###PRIMARY CARE ACCESS IN THE U.S. Since the finalization of the Affordable Care Act in 2012, millions of Americans have entered the healthcare system for the first time, applying increased pressure on an already strained system. In 2014, the average wait time for a primary care appointment in the US was 19 days.1 With experts predicting crisis-level shortages in primary care providers through 2025,2 medical groups are grappling with access challenges while striving to not over-burden their clinicians.
The average wait time for a primary care appointment was 19 days.
Among primary care providers, the prevalence of burnout is already at 50% and has increased steadily over the last decade.3 As the nation’s healthcare system shifts increasingly towards paying for value rather than paying for volume, access to quality healthcare plays a pivotal role in that transformation. Over the past few years, new technologies have emerged that have the potential to enable health systems to increase access to care for patients without overtaxing clinicians. This paper investigates how a digital care team member can be used to supplement patient-centered medical home teams and solve access problems by using innovative technology.
###Changing the Face of Primary Care Over the past decade, physician assistants and nurse practitioners have played a growing role in the delivery of primary care in order to help manage the unmet patient care demand, as well as the challenges of patient access. Along those same lines, patient-centered medical home (PCMH) models utilize multidisciplinary care teams that include physicians, advanced nurse practitioners, physician assistants, nurses, pharmacists, nutritionists, social workers,educators, and care coordinators.
To maximize the benefits of a team-based care model, each clinician should practice at the top of license. Rather than relying solely on the physician to address all aspects of the patient’s care, highly functional PCMH practices look to nurse practitioners,behaviorists, social workers, and pharmacists to engage with the patient and deliver care. Reconciling medications, updating the patient’s medical history, and providing patient education are examples of tasks that non-physician caregivers can manage at a lower cost, and often, with better outcomes.
Early findings from Colorado and Oklahoma, which have statewide Medicaid initiatives around PCMHs, show that both states greatly improved access to care for Medicaid patients under the PCMH model. In Colorado, 90% of parents with children on Medicaid report improvement are getting appointments.4 In addition, one physician reported that his daily patient access went from 21 to 28 after his practice became a PCMH.5
###Meeting Patients’ Needs and Desires While PCMH models can be valuable in addressing more complex patient needs, not all patient visits warrant the involvement of a full multidisciplinary team. Furthermore, with the increasing availability of new technologies and competitive pressures, access to primary care services no longer needs to be restricted to the traditional realm of in-person visits at a physician’s office.
Patients now seek primary care services at retail clinics, employee clinics, video visits, or online using a virtual visit.
67% of patients prefer asynchronous communication over a video visit.
In a recent Advisory Board Company study, patients selected convenience as the main deciding factor when choosing where to seek primary care services, particularly for simple, common conditions.6 Perhaps most telling of technology’s impact on healthcare delivery is that 67% of patients indicated that they prefer asynchronous communication, such as email or virtual visits, over a video visit.7 Diversifying the ways in which patients access primary care increases the likelihood that patients receive the specific care they need, when they need it.
###Efficient Care for Common Conditions A substantial percentage of primary care patient visits are for common, simple conditions. In fact, minor skin conditions and viral upper respiratory tract issues are among the top disease groups in the primary care setting, together making up more than 60% of disease prevalence.8 A recent Health Affairs study found that respiratory illnesses are among the most common conditions for which patients pursue a virtual visit, accounting for nearly a third of all virtual visits.9
Meeting the needs of patients with these types of conditions in an in-person face-to-face visit is time-consuming work. It is also work that is often well below top-of-license practice for a physician. Adding a digital care team member to the patients’ care teams provides immediate access to care for the patients with low-acuity conditions, as well as accelerated care to those with higher acuity conditions who can’t be safely treated online. It is an easy, effective way to simplify a patient’s pathway to care.
###How is a ‘Digital care team member’ different than Telehealth? Telehealth is the delivery of care to a patient who is geographically distant from their provider, whether by telephone, secure message, or video. A digital care team member provides that same convenience to patients, and also automates a substantial portion of the care delivery process for providers, which makes that care markedly more efficient for providers.
As an example, Bright.md’s SmartExam™ system acts as a digital physician assistant, dynamically interviewing patients, gathering a thorough patient history and guided physical exam. SmartExam then takes the information gathered through that interview and dynamically documents it in the form of a chart-ready SOAP note.
A provider, who is part of the patient’s extended PCMH care team, can quickly review that information, choose a diagnosis and treatment plan, and deliver care in about 2 minutes, rather than the traditional 15 - 20 minutes per visit.
With a digital care team member, providers can deliver high quality care in 2 minutes.
Orders are automatically placed, prescriptions sent, personalized patient instructions delivered, billing completed, and follow-up managed. In addition, all care is documented in the patient’s existing Electronic Medical Record, using standards-based integrations.
These “virtual visits” offer a simple, convenient way to provide high-quality care for patients with low-acuity conditions, such as upper respiratory infections, allergies, bladder infections, and ear pain. For patients who can’t safely receive care online, either the virtual visit platform itself or the digital care team members can direct these patients to the most appropriate level of care for their condition.
This leads us to the first reason all PCMH care teams should have a digital care team-member:
#1 PATIENT CONVENIENCE:
With virtual visits, patients receive convenient, high-quality care from their providers. From the patient’s perspective, virtual visits can take place at any location and at a time that works best for them – a cornerstone of convenience. As technology has become increasingly incorporated into daily life, patients have come to expect the same access and ease of use with their healthcare as they do today with online banking and shopping.
Adding a digital care team member to the PCMH team also helps address the varying needs of patients. Not all patients have complex medical needs, nor do they require the support of a PCMH. For non-complex patients with low-acuity conditions, getting care from a digital care team member is one of the most convenient ways to address their care needs.
By providing convenient access to services that meet patients’ needs, delivery systems can help prevent the care fragmentation that has been driven by the retail-ization of low-acuity care. This enables them to better manage their patients’ broader care needs.
The Patient’s Hidden Costs of Care
Combined with the cost of the average copay, in-person primary care visits are not only inconvenient, they’re costly to the patient. Based on a research study from Harvard Medical School, the average cost to a patient, in terms of lost productivity, for each medical visit is $43.10 In addition to decreasing patient costs, virtual visits also decrease provider costs. On average, providers can deliver care through virtual visits for $20 or less per visit.
That brings us to the second reason all PCMH care teams should have a digital care team member:
Providing care through digital care team members offers the most cost-effective way to deliver high-quality primary care for low-acuity conditions. Affordability is achieved in many ways, a few of which are highlighted in this paper. Lower acuity patients can, by nature of their condition, be treated virtually by an advanced practitioner. Providing care in this manner expands in-clinic capacity for the physician to see higher acuity patients.
Existing 99444 billing codes are seeing increasing rates of reimbursement, typically in the $40 to $65 range. Assuming clinicians spend 2 minutes delivering care virtually,this reduces the cost of a low-acuity primary care visit by an estimated 81%. In other words, the per-visit margin for a primary care visit increases by 5 to 10 times traditional per-visit margins, when care is delivered virtually.11
It is worth noting that this calculation does not factor in the additional revenue opportunity from expanding access to more patients, or by seeing a greater number of higher-acuity patients in person.
Optimize the Medical License
In addition to easing capacity constraints, virtual visits help all clinicians practice to the top of their license. This is the third reason every PCMH should have a digital care team member.
Physician’s time is one of the most valuable healthcare resources.
Healthcare organizations who choose to adopt a virtual visit solution and centralize provider staffing for delivering care virtually achieve multiple gains in efficiency.
Firstly, the patients with low-acuity conditions who can be safely treated online receive care from advanced practitioners, rather than physicians. Secondly, the rate at which patients can be treated online with a virtual visit is up to 10 times faster than the in-person rate. In other words, using a digital care team member, a single provider can see 150 to 200 patients per day.12
Lastly, given the structure of a virtual visit, the time constraint under which providers operate when gathering information from a patient disappears. A virtual visit platform can consistently conduct a thorough exam without omitting key questions due to time limitations. This leads to more comprehensive information being collected from the patient without adding more provider time to the visit.
Given these gains in efficiency, virtual visits help liberate one of healthcare’s most valuable resources: physician time.
###Conclusion In summary, healthcare organizations seeking to improve access to primary care should examine the benefits of a virtual visit solution. Virtual visits offer convenient, affordable, and efficient care for both patients and providers. As the nation’s healthcare system shifts from fee-for-service to risk-based arrangements, adding a digital care team member to the PCMHs reduces costs, increases access, and leads to all patients getting the proper care they need, when they need it.
If you are interested in learning more about virtual visits, please contact Bright.md at 877.888.5242.
- Elisabeth Rosenthal, “The Health Care Waiting Game: Long Waits for Doctors’ Appointments Have Become the Norm,” NYT Sunday Review (July 5, 2014).
- Whitney L.J. Howell, “Medical Schools Develop Programs to Grow Primary Care Pipeline”, AAMC Reporter (November 2015).
- Inge Houkes, et al “Development of burnout over time and the causal order of the three dimensions of burnout among male and female GPs. A three-wave panel study,” BMC Public Health (2011).
- Bazemore, Andrew MD, MPH et al, “The Diversity of Providers on the Family Medicine Team,” Journal of the American Board of Family Medicine, Vol. 29, no. 1 (January – February 2016).
- Christine Sinsky, MD and Ellie Rajcevich, MPA, “Implementing team-based care,” AMA: StepsForward (2015).
- Anna Yakovenko et al, “What Do Consumers Want,” Advisory Board Research Briefing (2014).
- Yakovenko et al.
- Jennifer L. St. Sauver et al, “Why Patients Visit Their Doctors: Assessing the Most Prevalent Conditions in a Defined American Population,” Mayo Clinic Proceedings, Vol. 88, Issue 1, http://www.mayoclinicproceedings.org/article/S0025-6196(12)01036-1/fulltext (January 2013).
- Lori Uscher-Pines and Ateev Mehrota, “Analysis of Teladoc Use Seems to Indicate Expanded Access to Care for Patients without Prior Connection to a Provider,” Health Affairs, Vol. 35, no. 2 (February 2014).
- Felice J. Freyer, “It costs you $43 every time you wait for the doctor,” Boston Globe (October 5, 2015).
- Carrie Pallardy, “30 statistics on average commercial reimbursement by specialty in 2014,” Becker’s Healthcare (February 6, 2015).
- Based on initial data from sample clinical partners of Bright.md.