Like many primary care practices, after a hasty transition to a year of phone calls and video visits, my practice is slowly transitioning back to “normal,” meaning that we are now seeing more patients in person than by video. However, as I reflect on the past year, I wonder how central this notion of the “in-person office visit” is to the delivery of primary care.
One of the unanticipated consequences of the COVID-19 pandemic is its acceleration of telehealth implementation. Over the past year, many patients who, prior to the pandemic, might never have had any inkling to obtain care remotely now have become accustomed to this new telehealth age.
Admittedly, some patients have been unable or unwilling to access care virtually, yet a surprising number of patients have embraced it. For better or worse, I have conducted virtual visits with patients from their bedroom, their office or workplace, and even their car. Now, fully vaccinated patients tell me that they still prefer video visits to in-person visits because they do not have to leave their home, fight traffic or miss work to see me. Many of my patients are very receptive to monitoring their blood pressure remotely as well.
Despite the benefits of virtual care, the number of tasks outside a patient visit has also recently seemed to skyrocket as patients have become more comfortable with asynchronous care driven by technology, such as MyChart messages, immediate result review, e-visits, and remote monitoring. Even on days when I don’t have patients scheduled, my workload consists of responding to patient messages, renewing prescriptions, following up on laboratory and imaging results and discussing these with patients, reviewing home blood pressure monitoring measurements, and reaching out to subspecialists and my nursing staff to coordinate care. Often one of these tasks leads to a cascading list of other tasks: An abnormal laboratory test leads to a MyChart message and response, followed by abdominal ultrasound and phone call, followed by a CT scan and another phone call, and possibly a message to a specialist. An elevated average blood pressure measurement leads to escalation of therapy, perhaps repeat lab work, a series of MyChart messages, and communication with my staff to arrange follow-up.
I often am in touch with patients virtually much more frequently than I would be if I relied only on in-person visits. I truly believe that this combination of virtual visits and asynchronous care facilitated by technology, combined with in-person visits when the need arises, enables me to deliver better and more patient-centered care than in-person visits alone.
While we are not completely there yet, in my idealized vision of primary care, nursing staff would asynchronously help ensure my patients are up-to-date on preventive services, aided by accurate reports of patients overdue for tests or vaccines. Nursing staff and I would continue to use remote monitoring to review not only patients’ home blood pressure values, glucose levels, and even activity levels from smartwatch data. Virtual group visits would help educate and empower my patients to manage their chronic diseases.
Unfortunately, the traditional fee-for-service model of primary care does not currently support this vision of primary care. Chronic care management and remote monitoring billing codes have been developed and expanded in recent years as an attempt to capture the additional time spent by physicians caring for patients beyond the traditional in-person patient visit.
But billing for these codes requires us to obtain separate patient consent, track time, and provide additional documentation that are significant barriers to more widespread use. In the case of chronic care management, not all patients are eligible for these services. Currently, under the telehealth waiver, both virtual check-in and e-visit codes can be used to bill for phone calls and MyChart messages, but this is difficult to do when patients are already accustomed to receiving these services at no cost, and it is unclear whether these codes will continue to be allowed once the waiver expires.
Alternative payment models, such as accountable care organizations or CMS’s Primary Care First model are intended to support a transition away from fee-for-service payment and support value-based care, but there are still many barriers to their success, with criticism of some of these new models.
The direct primary care model, through a membership fee paid by patients as an alternative to fee-for-service payment, allows physicians to spend more time with their patients, yet this model lacks outcome data and widespread use could decrease access to primary care. Global payment for primary care services (such as a per member per month amount) may be one method of supporting an enhanced vision of primary care through payment reform, yet more research is needed to design this model optimally.
Our ability to prevent, diagnose and treat disease has drastically evolved over the last hundred years. Yet astoundingly, the mechanism by which care is still delivered, the in-person office visit, has not drastically changed. As we transition to the post-COVID era, it is time for primary care to embrace innovative modes of care delivery beyond the in-person office visit and identify alternative payment models to support this patient-centered care.
Cara Litvin is an internal medicine physician.
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