Is the Doctor’s Office Dead? Practice of Primary Care Goes Virtual

“The doctor’s office is dead,” said Nick Desai, co-founder and CEO of Heal, a virtual primary care company that leverages telemedicine and home visits to connect patients with providers.

Primary care has been in a tough position for years. Poor access to care, inadequate reimbursement, increasing overhead costs, financial insecurity, and clinician burnout are some of the challenges practices have recently faced. And each of these has been exacerbated by COVID-19.

Primary care practices are slated to lose $15 billion in 2020 as a result of visit cancellations at the start of the pandemic, a recent study from Harvard Medical School and American Board of Family Medicine revealed.

Independent and smaller practices will be hit the hardest by the financial losses unless payment policies or other aspects of the healthcare system change, researchers warned.

“We're already seeing a major uptick in independent primary care practices struggling and companies closing,” stated Andy Ellner, MD, MSc, founder and CEO of Firefly Health, another virtual primary care provider. “They've been dependent for a long time on revenue tied to in-person service visits. So, many of them took a huge revenue hit overnight.”

Companies like Heal and Firefly Health are looking to be the change primary care needs to remain operational in the face of new patient demands for more convenient care access, innovative technologies, and even a global pandemic.

“The primary care system is struggling. Doctors waste about 65 percent of their time on bureaucracy, leaving them with an average of only seven minutes per patient and creating potentially threatening gaps in diagnosis and treatment,” Desai said.

Heal is looking to address the obstacles of primary care by modernizing the business model to deliver virtual, home-based care. And the model is achieving the goals of modern medicine: higher quality care at lower costs.

“By focusing on house calls from unhurried doctors, data-driven care, social determinants of health, and seamless care delivery, Heal has delivered 200,000 house calls and telemedicine visits across the US in less than five years, driving more than $68 million in healthcare cost savings and reducing unnecessary trips to the emergency room and urgent care by 71 percent,” Desai reported.

“With the impact of COVID-19, Heal has broadened its application of telemedicine services in addition to doctor house calls,” added Desai. “Currently, Heal is delivering approximately 8,000 telemedicine appointments per month while also doing about 33 percent more house calls since the pandemic began.”

Firefly Health, the virtual primary care providers based in Massachusetts, is also seeing a major surge in demand during the pandemic.

“What we're experiencing in the marketplace is employers, and increasingly the public, expect something different from primary care and healthcare in general than what traditional providers have been able to offer,” said Ellner. “They've been accustomed to other services in their life that have one click or come to them in their home, and they're just beginning to get a taste of that being possible in healthcare. We're seeing demand for models much more like that. So, I think it's going to be difficult for traditional providers to thrive in the future, especially with serving younger patient populations.”

Firefly Health replaces a patient’s traditional primary care provider with a “continuous virtual service,” Ellner explained.

In other words, individuals or employees of workplaces that sign up get a care team with a physician, nurse practitioner, and a health coach, as well as on-demand access to a behavioral health specialist. The team connected with patients through technology, providing nearly all care virtually unless in-person care is needed. In those cases, patients are referred to Firefly Health’s network of specialists and urgent care centers.

Telehealth has been a boon to COVID-19 response efforts, enabling providers to continue office visits even when shelter-in-place orders kept patients at home. But implementation of virtual primary care has not been easy for primary care practices.

“Independent practices are often not as well set up to be able to provide care remotely,” according to Ellner.

Telehealth implementation is a hefty investment for practices, which do not have the deep pockets of hospitals and health systems. Regulatory flexibilities and payment parity have helped practices scrape up the capital to invest in a system, but the temporary measures may leave practices without a sustainable telehealth strategy.

“While we think that the shift to telehealth parity is an important step and it's something that's been helpful to us because we provide most care virtually, where we see the future from a payment or revenue perspective is going it's much more to capitation,” Ellner stated. “That might be a less accepted term at this point but some type of fixed monthly payment for a set of services. That creates a lot of opportunity to provide care in different ways.”

Practices with at least half of their income for primary care based on a prospective, capitated payment fared better than their peers entrenched in fee-for-service, according to experts at The Larry A. Green Center.

Capitated payments or the more popular per member per month reimbursement give primary care providers the flexibility to deliver care the way they and their patients want, including virtually.

“About 80 percent of the care that we provide at Firefly Health is not done through a visit, even if it's a video,” Ellner said. “When you move away from that context, you have this continuous connection with people and you can get a lot more done just over a simple chat. So, if you have a urinary tract infection and we have an established relationship and know your history, that’s the kind of thing we can take care of in literal seconds and we can do it very safely.”

Now, industry experts agree that telehealth and other virtual forms of primary care will never fully replace the in-person visit. However, virtual care capabilities combined with more convenient access to care, such as house calls and in-person visits only when absolutely necessary, can achieve what primary care has struggled to do: improve clinical outcomes, increase patient satisfaction, and lower healthcare costs.

But to realize those improvements and potentially make it out of a global pandemic, primary care providers will have to loosen their dependence on fee-for-service or encounter-based payments in order to develop the capabilities needed to become resilient and patient-focused.

“There’s no doubt that the need for house calls and telemedicine spiked during COVID-19, but we think the trend is here to stay,” said Desai. “The important thing to understand here is that it’s the combination of house calls and telemedicine – along with digital monitoring as well as tracking the social determinants of health – that together deliver the best value to patients.”