Grand Rounds Blog

This white paper was co-written by Ami Parekh, M.D., J.D. and Nupur Srivastava.

BenefitsPro published an abbreviated version of these predictions here

 

In the first months of the COVID-19 pandemic last year, the U.S. saw an increase in demand and usage of virtual care. Telemedicine visits spiked to 14% of all healthcare visits volume, representing a 13,800% increase compared to less than one-tenth of a percent of visits share just months earlier1

That said, the virtual-first care experience realistically needs to be 10x better in order to gain sustained adoption. Otherwise, patients and doctors will go back to the old, in-person healthcare experience once the pandemic finally ends.

What follows are our predictions for how virtual care will integrate into U.S. healthcare to form a new, virtual-first framework that will deliver the 10x better care experience:

 

1. 35-50%+ of previously in-person care will be delivered in a virtual primary care setting

Preliminary estimates suggest up to 35% of office visits and outpatient encounters could be administered virtually ². Given rapid advances in technology and devices, as well as development of digital tools to help patients and providers accomplish more virtually, we believe 35% is the low-end of the range. Practicing physicians whom we interviewed estimated that over 50% of the care they deliver could be done virtually, with some estimates going as high as 70%. 

With over a dozen well-capitalized companies already offering virtual primary care services, the quality of the services will rapidly improve through competition and more and more patients will have the opportunity to have a virtual primary care visit. Not all of those models will work, but some will work very well and patients will continue to come back for better convenience and access.

Significant tailwinds will push patients to try virtual primary care for the first time, and then the floodgates will open:

    1. Appointment wait times are too long. Even prior to COVID-19, an appointment with a PCP could have a wait time of up to 122 days depending on where you live³. Such scarcity is a significant barrier to care and a major contributor to worse health outcomes.
    2. Travel to appointments takes too long. Even prior to COVID-19, patients traveled an average of 34 minutes to receive in-person healthcare services and then waited an average of 11 minutes on top of the travel time⁴. The time spent seeking out care costs the American economy approximately $89 billion annually⁵.
    3. Remote patient monitoring (RPM) devices. RPM devices enable doctors to video call with a patient and run the same diagnostics he or she would run in an office setting: blood pressure checks, heart rate, respiratory rate, abdominal exam, ear exam, throat exam, skin checks and temperature measurement are all possible remotely.
    4. In-home lab testing. A number of common diagnostic tests are available in at-home kits where the test arrives in the mail, a patient collects their sample in the comfort of their home, and mails the test back to the lab for analysis. Infectious diseases, colon cancer and even the recently-FDA-approved COVID-19 PCR test are on the at-home test menu.
    5. Convenience of a navigator. Keeping track of appointments, bills, benefits, conditions, doctors, insurance coverage, medications, and more is exhausting. Care is being built around navigation services that use technology and skilled experts to unburden patients, and patients, providers and payors all stand to benefit from better convenience and efficiency.
    6. Millennial preferences. The millennial generation (those who are 24-39 in 2020) is the largest living generation in the US and will make up 75% of the workforce within 6 years6,7.  Health and wellness is a key aspect of daily life for millennials, and they exercise more, smoke less, eat more healthily and are more likely to adopt new technology than previous generations8,9.
    7. Provider preferences. Millennials will also soon account for a large share of practicing physicians, and those same preferences for better living through technology will apply. Up to 79% of PCPs already report being burnt out, driven by workplace inefficiency and schedule inflexibility. These providers will be attracted to good virtual primary care programs where they can practice better, more holistic medicine that is powered by more efficient tech and cuts down on their admin paperwork, as well as enjoy more schedule flexibility as a function of the care being virtual.

 

2. Chronic condition management will become majority-virtual

In 2016, chronic condition management accounted for $1.1 trillion in healthcare cost—equivalent to 6% of GDPand was driven by diabetes, hypertension and osteoarthritis11 . Common treatment for each of these conditions largely consists of medication management, medication adherence, active monitoring and potentially physical therapy, all of which can be delivered through virtual appointments with a primary care team. 

Our own data indicates that commercially insured patients turned to telemedicine for chronic care management at significantly higher rates than normal. The proportion of telemedicine claims related to diabetes, hypertension and back pain increased 642%, 441% and 258%, respectively. The transition to chronic care management is already happening, and that was just through traditional tele-urgent care. Once virtual primary care is well and truly launched, including tools and programs to help with chronic care management, we expect to see the majority of regular chronic care management transition to a virtual setting. 

That is not to say that in-person treatment will not be necessary. Many conditions will still require physical exams (e.g. retinal exams, foot exams for diabetics) and may require hospitalizations, but maintenance and monitoring appointments can be done virtually.

 

3. Virtual care will integrate physical and behavioral medicine and integrated models will become the only acceptable standard of behavioral healthcare

Patients who experience debilitating chronic pain are much more susceptible to depression and anxiety. Patients who experience depression are less likely to adhere to their diabetes medications. Medical literature has for many years shown that (i) physical and behavioral conditions are often comorbid, with 68% of adults with behavioral conditions also experiencing medical conditions12 and (ii) healthcare costs for those with comorbid behavioral and physical conditions can be over 2x the cost of those without behavioral conditions13. Three-year mean healthcare costs for comorbid patients with depression were $38,000 compared to $22,000 for those without a behavioral condition. The rates of hospitalizations, ED visits and hospital length of stay are all much higher for the comorbid population. As such, the behavioral and physical conditions must be treated concurrently in a coordinated manner in order to help comorbid patients effectively manage their conditions.

Primary care providers we’ve spoken with lament the fact that the economics of their practices do not enable them to keep a behavioral specialist on staff.  That is where virtual primary care programs can raise the standard of care. The regional and national scale of the programs can support an integrated physical and behavioral model, where primary care physicians and behavioral specialists routinely review patient files and share encounter notes

Considering the current behavioral health access crisis, we believe the convenience of virtual care combined with the effectiveness of integrated physical and behavioral medicine will draw unprecedented volumes of patients—these patients could even be the first early adopters and super-users of virtual primary care.

 

4. Healthcare navigation will become the core platform on top of which all viable virtual-first healthcare is built

At Grand Rounds, we assess new product categories against their ability to be at least 10x better than the legacy product offering. This value proposition ensures that early adopters will try out the product and that when they do, the product will work so well that soon you will have dozens more fast-follower customers. 

One of the most critical “10x features” of virtual primary care is a healthcare navigation platform. By being built on top of a navigation platform, virtual primary care becomes a truly virtual-first healthcare experience where members can both navigate their need—find a care advocate who fights a bill, a referral to a high-quality doctor, an expert medical opinion or even a chronic care management program — as well as receive care, all in one place. The synergies achieved will amplify the utilization and impact of the program by ensuring that many more people use the product and that when they do, they experience a more efficient, less costly care journey. 

Compare the above to legacy in-person care or telemedicine (functionally tele-urgent care), where the lack of easily accessible resources available to members on either side of a health appointment means that members do not know where to go for care, how much care will cost or how to manage their condition post-appointment. The fragmentation of the experience is a big driver of the 25%+ rate of waste in U.S. healthcare today. Absent a fully integrated navigation platform, a virtual primary care offering cannot be 10x better than in-person care or telemedicine because it will still have to route in and out of other niche services and recreate a fragmented experience that has already proven itself ineffective. 

However, we see in our own Navigation offerings that members who come to us initially with a financial need, such as double-checking a bill or understanding insurance coverage, are 2.5x more likely to seek us out for a clinical service in the future. This is the connected ecosystem experience behind why all viable virtual-first healthcare offerings will be built on top of navigation platforms going forward.

 

5. Hospitals will not be major players in virtual care and will instead seek to further consolidate to focus on more complex, more specialized inpatient care and procedures

25%+ of US healthcare spending is considered waste14. This has pushed more and more care into more appropriate and cost-effective settings, including (i) office-based visits becoming virtual and (ii) outpatient hospital care moving to more specialized, more efficient ambulatory service centers. 

Optimizing for appropriate site-of-care is a critical piece of the care navigation value chain and can save billions of dollars in spending annually. Healthcare navigators and insurance companies are already focused intently on this opportunity. At their November 2020 investor day conference, United Healthcare announced an effort to “materially expand [their] specialist incentives to promote increased ambulatory surgery alternatives where appropriate.” Other payors are likely implementing similar strategies, so hospitals will have a choice between investing to compete in the virtual care space or doubling down on complex care.

We believe hospitals will choose to consolidate and focus their businesses and care strategies around the more complex, more specialized inpatient care and procedures that multi-disciplinary hospitals are uniquely suited to treat and that payors will always need to include in their health plans. Virtual programs like remote expert medical opinions will ensure that patients can still access the hospitals’ top subspecialist experts for complex care recommendations, even if the hospitals do not widely enable synchronous virtual appointments.

The combination of a comprehensive healthcare navigation and high-quality telemedicine solution—for everything from receiving preventative care and the treatment of chronic conditions to having the support of a care team to resolve billing issues and track down medical records—will support a patient experience that’s timely, convenient and cost-effective. Patients will be able to access an exponentially better standard of care virtually, whenever and wherever they are, for as long as they need to, so that they can live healthier, productive lives.

 

Check back soon for part 2 of our future of telemedicine series, which focuses on advancements in technology that are helping drive a virtual-first healthcare model.

1.  Mehrotra, Ateev et. al. (2020). “The Impact of the COVID-19 Pandemic on Outpatient Care: Visits Return to Prepandemic Levels, but Not for All Providers and Patients.” Commonwealth Fund.
2. Bestsennyy, Oleg et. al. (2020). “Telehealth: A quarter-trillion-dollar post-COVID-19 reality?” McKinsey & Company
3.  Merritt Hawkins Team. (2017). “Survey of Physician Appointment Wait Times & Medicaid and Medicare Acceptance Rates.” Merritt Hawkins.
4. Rhyan, Corwin N. (2017). “Travel and Wait Times are Longest for Health Care Services and Result in an Annual Opportunity Cost of $89 Billion.” Altarum Center for Value in Health Care.
5. IBID
6. Fry, R. (2020, August 28). “Millennials overtake Baby Boomers as America’s largest generation.” Pew Research Center.
7. Nermoe, Katie. (2018). “Millennials: The ‘wellness generation’.” Sanford Health.
8. Goldman Sachs Investment Research
9. Vogels, E. A. (2020). “Millennials stand out for their technology use, but older generations also embrace digital life.” Pew Research Center.
10. Finnegan, Joanne. (2019). “A startling 79% of primary care physicians are burned out, new report finds.” Fierce Healthcare.
11. Water, Hugh and Graf, Marlon. (2018). “The Costs of Chronic Disease in the U.S.” Milken Institute.
12.Goodell, Sarah et. al. (2011). “Mental Disorders and Medical Comorbidity.” Robert Wood Johnson Foundation.
13. Sporinova B et al. “Association of mental health disorders with health care utilization and costs among adults with chronic disease.” JAMA 2019 Aug 2.
14. Shrank, William H. et. al. (2019). “Waste in the US Health Care System: Estimated Costs and Potential for Savings.” JAMA
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