Blog: Patients need virtual care with the full care team

Provider-based patient care appears ready to go virtual and real-time. In April, Robert Pearl, MD, CEO of the Permanente Medical Group, drew a lot attention at the World Health Care Congress in April when he predicted, by 2018, Kaiser Permanente patients would receive more virtual visits than in-person office visits. For me, as a primary care physician (and occasionally a patient), this is an exciting time! Technology is enabling big changes to make providers more accessible to patients when and where patients need healthcare. But is provider-patient virtual care enough to address the access needs of our aging population with more and more chronic conditions?

According to the CDC, 86 percent of healthcare expenses in 2010 were for Americans with chronic conditions, in part because almost one half of our population (117 million people) has a chronic condition and one in four Americans has two or more. Chronic conditions drive most of our provider-patient interactions, but to achieve commonly desired clinical outcomes like controlled blood pressure, diabetes mellitus or heart failure, provider-patient interactions are not enough. Patients need education, motivation and guidance about their self-management… and according to Hibbard and Greene in Health Affairs, they need to be activated, possessing “the skills and confidence...to become actively engaged in their health care.”

One of the biggest lessons from our collective patient-centered medical home experience in primary care is that the rest of the care team is as important as the provider in activating patients. So are we ready to provide real-time virtual care for full care teams to help activate patients with chronic conditions?

Geisinger Health Plan (GHP) thinks so. GHP has an extensive remote patient monitoring program for patients with heart failure to engage and activate patients at home, rather than require them to come to a medical office for care and interaction with case management. Patients measure daily weight, blood pressure, heart rate and symptoms of heart failure, all of which are monitored remotely by a telehealth nursing team that reaches out to patients who show signs or symptoms of worsening heart failure. GHP’s own published analyses show that its highly respected complex case management program was further enhanced by real-time virtual care—with a reduction in the probability of readmission by 44% and a 3.3:1 ROI.

HealthPartners thinks so. HealthPartners Medical Group in Minnesota deployed a remote patient monitoring program for clinical pharmacists to help patients better manage their hypertension; its published results show that a care team can effectively engage patients remotely and help lower blood pressure by an average of 11/6 mmHg.

New York City Health + Hospitals thinks so. NYC Health + Hospitals uses remote patient monitoring for patients with heart failure and also diabetes mellitus. Its published outcomes demonstrate an average HbA1c reduction of 1 percent across an all-urban, underserved and often non-English speaking population.

Is there a difference between virtual care with a physician versus the rest of the care team? For one, only some health insurance plans reimburse for care team virtual visits, such as NY State Medicaid; for most provider-based programs, other funding is required. However, providers who enter value-based purchasing arrangements, or payers themselves, do not face this obstacle—they benefit directly by the reduced cost of care with real-time virtual care programs like remote patient monitoring and can fund programs without requiring billable provider codes.

Additionally, recent published studies have shown that remote patient monitoring still requires a care team of people who work with patients to become activated and engaged in their care. Technology distribution to patients without integrated oversight and support by a care team does not appear to be sufficient; it can lead to low rates of patient adherence with monitoring programs, producing poor engagement and unsuccessful outcomes.

If we pay attention to what works and what doesn’t for real-time virtual care with providers and other members of a care team, I’m confident that we can meet Dr. Pearl’s challenge as an entire care team, not just as providers.

Jonathan Leviss, MD, FACP, is CMO at AMC Health. He is also a physician at Thundermist Health Center in Rhode Island and an assistant professor at the Brown University School of Public Health.