Health plans

The Pros and Cons of a New Twist in Health Plans Economy

During the height of the COVID-19 pandemic, people often relied on telemedicine for doctor visits. Now insurers are betting that some patients have liked it enough to adopt new types of health coverage that encourage video visits – or outright insist on them.

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

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

Often cheaper deals take advantage of the new familiarity and convenience of routine care online. But skeptics see a downside: the risk of overlooking something important.

“There is a gestalt of seeing a patient and knowing that something is wrong, like maybe detecting very early that he has Parkinson’s disease”, or listening to his heart and discovering a murmur, said Dr David Anderson, cardiologist affiliated with Stanford Health. Care in Oakland, California. He said online medicine is a great tool for follow-up visits with established patients, but is not optimal for an initial review.

When signing up for one of the new plans, patients are encouraged to select an online physician, who then serves as the patient’s first point of contact for most primary care services and can recommend in-person care. to a network doctor, if necessary. Patients may never meet their doctor online in person.

Many insurers offering virtual plans first hire outside companies to provide medical staff. Doctors may be licensed in more than one state and not be located nearby. Insurers say participating online physicians can access patient medical information and test results through the insurers’ electronic medical records system or those of the third-party online recruiting company. What could be tricky, according to experts, is the transfer of information from doctors, clinics or hospitals outside of an insurer’s network. Sharing patient information through EMRs is difficult even for physicians operating under traditional insurance plans with in-person visits, especially transferring data between different healthcare systems or specialist practices.

The concept of a virtual first was so new that Priority Health called on registrants this year to make sure they understood how it worked. “If people were more comfortable with bricks and mortar, they would have to choose other options,” Kincaid said, adding that the plans had attracted 5,000 registrants since January, a number she hopes to double. ‘next year.

Other versions of telehealth plans are available, offered by big names such as Humana, Kaiser Permanente, Oscar and UnitedHealthcare. Some emphasize but do not require primary care to start online. Some are aimed directly at consumers. Others are sold to employers.

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

“These are not just virtual plans,” said Marianna Spanos, vice president of Oscar and general manager of its virtual care division. “You can always go for a more traditional supplier. “

Although Kaiser Permanente uses its own in-house medical staff, most insurers rely on contract physicians, mental health therapists, and other staff, often provided by San Francisco-based Doctor on Demand.

Doctor on Demand launched in 2013, intended for individuals. Starting with a Humana contract in 2019, it has since expanded to staff several other insurers. The company, which has its own electronic medical records system, hires a range of primary care, mental health and other medical providers. Doctors must be certified by the board of directors. The salary is partly based on the number of patients they see, and there is no upper limit. Some want to work part time, for example, and many work from home.

In general, virtual health first plans may have lower premiums or offer financial incentives such as no copayments for online visits. They all boast that members can get appointments quickly, sometimes within minutes. Patients with serious problems are helped to organize emergency help. If online doctors determine that patients need a blood test, vaccination, or specialist visit, they refer them to a local practice, clinic or specialist within the network. insurer.

As a strategy to contain costs, think of HMO 2.0.

“There is more control over how patients interact and where they are referred,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

Nonetheless, patients should be aware that some of these plans may allow a physical visit only if their virtual doctor, who may never have examined them in person, deems it necessary.

Skeptics note that many circumstances require in-person care. A recent study estimated that about 66 percent of primary care visits required it. For example, reflexes cannot be checked and it is difficult to virtually examine tonsils for infection.

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

Kincaid, of Priority Health, noted that Doctor on Demand also establishes protocols for child welfare visits, which he says must be done in person.

“Getting accurate height and weight measurements and immunizations is important for child welfare visits,” Kincaid said.

When reviewing virtual plans first, advocates say patients should take a close look at not only premiums, but also deductibles and co-payments, which can be set at levels that discourage in-person care. . The rules are varied and dizzying.

The VirtualBronze plan offered in the federal ACA market in parts of Texas by Community Choice Health, for example, requires significant patient input for many types of in-person visits.

Patients do not incur a co-payment for the use of Doctor on Demand’s online physicians for primary care visits or for access to in-person preventive services as defined by the ACA, such as vaccinations or cancer screenings. But for other in-person services, Community Choice’s virtual plan will cost patients out of pocket as they pay the cost of care until they hit an annual deductible of $ 8,530.

The Kaiser Permanente Virtual Complete plan offered to large employers does not include a co-payment for online care. Patients can choose to see a doctor in person three times a year for primary care if they are willing to pay a co-payment. After these three visits, any additional in-person visits are subject to a deductible.

Plans sold in federal or state markets and those offered by employers must meet ACA requirements. This includes a range of services, from doctor visits to hospital care.

Corlette, in Georgetown, said consumers should be wary of plans that are not ACA compliant.

She fears the advent of plans that give patients “access to online providers, but nothing else.” And that, she said, “would not be considered major medical insurance.”

Kaiser Health News produces in-depth journalism on health issues. It is one of the three main operational programs of the Kaiser Family Foundation.


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