New Frontiers in Healthcare Delivery: Evolving Models of Primary Care and Disease Management

APRIL 5, 2022

Routine visits with a primary care physician can reduce the cost of healthcare by addressing medical conditions before they become catastrophic.

According to group health plan data from USI Insurance Services, an active primary care relationship significantly reduces emergency room visits, in-patient hospital admissions, average length of hospital stay, and hospital readmission rates. Regular physician engagement also increases general preventative care, including age- and gender-appropriate cancer screenings and early detection, which can have a significant impact on health outcomes and costs.

Yet, despite the benefits of routine care, 70% to 80% of adult  plan members do not engage in annual primary care visits, while 50% to 60% do not receive recommended screenings for various reasons: lack of access to care or physician engagement, financial or other barriers, or simply personal preference. While there have been advances in healthcare delivery methods, such as telemedicine and virtual care, traditional healthcare has not evolved much to meet the changing needs of plan members. Many vendors have been working to change this and meet members where they are. But can this have a material impact on plan usage and claims costs?

Alternative Care Options

The terms “telemedicine” and “virtual care” are vague and frequently used interchangeably, often causing confusion and unexpected costs, due to low engagement or little to no improvement in health outcomes. Understanding the differences between services is the key to assessing what value they may bring to an existing health plan.

Telemedicine: A vendor arrangement outside of a traditional physician practice, providing acute, non-emergency, non-primary care for minor illness and injury.

• Appointments conducted via phone or video
• Diagnoses made with visual/audio observation, without labs or screenings
• Employers typically charged an access fee plus fee-for-service or a flat per-employee, per-month fee
• Fees are a separate cost outside of the health plan
• Often low or no co-pay for plan members

While telemedicine can provide convenient access to immediate care, this type of service is meant to be a single interaction without follow-up. Treating medical staff do not have access to patient medical history, and the lack of labs or screening equipment make this less than ideal for routine healthcare.

Virtual Care: During the height of the pandemic, many traditional physician practices turned to virtual care to provide continued care to patients. Virtual care is similar to telemedicine in that visits are conducted via phone or video, but with some important distinctions:

• Treating staff have access to medical records
• Charged as an in-network fee-for-service, similar to an in-person visit
• Standard cost-sharing typically applies (deductibles/co-pays)

Unlike telemedicine, virtual care provided by a traditional physician practice group can help improve continuity of care. 

DPC: A Different Type of Healthcare: Combines elements of telemedicine with traditional physician care to provide patients with more personalized and convenient access to care. In addition to acute and non-emergency care, DPC can provide primary care, as well as:

• Specialty care for certain chronic conditions, such as hypertension and diabetes, and behavioral health
• Some lab and screening capabilities — either in home/at work or standalone/drop-off facilities
• Some prescription dispensing capabilities

DPC services are typically staffed by a lower-cost provider, such as a registered nurse (RN) or physician assistant (PA), and can provide more flexible access to care, such as video, phone and chat/text options, and/or in-home or at-work visits. Fees are typically charged on a per-employee, per-month basis, regardless of utilization.

A Sample of Healthcare Delivery Models Available in the Market

Note: These solutions and service providers may not be available in every region or marketplace. Contact USI to learn more about which services and solutions may be available for your organization.

To learn more about how USI can help improve healthcare engagement and reduce claims costs, contact your local USI benefits consultant or email ebsolutions@usi.com.