Time for health payers to go virtual-first

The pandemic has forever changed the role of technology in healthcare and the experience and expectations of health consumers. Before the pandemic, virtual care saw relatively low usage among patients and providers. Last spring, its use surged to 51% of physician visits. Although that declined to 17% when doctors' offices and other service sites reopened in the late fall, virtual care use still remains significantly higher than the comparable period.

Sociologists often refer to this phenomenon as a breaching experiment – where a social norm or commonly accepted rule is purposely broken to see how people react. The data shows that most people reacted favorably. In a recent Amwell survey of 2,000 healthcare consumers and 600 physicians, the vast majority of patients (91%) and providers (84%) said they were satisfied with the virtual care experience. Nearly all physicians (96%) said they were willing to continue to use telehealth – a key indicator for sustained adoption.

The virtual-first wave

To cash in on the trend, health plan and integrated delivery networks are taking notice and launching “virtual-first” insurance products. These low-cost products allow members to use video, chat and messaging to confer with a clinician or pharmacist, with the option for an in-person visit when necessary. According to health plans, these innovative products offer members more options for getting care while also addressing health inequalities.

Oscar’s virtual-first plan, introduced in 2020, is expected to expand to 18 states and 47 markets this year. Kaiser, meanwhile, launched its “Virtual Plus” offering in Washington state and “Virtual Forward" in the mid-Atlantic region. Another Michigan-based payer, Priority Health, launched MyPriority Telehealth PCP for the 2021 plan year, with members assigned a primary care physician through the Doctor On Demand network. Early enrollment data shows 5,000-plus members enrolled, with some switching from other individual plans offered by Priority Health.

What It takes to make the move

To be virtual-first, healthcare payers need a digital platform comprised of advanced technologies and a new operating model. Key components include:

• A virtual provider network. Virtual-first plans should have a strong virtual provider network. Payers can achieve this either by enabling virtual visits among their existing provider networks or by subscribing to established virtual provider networks such as Doctor On Demand or Teladoc. While using a third-party network enables payers to quickly launch a virtual-first product, it’s often a complex undertaking to integrate a data ecosystem and systems for engagement, care management and financials. Creating virtual capabilities organically – via existing provider networks and infrastructure – offers more control and likely smoother data and systems integration. Payers should take advantage of their already integrated provider networks to build an organic virtual-first capability.
• Product definitions and policies. Payers need to think through how they will apply coverage, liability and accumulator rules to their virtual-first product. Adjusting some rules, such as waiving cost sharing on app-based consults, could create incentives for adoption.

• Appropriate pricing for virtual services. By reducing or completely eliminating out-of-pocket costs for virtual services, and offering incentive programs for in-home monitoring devices, payers could accelerate adoption of virtual-first products. Early entrants may be setting consumers’ price expectations. Oscar offers no-cost virtual primary care in several states, tied to its own provider network and paired with vital signs measurement kits it provides to members. Detroit-based Health Alliance Plan has collaborated with the Henry Ford Health System to create Pivotal, a virtual-first plan for large employers that has zero member cost-sharing for virtual consults.
• Seamless and connected experience. The virtual-first product should act as a digital front door into the broader health system. It should be designed to recognize members’ unique needs and deliver real-time interactions, intuitive processes and well-curated, context-aware choices that reflect their health conditions and demographics. An elderly man with hypertension would receive a different set of check-in questions than a middle-aged woman with an autoimmune disorder. Consumers expect these qualities of any digital experience today, and they’re even more critical in healthcare. Members and providers must be able to navigate between virtual and physical networks and experiences without any loss of data fidelity or context.

• Digital care management. Population-specific chronic and episodic care management tools are critical components of the overall virtual product experience and enable payers to better position themselves to orchestrate member care. Payer care managers, physical and virtual providers should collaborate on care management models. As virtual-first offerings mature, payers can empower patients through digital diagnostics, such as determining vital signs or skin conditions, and enhanced care-finding tools, such as locating a provider with the earliest available appointment or finding a lab with the lowest out-of-pocket cost.

• Unified data and operating platform. Payers should ensure they can support new data streams and higher data volumes coming from medical sensors such as wearables, as well as in-home monitors and diagnostic tools. Other internal and third-party systems must have access to this data to create insights for delivery to members, providers and care managers. This calls for a robust data modernization strategy and orchestration platform and, likely, an upgrade of the appropriate infrastructure.

• Integrated traditional health plan services. Prior authorization, eligibility verification and referral functions should be incorporated into any virtual-first infrastructure to deliver a seamless experience to providers and members.

• Provider collaboration and experience. Payer and provider collaboration is critical for creating consumer-centered offerings that eliminate friction in the system. Areas to consider include reducing prior-authorization requirements and presenting 360-degree member views at the point-of-care that include member-generated data.

The virtues of virtual care

Virtual care adoption has reached a tipping point – most patients appreciate the benefits of it, and almost all providers want to serve their patients in more contactless ways. Virtual-first products enable insurance plans to become an active partner in their members’ healthcare journeys by providing a broad range of clinical and non-clinical services through a digital front door. This will not only enhance member engagement, but will also improve access to care and reduce costs.