Doctor On Demand and Virtual Primary Care: What is Virtual Primary Care?

25% of all American adults and 50% of those under 30 years of age don’t have a primary care physician (PCP) and of those with a PCP, only 15% see them at least once per year. Why? The nature of primary care, and of what patients are looking for from PCPs has evolved.

At Doctor On Demand, we believe the time has come for telemedicine to evolve to address the growing challenges in healthcare. As a result, we introduced Virtual Primary Care to the healthcare ecosystem. How has telemedicine evolved and what is Virtual Primary Care?

Read on this article and learn:

• What Virtual Primary Care provides that telemedicine does not.
• The impact that Virtual Primary Care is having on clinical and financial outcomes, as well as the patient and provider experience.
• How technology facilitates a better patient and physician experience.

Executive Summary

At Doctor On Demand, we believe the time has come for telemedicine to evolve to address the growing challenges in healthcare. As a result, we introduced Virtual Primary Care to the healthcare ecosystem. How has telemedicine evolved and what is Virtual Primary Care? This is the question that Doctor On Demand set-out to answer in this white paper. We assembled a team of Virtual Primary Care physicians and members of our leadership team to discuss the new category of Virtual Primary Care and how it is changing patients’ access to quality healthcare, creating a more holistic approach to healthcare and building a stronger relationship between patients and physicians.

In this paper, we will:

1. Discuss the challenges and state of primary care today, including the growing scarcity of primary care access.
2. Investigate why so few Americans have a primary care physician and its effects on their health.
3. Analyze the environmental factors that have led to shortages in healthcare.
4. Announce the emergence of a new healthcare category and define what Virtual Primary Care is and isn’t, as well as what Virtual Primary Care provides that telemedicine does not.
5. Illustrate the impact that Virtual Primary Care is having on clinical and financial outcomes, as well as the patient and provider experience.
6. Explain how technology facilitates a better patient and physician experience.
7. Discuss what a holistic approach to Virtual Primary Care means and how it improves continuity of care.

Introduction

One-fourth of all American adults and 50% of those under 30 years of age don’t have a primary care physician (PCP)1; and of those with a PCP, only 15% see them at least once per year. Why? The nature of primary care, and of what patients are looking for from PCPs has evolved. Gone are the days when patients are willing to travel across town to spend 30 minutes or more in the waiting room, next to people who are coughing, sneezing, and can potentially spread illness.

Patients are tired of doctor appointments where they sit down with a physician who is too busy looking at their electronic medical record to make eye contact or listen, and worst of all isn’t empathetic to the patient’s situation. Instead, the physician quickly hands the patient a prescription—with no explanation—for medication before hustling out of the room.

Thankfully, there is a much better alternative. Virtual Primary Care has evolved into the experience both patients and providers are looking for while providing access to the quality care they deserve.

So, what is Virtual Primary Care?

Virtual Primary Care is:

• Integrative, mind and body care
• A video-first platform with integrated voice and messaging channels
• A source of primary employment for physicians
• Coordinated in-network referrals

Virtual Primary Care is not:

• Urgent care
• Telephone and text-based
• Part of the gig economy
• Siloed capabilities

Today, Virtual Primary Care delivers on the promise of providing patients with a primary care physician who is familiar to them. The key difference is that the physician and his or her team are available wherever the patient is, can be seen in the convenience of the patient’s home, workplace, or while traveling on vacation.

Virtual Primary Care delivers a healthcare experience that is compassionate, efficient, and very respectful of the patient’s time. It is relationship-centered care with physicians who are passionate about shared decision making and who take time to explain medical concerns thoroughly to their patients. Those are just some of the defining traits of Virtual Primary Care, and throughout this paper, we will discuss more this emerging category.

The Status of Primary Care Today

Nearly 30% of Americans do not have a PCP and nearly half (45%) of 83 million American millennials do not have a PCP. So what led to this situation?

Consumer Reports On Health reported last year that the average wait time for a new patient to get an appointment with a family doctor was 29 days — which is up from three weeks in 2014. For specialists, it took 21 days to see a Cardiologist and it averaged 26 days to see a Gynecologist. Wait times to see a PCP have become worse than for seeing a specialist. As a result, consumers are responding to this by bypassing primary care and going to specialists, urgent care or the ER.

However, continuity of care has consistently shown to improve patient outcomes. Primary care professionals serve on the front lines of healthcare. For many, they are the first point of contact with the healthcare system. That means they are often the first to see depression, early signs of cancer or chronic diseases such as heart failure, and other health concerns. They ensure patients get the right care, in the right setting, by the best available provider, and with shared decisions based on the patient and family’s desires and values.

A primary care physician is the main healthcare provider in non-emergency situations. She provides preventive care and teaches healthy lifestyle choices. She identifies and treats common medical conditions, provides continuing care for chronic conditions, and when necessary makes referrals to medical specialists. A primary care physician gives you a trusting, ongoing relationship with one medical professional over time. – TriStar Southern Hills Medical Center

The data overwhelmingly supports the importance of primary care. Adults in the U.S. who have a PCP have 19% lower odds of premature death than those who only see specialists for their care. Patients who have a PCP save 33% on healthcare over their peers who only see specialists. Access to primary care helps keep people out of emergency rooms, where care costs are at least four times as much as other outpatient options. A study in a North Carolina ER found that nearly 60% of the patients’ problems could have been addressed in a primary care clinic.

Regularly seeing a PCP is also associated with improved health outcomes, including all-cause mortality, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. For instance, in an influential study, Basu and Berkowitz et. al. found that a greater density of PCPs is associated with better population health in locales across the United States. Their findings are consistent with an extensive body of research linking primary care with better individual-level as well as population-level health outcomes.

There is a patient-driven demand for continuity of care and excellent physician-patient relationships within primary care offered in local communities. However, the healthcare system in the U.S. has been shown to have many gaps in care, especially for preventive care and in preventing patients from becoming burdened with the onset of expensive chronic illnesses. These chronic illnesses include hypertension, diabetes, and cholesterol problems, which when coupled with the obesity epidemic, drives avoidable, high-dollar costs.

Catching and treating problems early, which happens during annual wellness visits, is also cheaper than treating severe or advanced illness, which often brings patients to specialists. If everyone saw a PCP first for their care, it would save the U.S. an estimated $67 billion every year, according to a study by the American Academy of Family Physicians. Another study conducted by the Oregon Health Authority, Portland State University, and other organizations found that for every $1 increase in spending in primary care resulted in $13 in savings in overall spending.

Shortages in Access to Care

Meanwhile, the number of PCPs in the U.S. has been declining in recent years, with only 20% of new physicians entering primary care fields, according to Health Affairs. PCPs in traditional settings face heavy workloads, lower pay than other specialties, and onerous administrative burdens.

These factors have been driving physician burnout and leading to doctors leaving primary care. The Association of American Medical Colleges has estimated that by 2032, the U.S. will face a shortage of more than 55,000 PCPs. Furthermore, one-third of all currently active doctors will be older than 65 in the next decade. Small towns and rural areas will feel the greater impact of these shortages, but urban dwellers will also find themselves in primary care deserts because of the physician shortage.

At Doctor On Demand, we believe the medical community can better support physicians by taking actionable steps to alleviate physician burnout. We are tackling this issue by creating more flexible schedules while eliminating overhead and administrative burdens. We believe healthy, engaged doctors take better care of patients and strive to maintain our 99% physician engagement score.2

Additionally, Doctor On Demand is creating an opportunity for physicians to practice medicine the way they want to by giving them the chance to take time with patients and deliver relationship-centered care. Doctor On Demand is also committed to providing ongoing training and learning opportunities for our providers.

Virtual Primary Care: The Next Big Step in Healthcare

So how can Virtual Primary Care help fill in the gaps left by in-person primary care? First, it’s important to understand telemedicine’s role and evolution, and how this has led to the creation of an entirely new category.

Factors like location, convenience and the high cost of urgent care and emergency room visits gave rise to telemedicine. This framework was a cost-effective alternative to urgent care and it gave patients the flexibility to schedule doctor visits at their convenience.

Doctor On Demand introduced Virtual Primary Care to address the pressing healthcare challenges which telemedicine could not fully impact.

Virtual Primary Care offers the access and convenience of telemedicine, but pairs those aspects with the benefits of traditional primary care. Through Virtual Primary Care, patients receive an integrated view of their health and receive continuity of care with the same physician, which is done virtually via video visits.

There are three key elements of Virtual Primary Care:

1. Dedicated care teams led by a national employed physician practice that creates a continuous, relationship-centered care environment for patients.
2. A single, integrated telehealth platform that enables smart referrals to support connectivity and interoperability across the clinical ecosystem (ensuring all member referrals, lab services, imaging, and prescriptions stay in-network).
3. Software and machine learning tools that provide clinical and administrative support to physicians and care teams, giving patients more control over the management of their health.

Virtual Primary Care provides patients with preventive health, chronic care management, urgent care, and integrated behavioral health, as well as continuity of care. Through Virtual Primary Care, patients can see the same physician on an ongoing basis and can establish this physician as their PCP. This is only possible when the virtual care provider has a fully-employed workforce of physicians, nurse practitioners, and care coordinators, to provide consistent care across patient needs.

In practice, Virtual Primary Care gives patients face-to-face time with their physicians across devices. The patient talks to a physician via video technology, and the physician and patient experience the benefit of seeing each other face-to-face. For both physician and patient, the technology behind Virtual Primary Care makes for a successful visit with thorough examinations and high patient satisfaction.

Continuity of care is established through regularly scheduled visits with a patient’s PCP, reducing fragmented care within the healthcare system. Additionally, Virtual Primary Care sets high clinical standards and offers specialized physician training. This model of Virtual Primary Care ensures that the patient and physician relationship is strengthened and preserved.

One element of traditional telemedicine that is preserved through Virtual Primary Care is the ability for patients to easily schedule an appointment with a physician. Patients can see their physician at home, during their lunch break, or on their commute. Physicians are available at times convenient to the patient’s schedule, not vice versa.

What Makes Doctor On Demand Physicians Different

Doctor On Demand provides an employed, dedicated medical practice armed with the tools of labs, video visits, home care kits, e-prescribing, and a care team to help between doctor visits. The physicians are all board-certified. The medical practice is also fully integrated with our behavioral health practice of licensed psychologists and psychiatrists.

We surround these talented physicians with a multi-disciplinary care team designed to provide support to both the patient and the physician in providing relationship-centered, proactive primary care. Our care teams have advanced practice nurses, pharmacists, dieticians, referral coordinators, and other connected, caring staff. Care teams have a special value for patients with chronic illnesses. Many patients with diabetes or with the common combination of high blood pressure and high cholesterol, take three or more medications daily, following national best practice guidelines. Chronic care teams that include pharmacists add value in these situations.

In summary, each member who enrolls in our Virtual Primary Care program through their health plan or employer has a digital front door to primary care which works more efficiently and timely than the traditional brick and mortar clinic model.

Reimagining the Physical and the Exams that Matter Most to Patients

What about the “Annual Physical Exam”—how does Virtual Primary Care provide this? Multiple research studies have shown that an annual physical exam is not useful in the average adult—and is a waste of valuable resources. Experts differ on the value of physical exams in adults with no symptoms, but most experts agree that an annual wellness check can be very beneficial for most adults.

An annual wellness check involves discussing a person’s risk factors based on family history, social history, occupation, stress factors, and previous results in one’s health record. So it is the personal attention to the individual in an unhurried visit, leading to detailed lifestyle recommendations that add the unique value to these annual wellness checks for adults. It is the relationship—with a doctor who knows a patient—that makes a true difference.

What about pap smears, breast exams, prostate exams, etc.? Through Doctor On Demand’s Synapse platform, when a doctor orders a referral, the patient will receive special instructions in their visit notes. A patient’s Doctor On Demand PCP will refer the patient to a gynecologist, urologist, or other appropriate specialist or physician in their health plan network. Patients will also receive a custom email notifying them that a referral coordinator will contact them to find a specialist and help them schedule an appointment.

For patients, this approach immediately helps speed up timely follow-up of important issues. In the larger scheme, though, these conscientious referrals also help alleviate the bottleneck of downstream spend. While PCPs only represent 5-8% of total delivery spend, PCPs directly influence the remaining percentage of downstream spend based on their referrals—many of which are out of network. PCP miscommunication with specialists, or “referral leakage,” costs our systems over $150B a year. By keeping referrals in-network, Doctor On Demand PCPs provide cost relief for patients and help mend the referral gap at large.

What about children and adolescents? Our physicians follow the U.S. Centers for Disease Control/Advisory Committee on Immunization Practices (ACIP) Guidelines on recommended exams for children and adolescents. Our doctors have received special training on these issues and are enabled with tools to bring up these guidelines during video visits. Additionally, ACIP immunization guidelines are reviewed with parents, with referrals to local sources of child and adolescent vaccinations.

What if a patient has a condition that needs long-term treatment and monitoring? As we’ve mentioned, our doctors are deeply experienced in common chronic conditions such as asthma, hypertension, diabetes/prediabetes, obesity, and cholesterol problems. Our fully-employed national medical practice with integrated labs and behavioral health offers easy access to a quarterback for chronic care: a patient’s Doctor On Demand primary care physician.

A system where you have to drive some time to a clinic and where you have to wait for 30 minutes or more to see a doctor who runs in and spends 5-10 minutes with you—is woefully inadequate to address the needs of most people with a chronic condition. What is needed is a system that hovers, and feels nearby to you, addressing your needs in depth with little to no friction. – Patient-Centered Primary Care Collaborative

Integrated Behavioral Health Resources

Behavioral health is a concern for a significant percentage of individuals, families, employers, and health plans. The Centers for Disease Control and Prevention (CDC) has calculated that 20% of Americans will have a mental health concern. Additionally, statistics show that 16 million adults in the U.S.—roughly 7% of the adult population—have had at least one major depressive episode in the past year. At Doctor On Demand, 30% of our medical patients express a mental health concern. For these reasons, we have trained our PCPs to recognize and assess the severity of depression and anxiety.

At Doctor On Demand, our patients have a choice of whether they want to be evaluated by a PCP, or by a licensed psychologist or psychiatrist. A referral to a psychiatrist is important when there is a question of bipolar illness, psychosis, or schizophrenia, when suicide risk is significant, when the diagnosis is not clear, or when patients do not respond to initial treatment. In all situations, we offer care from the privacy of a patient’s home. We bring high quality, empathetic physicians and psychologists to small towns, rural, urban and suburban areas.

At Doctor On Demand, we provide full mind and body integrated care. Too often in traditional healthcare clinics, our medical care is disconnected, with mental health clinicians and medical doctors not knowing or communicating directly with each other. It is frustrating for many patients that their primary doctor does not know anything about their mental health or medication history. Instead, our medical doctors and behavioral health professionals share seamless electronic health records and recommendations, which leads to building trust with our patients, and better continuity of care.

Here’s a story from one of our physicians, Dr. Tony Yuan:

I saw a member for the first time in July for an infection. The patient has diabetes and also mentioned casually that he was experiencing persistent fatigue near the end of his visit. I offered to order some labs for him including CBC, CMP, TSH and testosterone levels to evaluate for possible causes of his fatigue. He just got new insurance and a new primary care doctor so I told him to take his labs to his doctor for further work up of his fatigue. The patient saw his primary care doctor as scheduled. However, the patient scheduled an appointment with me as a followup because he was still experiencing extreme fatigue which wasn’t addressed by his new primary care doctor. We went over his labs which were all essentially normal so I was unable to tell him the exact cause of his fatigue.

Then using the new knowledge and tools I have gained through working for Doctor On Demand, I started asking him questions about possible depression which the patient had never been diagnosed with. I performed the PHQ-9 questionnaire for depression and he scored 22, which meets criteria for major depression. I spent 35 minutes with this patient and we came to the conclusion that his extreme fatigue was probably due to his underlying depression. We agreed on a plan to start him on an antidepressant as well as refer him to our behavioral health practice to start counseling, which the patient was very happy about since he preferred seeing the doctor from the comfort of his own home. I then sent in a referral, through our Care Team who scheduled a follow up appointment with me as well as with a psychologist. – Dr. Tony Yuan

Conclusion

By exploring the topic of Virtual Primary Care, we want to illuminate the issues and difficulties patients face today when it comes to receiving quality care and provide solutions for how this can be improved through Virtual Primary Care.

Highlights from this white paper:

• One-fourth of American adults do not have a primary care physician, and nearly half (45%) of 83 million millennial Americans do not have a primary care physician.
• Meanwhile, the number of PCPs in the U.S. has been declining in recent years, with only 20% of new physicians entering primary care fields, according to Health Affairs. The Association of American Medical Colleges has estimated that by 2032, the U.S. will face a shortage of more than 55,000 PCPs.
• If every patient saw a primary care physician instead of an urgent care physician or specialist for their care, it would save the U.S. an estimated $67 billion every year.
• Virtual Primary Care can help fill in the gaps left by in-person primary care. There are three key elements of Virtual Primary Care: (1) Dedicated care teams led by a national employed physician practice; (2) A single, integrated telehealth platform that supports connectivity across the clinical ecosystem; (3) Software and machine learning tools that provide clinical and administrative support to physicians and care teams.
• Video visits foster stronger personal connections between doctors and patients and more meaningful interactions. More than 50% of face-to-face communication is non-verbal and these non-verbal cues convey clinically important information for both doctors and patients.
• At Doctor On Demand, our virtual care is delivered via video visits and supported by voice and secure messaging. This allows the patient and the doctor to see each other online, face-to-face and discuss medical conditions or concerns as if they were meeting in-person. Ultimately, this can help to create a stronger patient-provider relationship.