Until COVID-19, healthcare was either all in-person or all virtual. Patients had to choose. Some patients chose both — an in-person health system for most things and perhaps Livongo for diabetes care or Hinge Health for back pain care.
The problem with this approach is that in-person all the time is inconvenient and a waste of time when all a clinician is doing is looking at a wound or responding to lab results. But all-virtual is not great when things are uncertain or patients need to be examined. While there are few silver linings to the horrendous COVID-19 pandemic, one is that nearly all providers and most patients have experienced virtual care and most have found it useful. This widespread adoption of virtual care, we believe, will lead to hybrid models that we call “click-and-mortar,” which combine the best elements of in-person and virtual care to deliver better outcomes more reliably and efficiently.
The uptake of virtual care in 2020 is stunning: 97% of primary care doctors provided some kind of telehealth care in 2020. Moreover, nearly 44% of Medicare beneficiaries’ primary care visits were provided by telemedicine in 2020, compared with a mere 0.1% the year before.
The notion of virtual care has become so common that Google searches for “doctor online” result in a specialized tool displaying widely available virtual care platforms, such as Teladoc, Amwell, Doctor On Demand and MDLive. Moreover, telemedicine providers like Doctor on Demand, MDLive, Galileo and Firefly have all launched “virtual primary care” services designed to deliver non-urgent longitudinal primary care virtually. While these services may meet the needs of healthier patients, the absence of a physical location for physical examinations, diagnostic tests and procedures may limit their utility.
This widespread adoption of virtual care, we believe, will lead to hybrid models that combine the best elements of in-person and virtual care to deliver better outcomes more reliably and efficiently.
Nonetheless, there are several potential advantages of virtual primary care. The ability to see patients in their homes can contribute new information about safety, social support and social determinants. In cases like behavioral health, they can decrease the stigma associated with accessing care. Virtual care platforms can more easily incorporate remote monitoring data, and virtual visits can occur as groups with teams of caregivers or other specialists simultaneously.
Furthermore, virtual visits may allow for more frequent “microvisits” to monitor how patients are progressing. They also facilitate more rapid treatment adjustments because they eliminate the need to travel to a doctor’s office. Virtual visits also have lower cost for physicians, avoiding brick-and-mortar overhead costs, and for some services offer 24/7 access, which may reduce the need to seek urgent care or emergency department care. Finally, patients may be able to gain expanded access to clinicians who match preferences based on things like ethnicity, LGBTQ orientation and gender, particularly in rural areas where options are limited.
For pure-play virtual care models to work, they need to rely on connected devices and patient cooperation. Using connected blood pressure cuffs, stethoscopes, oximeters, thermometers and scales, it is possible to replicate much of the physical exam. Just like for in-person care, a virtual provider can order lab tests, although it is impossible to do a quick urinalysis or strep test virtually without the supplies on hand.
Virtual providers who work closely with health plans may have more data on cost and quality to inform referrals but perhaps less local knowledge. A possible consequence is that virtual providers may have more transactional relationships with specialists and traditional local brick-and-mortar providers.
Data have shown virtual care delivers better clinical outcomes in certain cases. Virtual care has been shown to reduce emergency department visits and antibiotic overprescribing. Chronic conditions like Type 2 diabetes are examples where virtual care has outperformed in-person care. Virtual physical therapy has generated cost savings and resulted in fewer back surgeries.
Despite these benefits of purely virtual care, we believe that ultimately the most efficacious model of primary care is a hybrid one combining virtual and in-person interaction. We think that the mix of in-person and virtual is probably 80% virtual. We also think that most visits will be triggered by clinicians reaching out to patients in response to a change in remotely monitored data, perhaps a new fever, change in sleep patterns or weight change for a patient with heart failure.
The implications of visits being mostly virtual and largely triggered by changes in data are profound. It means that offices become places for problem-solving and procedures. It means clinicians spend their days responding to signals from patients and probably have their schedules largely unfilled until the night before. It means that patients will need to adopt passively collected and remotely monitored data.
We think this model ultimately will result in more frequent, shorter, virtual interactions that happen nearly continuously over text and be supplemented by email, phone and video. We also think this approach will deliver much better clinical outcomes and more rapid improvement since both the patient and clinician have much more data on how diseases are progressing.
There are risks with this model. It requires patients with mobile phones and devices to engage and respond to clinicians and ensure their remote monitoring devices stay online. Most importantly, patients need to follow the advice of virtual providers and prompts to get in-person labs, diagnostics or care when needed. Further, clinicians will need to be trained to conduct virtual clinical examinations and to incorporate as well as respond to remote monitoring data.
The COVID-19-fueled adoption of virtual care will hopefully create the demand on the part of patients and desire on the part of clinicians to embrace our “click-and-mortar” vision for care. These models have the potential to deliver more proactive, more engaging and, we think, far better care.
