Virtual health care evaluated by UCSF and Stanford

Student pharmacists at the UCSF School of Pharmacy and a student at the Stanford Graduate School of Business are teaming with a UCSF School of Pharmacy health economics professor to understand the rapidly evolving virtual health care world and how it is impacting the efficiency, effectiveness, and cost of care.

The first step was to identify the full spectrum of virtual health care already bringing doctors and patients together in new ways. They are also working on a systematic literature review of the economic impact of these virtual systems to better examine how integrated virtual health care systems impact patient health care quality and costs.

The students are second-year UCSF doctor of pharmacy (PharmD) students David Szeto, a member, and Ashley Kim, the president of the UCSF student chapter of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). They came to UCSF Department of Clinical Pharmacy economics professor and ISPOR faculty advisor Leslie Wilson, PhD, seeking a collaborative research project in the health services field. Wilson introduced them to Jackson Lai, a former associate at Madison Dearborn Partners and a second-year Stanford Graduate School of Business student working with HealthTap, a virtual health care startup. Together they reviewed the entire virtual health care landscape and research on its economic effects. Virtual health has a growing presence in the health care market, and the pharmacy students recognized the need to understand the presence in order to keep pace with the rapidly evolving health care system.

Presented below is an overview of the economic potential of virtual health as initially reviewed by a UCSF-Stanford student team. This work is intended to lead to a comprehensive research paper.

The new virtual health care landscape

The student team describes five levels of virtual health care, from simple to complex:

1. Single, isolated technologies
2. Single electronic health services components (SEHS)
3. Virtual points of care (VPCs)
4. Virtual add-ons to existing health care systems
5. Complete virtual systems of health care

1. Single, isolated technologies

Single, isolated technologies are the simplest form of virtual health care—resources that help solve small inefficiencies in the health care workstream, such as lack of patient access to primary health care and lack of adherence to a plan of care. Examples are ZocDoc, HealthVault, and Alme Health Coach.

The direct cost of non-adherence to doctors’ advice is estimated at $100 billion to $289 billion annually. Estimates indicate that a cost-to-savings ratio of 1:10 can be reached with improved self-management of chronic diseases.

2. Single electronic health services components (SEHS)

Virtual components of health care

The second level consists broadly of Single Electronic Health Services (SEHS)—isolated health services that can be integrated into different health care systems either synchronously or asynchronously.

Asynchronous SEHS examples include Zipnosis, which relies on an online survey to quickly provide a local clinician’s diagnosis, and NextMD, which enables patients to email their health care providers with non-urgent medical questions. Synchronous models include Teladoc, American Well, and Doctor on Demand which enable virtual consultations with doctors over phone or video at $40 to $50 per visit.

As with the first level, these are not meant to replace actual in-person visits and may act as key virtual health care components that can be funneled into an actual virtual health care system.

3. Virtual points of care (VPC)

Single health services bundled into an isolated point of care

Virtual Points-of-Care technologies (VPCs) exist in a variety of settings such as virtual kiosks and corner clinics in local pharmacies, hospitals, retail stores, or employer sites, like HealthSpot and MedAvail MedCenter.

VPCs offer a comprehensive virtual primary clinic visit with face-to-face physician interaction, in-kiosk diagnostic tools, prescription drug dispensing, and virtual consultation with a pharmacist. Larger health care systems, such as Kaiser Permanente, use these point-of-care services to make their care delivery more efficient.

4. Virtual add-ons to existing health care systems

Existing health care systems building in virtual health care components

The fourth level consists of existing health care systems, medical homes, or teaching hospitals that incorporate virtual health care to improve patient access and realize cost savings. For example, Kaiser Permanente has been effectively implementing single technologies, SEHS, and VPC to support preventive care and suggest that more than 50 percent of patient visits are already virtual.

Other examples include Carolinas HealthCare System (CHS), a large public health care system in North and South Carolina, and the Cleveland Clinic, which offers both virtual consultations and visits to health care providers through Cleveland Clinic MyCare, a free mobile application, and HealthSpot stations (walk-in kiosks). Consults and visits cost $49 each.

5. Complete virtual systems of health care

The most integrated approach to virtual health care

The fifth level is complete integration. HealthTap is the only complete virtual system of health care uncovered by the student team. The forthcoming Veterans Administration virtual hospital will also fit into this category. These systems approach care from a virtual perspective first and contain all the key components of care.

HealthTap, for instance, is supported by a network of 71,000 board-certified and physicians licensed in the United States (U.S.), providing free health care information along with guidance via both asynchronous and real-time consults. Unlike virtual health care added on to existing health care systems, these physicians can decide for themselves how much virtual care they provide, and what hours they work. They also can build their own panel of patients entirely within HealthTap and have a true virtual medical practice that provides continuity of care.

Systems reaching this final level of virtualness in our spectrum must integrate several levels of virtual services. HealthTap’s platform, for example, works by triaging users through six levels:

• Level 1 is a question and answer (Q&A) forum rich in information on every possible health topic and is free to the public.
• Level 2 enables registered users to ask 150-character questions and receive personalized answers from HealthTap doctors.
• Level 3 is an asynchronous text message (SMS) consult with a U.S.-licensed doctor for $44.
• Level 4 is a live video consult with a doctor on any mobile device or personal computer also for $44.
• Level 5 is when a HealthTap doctor recommends an in-person visit to a doctor.
• Level 6 involves a recommended trip to the emergency room (ER) or an urgent care center.

In addition to health care information and virtual medical care, doctors provide personalized checklists and reminders to help patients stay on top of their health. As per the assessment of the student team, these complete virtual health care systems have the most potential for increased patient access and health care savings at all levels of care.

What does it cost? What does it all mean?

The abundance of new virtual health care companies highlights widespread confidence in the potential economic benefits when integrating virtual components into the U.S. health care system while increasing quality of care.

Take, for instance, the parents of a two-year-old suffering from an earache in the middle of the night. They may seek online advice about earache symptoms and treatments or follow simple point-and-click instructions to initiate a virtual consult with a doctor on call. During the virtual consult, the pediatrician asks a series of questions and, if needed, prescribes medications from their local pharmacy. Alternatively, the pediatrician could recommend an in-person visit. Data shows that the average time to schedule an appointment with a primary care provider is 19.5 days, excluding other factors such as travel and wait time inside the doctor’s office. The ease, comfort, and accessibility of receiving care immediately without having to leave home are therefore very attractive.

The potential savings depends on the level of services within the virtual health care spectrum, the first of which comes from the ability to triage what would otherwise be general, office-based visits to lower-cost settings. This can generate a savings of $123 billion annually within the U.S. health care system. The CDC suggests that of the one billion annual doctor visits, 55 percent are to primary care physicians (PCPs) and the rest are to specialists. The number one reason to visit a PCP is a cough.

As the Kaiser Permanente and Mayo experiences demonstrate, 40 to 50 percent of PCP visits can be converted to virtual appointments, resulting in potential savings of $11 billion. Savings triple to about $28 billion when specialist visits are converted online. De-escalation of just 60 percent of the 80 percent of ER visits could reduce the average cost from $1,200 to $120.

Savings may be just as great, if not more, from the clinician’s point of view, as there is a clear need for increased efficiency. A typical in-office visit for a patient with a chronic issue is about 15 minutes, with an additional two minutes for documentation. With a virtual visit, this becomes about 3.6 minutes including documentation.

Savings can also include those addressing the shortage of doctors, including time wasted by patients who fail to keep appointments for in-person office visits (“no shows”). The Association of American Medical Colleges (AAMC) Workforce Studies projected a deficit of 62,900 physicians in 2015, doubling to 130,000 physicians by 2025, thereby stressing the need for virtual services.

Virtual health care visits can also potentially reduce the need for hospital admissions and readmissions. In 2013, CHS implemented a telemedicine pilot for patients with a primary diagnosis of heart failure. Results showed a reduction in readmission rates from about 19.39 percent in 2010 to 9.82 percent in 2013.

In addition, complete virtual health care systems have the most potential for leveraging additional efficiencies of care for the patient by partnering with other types of health care services such as pharmacies, laboratories, radiology, and care management services. These partnerships can lead to more standardization across these services. Moreover, virtual health care systems that collaborate with integrated diagnostics firms or pharmacies can eliminate the need for an in-person visit to order a test or write a prescription.

Virtual health care systems take tools that already exist in health care, such as telemedicine, information, algorithms, and physical physician visits, and remove silos to make the continuum of health care a seamless experience. The more complete the virtual health care on our spectrum, the more potential for improvements in the patient experience and efficiency to the health care system.

Although patients naturally prefer to see their doctor in-person, they are generally positive about virtual health care visits. More research is needed to better define when virtual visits are most appropriate. In addition, insurance systems and clinician practice requirements need to change to catch up to virtual health care.

Note: The article is the sole responsibility of the authors who all approved the final version. One student was an intern with HealthTap when compiling cost savings of virtual health.