Over 2 years into the pandemic, the shift to virtual health has proven that it is here to stay. Increased patient demand, increased provider offerings, as well as regulatory changes to increase access and reimbursement have led to changes in the way patients access care and their healthcare journeys. Payers are looking at the proliferation of virtual care, telehealth, remote patient monitoring, and digital tools, and leveraging the associated technologies in order to provide more cost-effective high-quality care.
Several payers have launched virtual-first health plans, taking the emerging and evolving telehealth and virtual care tools to offer a health plan where the first entry point to getting medical care is with a virtual provider. These models are different than a virtual urgent care visit and instead look to build a virtual primary care provider (PCP) relationship to help manage chronic conditions and all nonemergency medical questions. Payers are building out different models for this, some with a virtual first PCP approach, others more blended with a virtual and in-person collaboration, or even a virtual and in-person collaboration with the same provider.1,2 No matter the model, these payers are trying to offer a new way to make care accessible and keep costs affordable.
Although the first virtual-first health plan approach was launched prepandemic in 2019 by Humana, many others have since followed suite, with entrants in the commercial, Affordable Care Act, and even Medicare Advantage markets.2,3 These entrants span national payers, such as Cigna, UnitedHealthcare, Humana, and Aetna, as well as many regional plans. Advantages that have been outlined regarding these virtual health plans include convenience, higher quality care, better outcomes through better preventative care, and reduced costs due to efficiencies.2 However, due to the recent rollout of these type of offerings, data is not available yet to support the impact on quality of care or the long-term impact on total cost of care, and the industry will anxiously be looking to see how effective these plans will be.
One of the first plans to offer a virtual-first health plan was Oscar Health. Their virtual-first health plan includes $0 access to virtual primary care but also builds in additional benefits into the plan design regarding labs and medications. For example, if your virtual provider prescribes or orders one of those services, they waive those cost shares as well. Oscar Health also offers a virtual urgent care benefit. Launched in 2021, they have seen early indicators that virtual care will be able to produce savings for the payer. They have found an 80% first-fill medication adherence rate for medications that their virtual care prescribers prescribe and have shown that 24% of prescribers are less likely to prescribe high-cost drugs when a lower-cost option is available.2
This change to a virtual-first health plan model impacts many aspects of care delivery. The way in which treatment decisions are made, how patients are educated and monitored, where and how patients are referred, and how they are receive follow-up care are all evolving in a virtual environment. These virtual-first models will likely serve as gatekeepers to downstream services, and they will look to refer to labs, imaging facilities, and network specialists that have proven that they can deliver high-value care. Drug selection will also likely be integrated into these virtual providers’ EMRs, driving providers toward lower cost alternatives when available. Patient education in a virtual setting may require new types of tools, which will warrant consideration of health literacy as a barrier. Comprehensive chronic care management and care navigation will also look different in a virtual model, and it will be imperative that these models are successful in ensuring that patients remain engaged and adherent with their care plan.
As patient-provider interactions change to a virtual setting, manufacturers will need to ensure that they are also evolving to provide the needed tools and support in this care delivery setting to drive market access for their products. Manufacturers will need to understand some of the additional challenges these virtual models may create, with the payers potentially having more choice in drug selection through EMR integration for these virtual PCPs. It will be important for manufacturers to demonstrate their products’ value to the decision-makers for the virtual platform to ensure prescriber demand in a virtual setting. In this new care delivery model, it will be important to ensure that virtual tools to facilitate patient education and other resources to help virtual providers across the patient journey are available. Manufacturers should also monitor the adoption of these types of plans and understand their growth in the market to determine the level of resources needed to support this type of care model.
- Whitehead DC, Mehrotra A. The growing phenomenon of “virtual-first” primary care. JAMA Network. Published November 22, 2021. https://jamanetwork.com/journals/jama/article-abstract/2786666
- Waddill K. How payers can launch a virtual-first health plan. Health Payer Intelligence. Published August 23, 2021. https://healthpayerintelligence.com/features/how-payers-can-launch-a-virtual-first-health-plan
- Waddill K. Three common characteristics among virtual-first health plans. Health Payer Intelligence. Published March 1, 2021. https://healthpayerintelligence.com/news/three-common-characteristics-among-virtual-first-health-plans