“Can you explain what internet is?”

Over the last 60 days, I’ve had multiple conversations with really talented benefit leaders that I respect and admire, who continue to struggle to understand how care can be delivered virtually with the same impact as an in person visit.? Because I use virtual care, I believe in it, but I’ve also struggled to explain the value that I have personally experienced.? I'm realizing that one of the challenges in describing the value of virtual care is the context, which generally starts from the perspective of a physical office visit.? Explaining the value of virtual care from the starting point of an office visit is like trying to explain cloud storage from the context of a metal filing cabinet.? (Remember:? “the files are in the computer!”, or this one:? “Where are the servers?!?”).??

Back in the early 90s Katie Couric, Bryant Gumbel, and the rest of the Today show staff struggled to understand the internet in a now infamous video clip:? “Can you explain what internet is?”? They couldn’t begin to imagine the possibilities of the internet, probably like a lot of us at that time, because they tried to understand the internet from their context in 1994.??

Someday (hopefully sooner than later), I believe we will look back and laugh at how we think about and try to define “virtual care”.? In fact, I don’t think we will define it as virtual care but rather we will think about the meaningful relationships we have with our primary care doctor and care team, which we choose to access physically or virtually or both based on our preference.?

In my opinion, the big challenge to get from here to there is to transition away from the idea of a “Visit” being the construct that provides value to improve our health, to the expectation that?a direct relationship with a care team is what really helps us manage and improve our health. Unfortunately, the Visit remains a powerful mechanism in healthcare.? My partner at Crossover, Scott Shreeve, wrote a great post back in July 2019 about the ”Tyranny of the Visit” And while our familiarity with virtual care has increased exponentially since the pandemic, our actual culture, billing, and administrative practice of medicine has moved only incrementally.

Building relationships into healthcare

Many of the questions I’ve received from my benefit leader friends inquisitively challenging virtual care are related to the lack of the physical exam when it comes to virtual primary care.? We are all so used to the experience of visiting a doctor in person for an issue and because we saw them in person, I guess that means it was a “good” visit?? If we stop and think about it though, those visits aren’t generally deep conversations or particularly meaningful interactions.

Community providers struggle to be comprehensive because most of them don’t have time which leads to shorter medical histories that are more narrowly focused.? There is no time to talk about lifestyle and we certainly don’t talk at length about social factors that limit our ability to live healthier (no CPT code for housing instability). ? FFS has guaranteed that those visits will be short,? impersonal, and by their nature imprecise.? At Crossover, our physical examinations are longer and more personal in large measure due to the comprehensive medical history we consistently take…on every single one of our members whether they engage in person or online. In fact, Crossover providers are measured on the same 60+? primary care metrics regardless if they work at an Onsite or Nearsite Health Center or if they deliver care to our members virtually.??

As I’ve shared with my benefit leader friends, Crossover’s goal isn’t to replicate the visit online; our goal is to build trusting relationships.? The debate shouldn’t really be about Physical Visits vs. Virtual Visits. The debate should be about whether we built a meaningful relationship with the members.? We build these relationships not by counting short or long visits but by trying to help our members solve their problems.? This could be by solving the specific issue for why they scheduled the visit or being available in a time of need, or even playing the quarterback for a complex issue between multiple specialists.? Along the way of solving these items, we stay connected with each member with regular, natural, and continuous outreach.? We ask them about their physical activity and changes in their mental health.? This is all part of the value in a relationship.??

I think for many, the idea of this type of relationship with a primary care team makes total sense.? The next concern is how do employers pay for it?? I love this quote from Implementing High Quality Primary Care:??

“Any effort to implement high-quality primary care must begin with a commitment to pay primary care more and differently because of its demonstrated and superior capacity among healthcare services to improve population health and health equity for all society, not because of any ability to achieve short-term return on investment for a specific payer. High-quality primary care is not a commodity service whose value needs to be demonstrated in a competitive marketplace but rather a common good to be promoted by responsible public policy and supported by private sector action.” (pg 373)

I’m not going to get into the issues on FFS and Primary Care here but I will say that transitioning to a new payment model in primary care will be challenging.? How will a large payer change its monolithic claims system receiving and paying FFS visit fees into paying primary care teams for established patient relationships???

While I do think some small teams within a few payers are working to provide a breakthrough, I still believe large employers will likely have to contract directly with primary care medical groups, or the large employers will need to transition from their current payer partners and look for smaller and more innovative TPA or ASO partners who can create the right payment mechanism.? However, I believe once large payers create the model at scale, primary care providers will quickly restructure their medical groups to pivot towards relationship based care and away from the high volume visit business model.??

In the end, I am still left with the problem of helping people understand the context. The 1994 Internet Meme remains one of the best to help people get in the right framework, and I believe as Crossover and others can demonstrate the proof points that people will begin to drop the term virtual from care because they realize that when you have a strong relationship with a care team, Care is Care, regardless how you access it.?

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B Roll

Below I added our responses to specific questions from some benefit leaders on virtual care.? I thought these responses might be helpful for others trying to work out the value of virtual care in their minds. I also interviewed a few of our virtual providers (primary care, PT and mental health) about their experience delivering care virtually.? If you are interested, you can watch it here.??

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Question 1: ?Is “virtual” care just as good as an in person visit?

Answer:? We believe a relationship is much better than a visit.? We believe care is less about virtual vs. physical visits and more about establishing a relationship with our members.? We try to focus on solving meaningful issues for our members and in that process of making healthcare simple and more valuable, we are able to build trusted relationships long term.???

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Question 2:? Nate has talked about his tick bite and the questions he received from his virtual provider? about the tick bite.? If Nate had been a new patient with the provider, rather than an existing patient, what additional questions would the provider have asked???

Answer:? All of our providers are expected to establish provider-patient relationships as part of the regulations of state regulatory boards. That means that we ask all of our new members the same questions that would be expected of an in person physician to establish a relationship. We ask about medical history, medications, allergies, to get background as well as about current symptoms. What we find is that we often have the advantage of time in the virtual space to be able to get a comprehensive history for our members who can take time with their responses because we don’t have a waiting room of members who are tied to a specific appointment time to rush us through our visit.?

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Question 3:? How do you assess vitals virtually?

Answer:? This is where it is more upon the member to assist us with vitals. However, vitals are not necessary at every visit for every concern. We ask members to provide us with their height and weight and if they have access to a blood pressure cuff either at home (or at their pharmacy kiosk if available) we will ask them to provide us with their latest reading. There are many apps now that can help assess heart rate and even pulse oximetry (oxygen saturation). We also try to get waist circumference measurements since this can be a good screening tool for risk of diabetes and heart disease, so we will guide them through how they can check this at home with a tape measure if they have one on hand. We also review all outside records to document what vitals have been done already to graph trends. When members do not have access to these tools for home measurements, we can send them to get these either through a Crossover Nearsite Health Center or community provider or it is also possible to request via a biometric screening order at third party lab facilities.?

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Question 4:? Why don’t you require an online / synchronous visit on the first visit with a member to see them and evaluate them?

Answer:? We offer it but many members don’t want it for primary care since it can be much more efficient to have a messaging visit that doesn’t require blocking off time during the workday to get online. While synchronous communication is the way we are used to thinking of engaging with our doctors, it can be highly inefficient and sometimes ineffective since members need to think on their feet to the questions and don’t have the luxury of thinking through their responses. Also, sometimes members feel more comfortable not being face-to-face to discuss sensitive topics and so it can feel more safe to reveal through messaging versus video visit. We still leverage other tools such as photo uploads which can often be higher resolution to see what may be going on then through a video image where it is hard to zoom in. We have received great feedback from members who develop deep meaningful relationships with their Crossover virtual primary care provider whom they have communicated with frequently via messaging but never engaged with face to face. However, there are some members who feel more comfortable communicating face to face and so we always offer both options. We have found that more members prefer video communication with mental health, physical therapy, and health coaching and so most of those providers conduct their visits live online but then will have frequent touch points in between scheduled visits with messaging in between, which we find to lead to overall shorter treatment times with the combination.?

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Question 5:? Care Navigation:? If a virtual patient is referred by a Crossover provider to a local primary provider to do a confirmatory visit (e.g., check vitals, etc.), does / can the Crossover Care Navigator do anything to limit that provider from billing codes outside the confirmatory visit focus?

Answer:? We find that we are able to do virtual care for about 80% of primary care cases but there are times when a member needs to be seen in person for a procedure (e.g. Pap, sutures) or further evaluation. We can send them to? third party labs or radiology facilities, or order tests directly such as Holter monitors, sleep studies, etc. As mentioned earlier, labs such as Quest and Labcorp are offering biometric screening to obtain vitals if ordered. If we have to send a member to a local primary care provider, our Crossover providers can reach out to do a warm hand off and afterward always close the gap to bring the care back to our virtual providers as the primary point person if desired. However, we also try to establish relationships with community primary providers so that we are able to collaborate on care for our members since there may be ongoing instances that we will need to send members in to be seen. Below are additional ways that we try to streamline efficiency and reduce unnecessary costs:?

1. Refer to in-network, high-quality & low-cost providers
2. Sharing relevant recent visit notes prior to the visit with the community PCP to reduce overutilization?
3. Workflow includes getting visit notes back to our provider to decide on next steps and discuss with the member before scheduling more services
4. Building relationships where we set business rules to let us know before ordering additional services?
5. Crossover providers rate the community providers based on overutilization
6. Care Navigator’s can log into health system platforms and review any additional services that are ordered and let our providers know
7. Reviewing member’s employer benefits before placing a referral to see if they have additional employer sponsored benefits that can help their condition