Insurance with a focus on virtual visits? The pros and cons of a new twist in health plans

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At the height of the Covid-19 pandemic, people often relied on telemedicine for visits to the doctor. Now insurers are betting that some patients have enjoyed it enough to take advantage of new types of health insurance that video visits will encourage – or insist outright.

For example, Priority Health in Michigan offers insurance coverage that requires online visits for non-emergency primary care first. Harvard Pilgrim Health Care, which sells to employers in Connecticut, Maine, and New Hampshire, has a similar plan.

“I would first describe it as virtual, a real replacement for primary telemedicine,” said Carrie Kincaid, vice president of individual markets at Priority Health, which launched its plans in January to complement the more traditional offerings of the Affordable Care Act.

The often cheaper offers benefit from the new familiarity and convenience of online routine care. However, skeptics see a downside: the risk of overlooking something important.

“There is a form of seeing a patient and knowing that something is wrong, such as recognizing early that he has Parkinson’s,” or listening to his heart and detecting a sound, said Dr. David Anderson, a cardiologist with Stanford Health Care in Oakland, California. He said online medicine is a great tool for follow-up exams with established patients, but not optimal for an initial exam.

When enrolling in one of the new tariffs, patients are advised to select an online doctor who will then serve as the first point of contact for the patient for most primary care services and who can make referrals for personal care by a doctor on the network if necessary. It is possible that patients never meet their online doctor in person.

Many insurers that offer virtual-first plans hire outside companies to provide medical staff. Doctors may be licensed in multiple states and not be nearby. Insurers say participating online doctors can access patients ‘medical information and test results through the insurers’ electronic health record system or online recruitment company. Experts warn that it could be difficult to transmit information from doctors, clinics or hospitals outside the network of an insurer. Exchanging patient information through EMRs is challenging even for physicians working under traditional insurance plans with face-to-face visits – especially moving data between them different health systems or specialist practices.

So new was the virtual first concept that Priority Health called those who signed up this year to make sure they understood how it works. “When people are more comfortable with brick and mortar retailing, they should look to other options,” Kincaid said, adding that the plans have attracted 5,000 enrollers since January, a number that will double over the next year.

Other versions of telehealth plans are available, offered by big names like Humana, Kaiser Permanente, Oscar, and UnitedHealthcare. Some emphasize that basic services start online but are not required. Some are aimed directly at consumers. Others are sold to employers.

Oscar Virtual Care’s health plans, sold in several states including Texas, Florida, and New York, allow patients to choose between online or in-person services.

“These aren’t just virtual plans,” said Marianna Spanos, Oscar vice president and general manager of the virtual nursing division. “You can always opt for a more traditional provider.”

Although Kaiser Permanente employs its own in-house medical staff, most insurers rely on contract doctors, psychotherapists, and other staff, often provided by Doctor on Demand from San Francisco.

Doctor on Demand was launched in 2013 and is aimed at individual consumers. Starting with a Humana contract in 2019, it has since expanded to include staff for several other insurers. The company, which has its own electronic health record system, hires a number of primary care, mental health and other medical services providers. Doctors must be certified by the board. The pay depends in part on how many patients see them, and there is no upper limit. For example, some want to work part-time and many work from home.

In general, virtual first health plans can include lower premiums or provide such financial incentives as there are no co-payments for online visits. All boast that members get appointments quickly, sometimes within minutes. Patients with serious problems are supported in arranging emergency help. If online doctors find that patients need a blood test, vaccination or a specialist visit, they refer them to a local practice, clinic or a specialist on the insurer’s network.

Think of HMO 2.0 as a strategy to contain costs.

“There’s more control over patient interaction and where they’re referred,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

However, patients should be aware that some of these plans will only allow an inpatient visit if their virtual doctor, who may never have seen them in person, deems it necessary.

Skeptics find that many circumstances dictate this personal care. A recent study estimated that around 66% of primary care visits require it. For example, it is impossible to check reflexes and virtually examine tonsils for infection.

Patients in some programs, including Harvard Pilgrim, are given kits that may include devices such as blood pressure cuffs and thermometers – although medical gauges at home are often not as accurate as those in offices. Online doctors can also ask a patient to check for swollen lymph nodes, shine a light down their throat on camera, or take other action to help the doctor diagnose a problem.

Priority Health’s Kincaid noted that Doctor on Demand also establishes protocols for children’s wellness visits that they say must be done in person.

“Getting accurate height and weight measurements and vaccinations is important for children’s wellness visits,” said Kincaid.

When considering virtual-first plans, patients should look closely not only at the premiums, but also at the deductibles and co-payments that may be set at levels that discourage personal care, proponents say. The rules are varied and dizzying.

For example, the VirtualBronze plan, offered by Community Choice Health through the state ACA marketplace in parts of Texas, requires high patient contributions for many types of face-to-face visits.

Patients do not pay co-payment for using Doctor on Demand online doctors for visits to primary care or for access to personal preventive services as defined by the ACA, such as: B. Vaccinations or cancer check-ups. But for other personal services, Community Choice’s virtual plan costs patients out of pocket as they pay the cost of treatment until they meet an annual deductible of $ 8,530.

Kaiser Permanente’s Virtual Complete plan is offered to large employers does not bear any additional payment for online maintenance. Patients can opt to see a personal doctor three times a year for primary care if they are willing to pay a co-payment. After these three visits, a deductible will be charged for all further personal visits.

Plans sold through state or state marketplaces and plans offered by employers must meet the requirements of the ACA. This includes a range of services, from visiting a doctor to providing hospital care.

Georgetown’s Corlette said consumers should be wary of plans that are not ACA-compliant.

She fears the emergence of plans that give patients “access to online providers, but nothing else”. And that, she said, “wouldn’t be considered a major health insurance policy.”

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Reference: khn.org

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