Tuesday, November 9, 2021

Virtual-first primary care: will the proof be in the pudding?

Six months ago, Dr. Elisabeth Rosenthal, editor-in-chief of Kaiser Health News and a former emergency medicine physician, wrote a commentary titled "Telemedicine Is a Tool - Not a Replacement for Your Doctor's Touch." She warned that since the expansion of telehealth driven by the exigencies of the COVID-19 pandemic had outstripped the evidence of its effectiveness and cost-effectiveness, "deploying it too widely risks poorer care, inequities and even more outrageous charges in a system already infamous for big bills." At that time, my office was transitioning back to seeing a majority of patients in person, a process that has continued to the point that virtual (video or audio-only) visits now make up only about 10-20% of my daily schedule. I have welcomed this return to normal. Like nearly all clinicians, I experienced my share of awkward telemedicine tales and never quite figured out how to virtually diagnose and manage conditions that require a hands-on physical examination, such as musculoskeletal issues. My telehealth experience also confirmed my prior suspicion that connecting with new patients via tablet or computer screen was more difficult than in the physical proximity of an examination room.

In contrast, some health care insurers and vendors are going all-in on virtual care, offering "virtual-first" plans with lower premiums that steer patients to primary care physicians whom they may never meet in person. Teladoc offers Primary360; Amwell has Virtual Primary Care; CareFirst is advertising CloseKnit; and United Healthcare is launching NavigateNOW. All of these services offer more scheduling flexibility than traditional practices, self-monitoring tools, and promise to refer patients for in person visits with primary care or specialist physicians if necessary. It seems that these plans are targeted at younger adults, who are less likely to have an established source of primary care and more likely to be comfortable having solely digital relationships with physicians. (A research letter published this week in Annals of Internal Medicine found that fewer than 1 in 4 U.S. adults over age 65 used telemedicine services in 2020.)

This phenomenon raises a number of questions. Who are these companies hiring to provide care? I periodically receive unsolicited e-mail requests to moonlight for commercial telehealth providers that tout flexible schedules and generous payment rates, but the idea of sitting in front of a screen any more than I already am makes it a nonstarter. I very much doubt there is an existing pool of doctors or nurse practitioners who have been doing nothing during the pandemic. And although some have suggested that practicing virtual medicine well requires specific training, core competencies and curricula remain to be developed. That means that there's no way to assure that present-day "medical virtualists" are actually well-qualified to practice in this challenging environment.

Drs. Kurt Herzer and Peter Pronovost have argued in a JAMA Viewpoint that like in-person care, it's important to demonstrate that virtual care is high-quality: that is, safe and effective, efficient and timely, patient centered and equitable. None of these are so clearly true that the research doesn't need to be done to find out. It's quite possible, in fact, that virtual-first primary care could lead to more incorrect diagnoses, unnecessary visits, and excessive testing, and worsen health disparities due to inequitable access. 

As a believer in the value of a longitudinal relationship with a primary care clinician, I think that if virtual-first plans end up creating such relationships where there wouldn't have been any, then they will likely improve health for some people. If, on the other hand, these plans lure large numbers of patients away from brick-and-mortar practices due to convenience, costs, or reduced choices (e.g., being the only type of plan offered by an employer), I forecast that accomplishing key primary care tasks such as care coordination will become even more difficult. In the past two decades, patients enrolled in fee-for-service Medicare saw more outpatient specialists without increasing their contacts with primary care physicians. It's hard to imagine that a virtual primary care doctor in California (or India or China, for that matter) is going to have more than a superficial knowledge of subspecialists, behavioral health, or health care resources available in Washington, DC. But like it or not, the future of primary care is coming, and time will tell if it makes things better or worse for us all.