “KPOncall” a service initiated in 2010 by Kaiser Permanente.

• _{American Well, a telehealth company founded in Boston in 2008,}2,3 _{partnered with WellPoint (a for-profit managed}

care firm) in 2013 to offer the LiveHealthOnline (LHOL) service to consumers and to delivery systems.4 _{LHOL has a}

number of academic medical system clients, including UCLA Health through the Anthem insurance plan.

In addition to these providers a number of commercial insurance plans contract for tele-visit services, for example many of the state Blues plans, United, and several VA programs offer members’ access to LHOL. AllinaHealth, a provider network in Minnesota, offers a service they refer to as” e-visits” to their members. Carena in Seattle contracts with providers to install “tele-clinic” systems which Carena will staff with its own clinicians or with the clients’ clinicians whom they will also train. Some academic medical centers, such as the UniversityofPittsburgh, have also developed their

Complexity

Focused. When delivery systems contract with a vendor who provides a secure platform and physician services. If

the online consultation reports are filed in patients’ records and reported to their primary care physician, connectivity bridges must be developed, installed and maintained. Communication programs are required to make enrollees aware of the service and encourage them to register with it. TelaDoc, Carena, and LHOL report that they work with the delivery system’s IT and communications departments for implementation, which can be done in less than a year. LHOL summarizes the preparation required by a delivery system as primarily “physician’s time, hardware and internet connection.”5

May be complex when delivery systems build their own internal service and requires enrollees to register with that service. Kaiser reports that they invested in multi-year efforts to register patients, train MDs, and develop use of its KP Oncall service.6 _{Virtuwell reports that their online care service was designed, implemented, and realized savings within two years.}

Savings

Yes.Virtuwell reports savings of $88 per episode. Both TelaDoc and Virtuwell report fees per tele-visit as $40 or $38

respectively.7 _{Average costs for primary care visit for an existing-patient physician visit is roughly $150.}8 _{To the extent}

that the telehealth visit substitutes for a physician visit, the immediate direct savings would be $110/visit. Where telehealth visits substitute for ED or urgent care clinics, the savings would be much larger. TelaDoc visits were found to have lower rates of follow-up visits than face-to-face visits in a study of California state employees in an HMO offering TelaDoc consultations.9

Mercer did an assessment of TelaDoc patients surveyed to determine what mix of alternative care (urgent care clinic, ED, primary care, specialist care, or no care) the user would have sought if TelaDoc were not available to them. Using this weighted mix, they found a net savings of $92 per case.10

Two other tele-primary care providers have reported estimated savings: A study of e-visits at University of Pittsburgh found that for Medicare patients with urinary tract infections (UTIs) the average savings per case was $19 (including visit, lab tests and scripts).11 _{Wellpoint reported LHOL savings on average of $45 per e-visit compared to a face-to-}

face visit.12

In a capitated system, the delivery system may realize savings by substituting tele-visits as lower cost interventions for office or urgent care visits. Health Plans may realize savings when they pay lower levels of reimbursement for virtual than for office visits. Patients may realize savings where their out-of-pocket charges for virtual visits are less than that of face-to-face care that they would have obtained.

Access

Yes. Patients gain access to clinicians during non-standard practice times and have virtual access to clinicians from home, office, and other sites where they have connectivity. A study of TelaDoc services to an HMO patient population found that more than a third of tele-visits were made on weekends. The same study found that 21% of TelaDoc patients had not used health care previously during the study year.13

Patient experience

Yes. A survey of Virtuwell patients by HealthPartners found that 98% of patients “would recommend” this service.14 _A

Mercer study of TelaDoc patients reported patient satisfaction to be over 90%, with 85% of cases resolved through the online encounter.15

Engagement

No information was available on patient engagement.

Outcomes

No reports of patient clinical or functioning status outcomes were found for TelaDoc or Virtuwell patients.

At the University of Pittsburgh a study comparing treatment records for e-visit and office visit patients with UTIs and sinusitis found equivalent rates of follow-up visits and calls. This finding suggest similar rates of treatment success; however, the same study found somewhat higher rates of antibiotic scripts for e-visit patients and lower rates of preventative care interventions.

Spread

An estimated 40 private insurance firms and delivery systems offer tele-primary care visits. Most of the commercial services, such as TelaDoc, also have a direct-to-consumer service. No Medicaid program adopters were identified.

Barriers and Drivers

Barriers

Regulatory: Due to state licensing regulations, virtual physicians may only have encounters with patients in states of

licensure. Tele consultation services report that recruiting and maintaining access for care by MDs licensed across multiple states is a key restriction on expanded geographic coverage.

Regulatory: Some states have regulations requiring that prescriptions can only be given based on a face-to-face

encounter or where the patient and physician have an established relationship.

Regulatory: Some states also require that a prescribing physician must be located in the same state as the patient,

regardless of licensure.

Drivers

PatientPreference: Patients strongly prefer virtual access to primary care;

Similar innovations

Other telehealth care services such as tele-dermatology and tele-dentistry (both of which are profiled) and tele-

psychology rely upon audio-visual connectivity to deliver care. In the summer of 2014 Verizon introduced a virtual visits service on its android mobile telephones. These visits can be conducted over 3G or 4G connections, and the service is provider agnostic and available for a fee to any primary care provider to use for telehealth consultations. MDLive also offers a telehealth app for MD visits. Sherpaa offers telehealth consultations to business and as a consumer product. Most recently, Pager launched an offering.

Innovation contact

Teladoc, Daniel Trencher, Senior Vice President, Business Development Virtuwell, Kevin Palattao, Vice President

E-mail Address

Website

Original Date of Post

2014

Endnotes

1 Health Partners’ internal online clinic, virtuwell, has a list of 40 conditions that its nurse practitioners treat. Courneya, Kevin, et. al. HealthPartners’Online Clinic for Simple Conditions Delivers Savings of $88 Per Episode and High Patient Approval, Health Affairs, 2013. 2 American Well also partners with Blue Cross, Blue Shield, WellPoint, Ascension Health, Medibank (Australia/New Zealand), Rite Aid,

Tufts Medical Center, U.S. Department of Veterans Affairs, and others, American Well: Our Partners. http://www.americanwell.com/ patient/aboutUs.html).

3 American Well launched a three-pronged telehealth pilot program at Mass General focusing on Child and Adolescent Psychiatry, Heart Failure and Neurology [American Well Announces Telehealth Pilot for Clinical Care Programs at Massachusetts General Hospital. (April 8, 2013). http://www.redorbit.com/news/health/1112818177/american-well-announces-telehealth-pilot-for-clinical-care-programs-at/.] 4 The software platform was developed by American Well in Boston. There are multiple other installations of the software, but they are

branded otherwise. E-mail communication from Wallace Adamson, Sr VP, Strategic Partnerships, Live Health Online®_{LiveHealth Online}

currently operates as a registered trademark of WellPoint, Inc. LHOL plans to launch a “Practice Edition” which will allow providers to

use LHOL in their own practice for their own patients. LHOL also makes its systems available to delivery systems to operate with their own clinicians who may be physicians or nurse practitioners or physician assistants

5 Ibid.

6 Perle, R. Kaiser Permanents Northern California: Current Experience with Internet, Mobile, and Video Technologies, Health Affairs, 2014. 7 Courneya, op.cit.

8 Average fee in US for a primary care physician visit is reported to be $158/visit. http://www.fchp.org/members/resources/guide-to-costs.aspx 9 Uscher-Pines, Lori, Analysis of Teladoc Use Seems to Indicate Expanded Access To Care For Patients Without Prior Connection to a

Provider, Health Affairs, 2013.

10 Fifer, S, Telemedicine MD Visits: Patient Satisfaction and Use Patterns Among Working Age Adults, Mercer White Paper, 2008.

11 This estimate was based on Medicare fees in CY 2010 and 2011. Mehrota, A, A Comparison of e-Visits and Office Visits for Sinusitis and Urinary Tract Infections. JAMA Internal Medicine Research Letter, January 2013.

12 This estimate is based on assumptions that include alternative face to face care would involve a portion of ED visits. http://www.americanwell.com/telehealth-benefit-for-employees.html

13 Uscher-Pines, op. cit.

14 Health Affairs: HealthPartners’ Online Clinic For Simple Conditions Delivers Savings Of $88 Per Episode And High Patient Approval. (February 2013.) Note: this article is about services rendered by Virtuwell, a HealthPartners online care service in Minnesota. 15 Online Care for Employers: Cost Savings Analysis (Mercer). Note: this analysis was prepared for American Well and cites American Well