Virtual Primary Care: Separating evidence from hype

By Justin Wu, MD

Healthcare seems to be settling into a normalizing phase, after the sudden jolt the pandemic sparked in telemedicine and virtual care through their adoption-by-necessity, and the temporary relaxation of regulations that enabled them.

Experiencing this transition as a primary care provider (PCP) now working in digital health, I believe it is a great time to take a step back and ask some critical questions looking at virtual primary care (VPC) in particular. To level-set on what I mean by VPC—in contrast to addressing mental health through telemedicine or offering 24/7 on-demand care for acute needs—VPC delivers wellness visits, chronic disease management, and care navigation through a modern technology platform.

Is VPC what patients/consumers really want?

A recent Mercer survey of over 700 employers found that 40% will offer a VPC physician network or service in 2023. Similarly, an Elevance Health online study of over 5,000 U.S. adults showed that only about one-third of respondents had even used VPC before, so we’re still in the relatively early stages of widespread VPC adoption. Convenience and improved access to care were not surprisingly among the top reasons people like VPC, but the truly interesting takeaway was the type of usage people reported—most commonly, prescription management, general wellness/treatment plans and wellness visits.

For the typical busy PCP, these are the areas most likely to get deprioritized in the 27 hours needed per day to follow recommended guidelines, so VPC may serve as a much needed channel to fill in those gaps. Rock Health’s 2022 Consumer adoption of digital health report continues to show an increased preference for telemedicine to handle prescription refills and minor illness visits. However, respondents in this survey still continued to prefer in-person care for chronic conditions and annual wellness visits, indicating that VPC is still on an uphill climb to be the preferred mode of care delivery for these visit reasons.

Does VPC lead to improved outcomes?

A serious concern about VPC is the possibility that it leads to suboptimal or poor care, but there is a small but growing body of research evaluating the effectiveness of VPC and its impact on clinical outcomes, which offer reasons for hope. One large-scale, longitudinal study by Lu et al. of over 9,000 patients, examined the VA’s Virtual Integrated Multisite Patient Aligned Care Team (V-IMPACT), which delivers VPC through in-clinic video appointments to rural veterans. It found that diabetes and blood pressure control were at least equivalent to traditional in-person care.

Additionally, a systematic review by Carillo de Albornoz et al. found that telemedicine in primary care generally had comparable quality to face-to-face visits in outcomes such as antibiotic use and guideline-based antibiotic management. As a whole, however, high-quality evidence is lacking, and more research is needed to evaluate VPC’s impact on patient safety, the timeliness of appropriate care, and the avoidance of harmful delays—particularly for acute conditions that require in-person treatment—and of course ensuring that VPC is equitable and at the very least, not worsening health disparities.

Does VPC reduce provider burnout?

While some recent data, such as Medical Economics’ 2022 Physician Burnout Survey show that for the first time in four years, there has been a slight improvement in burnout rates, still 94% of physicians reported burnout at some point in their career, and 73% of physicians reported feeling burnt out at the time they took the survey. In theory, VPC should help provide relief through improved appointment efficiency and work-life flexibility, but more research is needed to demonstrate the direct impact of VPC and telehealth on burnout.

The National Academy of Medicine’s report, Taking Action Against Clinician Burnout, presents a framework for a systems approach to clinician burnout and professional well-being, which calls out several work system factors such as job demands (unmanageable work schedules, time pressure) and work-life integration that VPC should be well positioned to address.

As we await stronger data on the impact of VPC on well-being, perhaps we can look to analogues such as the AMA’s 2021 Telehealth Use: Physician Survey to provide some early signal, in which a majority of respondents indicated that telehealth has improved the satisfaction of their work by 54.2%.

Is VPC cost effective?

If you’ve been following along in this post, you may have noticed a trend by now—the answer is still very much up for debate. There aren’t many health economics studies of VPC yet in the literature, but what we do have is a mixed bag.

In the same review by Carillo de Albornoz et al. mentioned above, telemedicine was associated with reduced cost compared with in-person visits, with economic evaluations showing shorter visits and cost savings due to reduced travel and parking, lower utilization (e.g. labs, imaging) and cost per episode. Additionally, a recent analysis by Epic’s Research team looking at over 18M primary care telehealth visits found that over 60% of the time, there was no in-person follow-up visit within 3 months, suggesting that most patients got the care they needed by the virtual visit alone.

On the other hand, an independent evaluation of Babylon’s digital service, GP at Hand, found that patients had a higher annual rate of consultations than shown in the national UK data, given their age and health status, potentially pointing to more utilization and an increased total cost of care.

What does the future of VPC look like?

Given the potential signals of how consumers are settling into their preferences in utilizing digital health, and early signs that clinical outcomes may be at least comparable, if not potentially better than in-person care, what does that say about the possible future of VPC?

Rather than patients having two PCPs—one in-person and one virtual, struggling with the question of who is quarterbacking the care plan, we’ll see more PCPs who already have an established relationship with the patient adopting virtual care platforms to expand access to their services, enhancing that continuity. This will generate operational efficiencies and maintain the integrated, team-based care coordination that’s necessary for a great patient experience and clinical outcomes.

The recent announcement by 98point6—an on-demand VPC company offering its virtual care technology now to ambulatory health systems—underscores this shift away from siloed VPC providers. Innovative models such as Sutter Health’s Tera practice, although few, have been leading the way in this hybrid virtual model of care for a number of years.

Conclusion

VPC and the digital health industry have passed the Peak of Inflated Expectations in Gartner’s hype cycle framework and are starting the slide down the Trough of Disillusionment at this juncture, but this is where the real work begins—when outcomes and cost savings need to be proven, and everything rides on figuring out how to scale what works.

There is no doubt a permanent place for VPC in the future of healthcare, but it will need to be well integrated with in-person primary care, show value for consumers and improve provider well-being before we really see it take off.

References

1. Whitehead DC, Mehrotra A. The Growing Phenomenon of “Virtual-First” Primary Care. JAMA. 2021;326(23):2365–2366. doi:10.1001/jama.2021.21169 Link

2. CB Insights. Unbundling The Family Doctor: How The Traditional Primary Care Experience Is Being Disrupted. Link

3. CB Insights. Healthcare in the Post-Covid World: 16 Ways Telehealth Could Transform Care. Link

4. Elevance Health. What Consumers Want from Virtual Primary Care- Findings. Link

5. MDLive. Virtual Primary Care data presented at the AHIP 2021 Institute & Expo. Link

6. Neves AL, van Dael J, O’Brien N, et al. Use and impact of virtual primary care on quality and safety: The public’s perspectives during the COVID-19 pandemic. Journal of Telemedicine and Telecare. 2021;0(0). doi:10.1177/1357633X211066235 Link

7. Pearl, R, Wayling, B, HBR. The Telehealth Era Is Just Beginning. Link

8. 2022 Deloitte Survey of US Healthcare Consumers

9. 2022 Deloitte Survey of US Physicians

10. Tera at Sutter Health/ website

11. 98point6 announcement

12. CVS VPC program (announced May 2022)

13. Medical Economics 2022 Physician Burnout Survey. Link

14. AHRQ Physician Burnout site

15. National Academies of Medicine. Taking Action Against Clinician Burnout. 2019 report.

16. Lu, A.D., Gunzburger, E., Glorioso, T.J. et al. Impact of Longitudinal Virtual Primary Care on Diabetes Quality of Care. J GEN INTERN MED 36, 2585–2592 (2021). https://doi.org/10.1007/s11606-020-06547-x

17. GP at Hand: patients are less sick than others but use services more, evaluation finds. BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2333

18. Kristina De Vera, Priyanka Challa, Rebecca H. Liu, Kaitlin Fuller, Anam Shahil Feroz, Anissa Gamble, Eunice Leung, and Emily Seto. Virtual Primary Care Implementation During COVID-19 in High-Income Countries: A Scoping Review. Telemedicine and e-Health.Jul 2022.920-931.http://doi.org/10.1089/tmj.2021.0377

19. Canadian Journal of Health Technologies. Approaches to Evaluations of Virtual Care in Primary Care. Vol 2, No 1, 2022. Link

20. Carrillo de Albornoz S, Sia KL, Harris A. The effectiveness of teleconsultations in primary care: systematic review. Fam Pract. 2022 Jan 19;39(1):168-182. doi: 10.1093/fampra/cmab077. PMID: 34278421; PMCID: PMC8344904.

21. Mercer Health News. Virtual-First Health Plans, Explained. Site

22. New York Times. According to Medical Guidelines, Your Doctor Needs a 27-hour Workday. Link

23. Rock Health. Consumer adoption of digital health in 2022: Moving at the speed of trust. Link

24. AMA 2021 Telehealth Use: Physician Survey. Link

25. Herzer KR, Pronovost PJ. Ensuring Quality in the Era of Virtual Care. JAMA. 2021;325(5):429–430. doi:10.1001/jama.2020.24955

26. Epic Research. Most Primary Care Telehealth Visits Unlikely to Need In-Person Follow-Up. Link.

This Proof Points edition was originally published on LinkedIn on 4/19/23.