Benefits Strategy

April 26, 2022

With its adoption and utilization accelerated by COVID-19, virtual health is poised to become an integral and critical component of health care. Growing investments into digital solutions and devices (e.g., care navigation support and remote monitoring tools) will further fuel this trend. The amount of venture capital funds entering the virtual health space has nearly tripled in recent years, and the possibilities created by technology are part of every serious conversation about the vision for the future of health care delivery and patient experience.¹

While virtual health has gained greater acceptance among employers, patients and providers—and has improved access to health care for many during the pandemic—there is now a heightened focus on quality of care received virtually, effective integration and extracting measurable value from the various modalities available to patients.

In creating a strong health care ecosystem that successfully integrates virtual health, input and considerations from various stakeholders need to be taken into account—especially from large employers, patients and providers. This article offers a set of insights and emerging challenges in virtual health, as well as ways that employers can broaden or rationalize their virtual offerings.

An Expanding Virtual Health Landscape

Increased uptake in virtual utilization alongside the increased demand for virtual care has led many employers to offer more virtual solutions within their health benefit offerings. These trends also have encouraged providers to transform their practices to offer virtual visit options. By utilizing a broad spectrum of innovations in technology (e.g., data monitoring, predictive analytics, sensor technology, artificial intelligence) and solutions (e.g., expert second opinion, physical therapy), there is an opportunity for virtual health to meet patient needs through a personalized experience within a connected ecosystem.

Over the past decade, digital technology has moved from operating on the fringes of the delivery of care to now aspiring to become an integral part of the services offered by traditional brick-and-mortar providers. The pandemic also acted as a major impetus to expand the availability of virtual care and reshape how care is accessed and provided. In an April 2021 survey, 84% of physicians were offering visits virtually and over half prefer to continue offering virtual care.¹ This trend, coupled with broad acceptance by patients, is indicative of how digital technology transformed the care delivery experience. Virtual care provided patients ease of access at a time when fear of exposure or suspended health care services prevented care from being offered at brick-and-mortar care delivery sites.

The most prevalent form of virtual health is telehealth visits for acute needs. According to the Business Group’s 2022 Large Employers’ Health Care Strategy and Plan Design Survey, nearly all respondents will offer telehealth and telemental health in 2022.² Moreover, virtual health for specific conditions (e.g., musculoskeletal, diabetes, sleep, and cardiac management) is estimated to see significant growth.²

Furthermore, virtual health is not limited to what is traditionally considered “medical” care. When asked whether employers planned to leverage virtual pharmacy solutions and digital therapeutics as part of their company’s overall pharmacy management strategy in 2022, 1 out of 10 respondents indicated that they will be tapping into these solutions and 29% are considering them for 2023/2024.² In addition, data from the Business Group’s 13th Annual Employer-Sponsored Health and Well-being Survey reveal that a growing number of participants offer or are considering offering virtual solutions for a wide array of well-being-related services in 2023 (e.g., subsidies for virtual fitness memberships and wearables).³

Today, patients can access virtual health services for a variety of needs, far beyond its initial application for acute care needs. Table 1 offers a breakdown of the major types of virtual solutions currently under development or available.^4-6

Table 1: Examples of Virtual Solutions

Virtual Consultations	Consumer Tools
Virtual urgent care (traditional telemedicine): On-demand medical consultation handling generalized and specialized urgent care needs; synchronous and/or asynchronous.	Digital remote monitoring for chronic conditions: Digital user input and monitoring devices that feed signals and triggers to broader care team.
Virtual primary care: Ongoing patient-provider relationship delivered either virtual only, virtual first or through a hybrid model approach where the primary care doctor also has a brick-and-mortar location.	Digital self-help tools: Digital tools used to help individuals with self-care for non-clinical needs.
Virtual visits with brick-and-mortar providers: A multichannel care model that leverages virtual and in-person visits as part of the care continuum with a provider.	E-triage: Care navigation tools that provide support in searching and scheduling care based on symptoms or conditions, along with cost and quality of providers.
Virtual expert second opinion: Virtual consultation with an expert resource in a relevant specialty for complex care situations to offer or confirm diagnosis and appropriateness of treatment recommendation.	Personalized digital content: Digital content that supports individualized education and self-management in the patient journey.
Teletherapy: Live, synchronized video interactions between patient and providers used to deliver therapy services (i.e., occupational, speech, dermatology, language, fertility and mental health therapy services).	Remote pharmacy and medical supply providers: Remote provision of certain prescriptions (e.g., contraceptives) via a web-based platform and/or smart phone application.
Digital Therapeutics	Artificial Intelligence (AI) Powered Provider Tools
Digital therapies: Evidence-based therapeutic interventions leveraging software to prevent, manage or treat a medical condition—potentially in lieu of traditional clinical treatments (e.g., pharmaceuticals). Click here to learn more about digital therapeutics and considerations for coverage.	Clinical decision making: AI-driven tools used to support provider diagnosis, recommend and develop treatment plans and flag anomalies.

Capitalizing on the Opportunity of Virtual Health

With new capabilities, virtual health has broadened its applications into primary care, specialty care and remote monitoring, among others. As such, employers have begun to evolve their virtual health offerings beyond basic telehealth and assess all their existing benefit programs through the perspective of the newly emerging care and engagement pathways.

Capitalizing on these opportunities can lead to:

Improving Access: Virtual care can improve access for everyone – including those in rural or health professional shortage areas. Patients in these areas may be able to access care more efficiently or gain easier access to specialists located in larger health systems, leading to improving quality of care.
Lowering Cost: Leveraging virtual care may allow providers to deliver certain care in a more cost-efficient way than in-person interactions without sacrificing the quality of care. By utilizing services virtually, lower acuity patients can be diverted away from costly care settings.
Supporting Patients: New technology such as remote monitoring devices allows providers to connect patients with the support they need before prolonged deterioration of their health or an acute medical event necessitating a hospital admission. Patients themselves, adapting to a virtual environment, may be more likely to use virtual monitoring devices more frequently (i.e., blood pressure monitoring), resulting in earlier risk identification.
Creating an Electronic Health Network: As technology evolves and virtual care solutions expand, care delivery will further be augmented with integrated data and automation to efficiently manage patients. This technology has the potential to conserve time for clinicians by reducing their administrative responsibilities and affording them more capacity to focus on delivering personalized care. Digital services such as E-triage also takes patient convenience into account by helping patients connect with their providers through an automated virtual setting.
Connecting the Care Teams: Creation of virtually connected care teams means that providers will be able to consult with another provider regarding the patient’s care plan. This will also give providers a better understanding of each patient’s care plan and future care that they may need. Through interoperability of data, enhanced care team interactions can be further augmented by having access to data that flows more freely and securely among payers, providers and patients.⁷

Overall, it appears that leveraging emerging technologies and innovations in virtual care has the potential to increase access to high-value care, improve outcomes and contain costs. Moreover, there is an opportunity for stakeholders to maximize these potential benefits by increasing integration of data and services.

The Progress in Mental Health Enabled Through Virtual Care

Virtual health has made a meaningful difference in recent years in improving access to mental health care and the patient experience. A study examining patient satisfaction with psychiatry services offered through telehealth found that despite it being a novel experience, most participants liked (and some even preferred) this modality, as it reduced their travel burden and increased access to specialty care.⁸ Digital mental health solutions can reduce barriers to care and address provider shortages across the country—particularly for those in rural communities with limited resources and/or connectivity. Though a majority of counties in the U.S. face a shortage of mental health providers, psychotherapy visits delivered virtually increased in 2020—underscoring in practice how telehealth has been leveraged to meet patient needs.^1,9 Children and adolescent mental health challenges continue to worsen, but employers can harness virtual care to help alleviate existing care gaps through expanded access.¹⁰ In fact, many respondents surveyed already offer a lineup of virtual care programs to employees as a way to achieve this aim - with telemental health leading the charge.²

Impact of Virtual Care in Other Specialties

While mental health was well suited to adopt virtual care delivery and enabled some gap closure, there are other specialties where there have been meaningful impacts on how care is delivered as a result of virtual expansion. Two examples include:

Oncology: Virtual care has played a major role in supporting cancer patients going through the course of cancer treatment, their caregivers and cancer survivors. For patients who do not live near a specialist or center of excellence, providers are offering virtual care to ease the burden of travel time and using remote monitoring to help their care team manage side effects and other disease-related issues.¹¹ Moreover, the risk of COVID-19 to the immunocompromised cancer patients has pushed utilization of telehealth in oncology to new heights—with one cancer center noting it went from having a small handful of telehealth visits per day to thousands at its peak.¹²
Musculoskeletal (MSK) Care: The Business Group’s 2022 Large Employers’ Health Care Strategy and Plan Design Survey found that respondents ranked MSK as the top condition driving health care costs and trend.² Through digital physical-therapy platforms, employers look to reduce the high rate of inappropriate surgeries and use of opioids among those living with chronic pain.¹³ When asked, 52% of respondents stated that they will offer MSK care management / physical therapy through a virtual setting in 2022 and 77% said that they will consider offering it in 2023/2024.² Click here to learn more on how you can address MSK conditions and physical therapy needs of your population.

How Primary Care Can Fundamentally Change with the Help of Virtual Care

A longtime challenge for many employers has been enabling plan members’ access to primary care providers through traditional brick-and-mortar settings. Research shows that utilization of primary care is associated with improved health outcomes.^{14, 15} Patients with a reliable source of care are more likely to be recommended to receive preventive services such as flu shots, blood pressure screenings and cancer screenings.¹⁵ Unfortunately, utilization of primary care is relatively low in the U.S., and the COVID-19 pandemic exacerbated the issue even further, with primary care visits dropping by 21% in 2020.¹⁶

Virtual primary care may be an effective tool for increasing access, and many employers have already embraced it as a benefits strategy. According to the Business Group’s 2022 Large Employers’ Health Care Strategy and Plan Design Survey, 22% of respondents reported that they have made virtual primary care services available to their plan members in 2022, and an additional 49% are considering doing so in 2023/2024.²

Importantly, virtual primary care isn’t just about access. It is also an opportunity to reduce total cost of care, improve quality, increase rates of patient experience reporting by making it much easier to gather information and boost patient adherence to evidence-based care.¹⁶

Virtual primary care is no longer simply a way to address acute problems. Longitudinal relationships are now possible between patients and primary care providers as they interact virtually making comprehensive virtual primary care a viable strategy. This goes for both virtual primary care delivered by providers who practice in a brick-and-mortar setting primarily, as well as those who practice entirely remotely under virtual-first arrangements. The need for effective, coordinated connections back to in-person care is vital for any virtual primary care approach to work, as some services like flu shots and certain cancer screenings are simply not possible to do remotely.

In addition, virtual care delivery used by a patient’s existing in-person primary care provider (PCP) to increase access to services outside of standard visits is also an effective way to coordinate care between virtual and in-person settings. Benefits of such arrangements include a consistent electronic health record and a strong patient-provider relationship.

Virtual-first primary care standalone vendors or health plans can easily increase access to primary care services, but employers must push any vendor offering these products to detail how they are creating seamless transitions from virtual care to in-person care and where and when each is necessary. Ultimately, the right balance between primary care services provided in-person and those provided virtually is going to vary based on patient needs and preferences and provider capabilities.

Risks and Barriers of Expanding Virtual Health

As the exponential rise and innovation within virtual health continues, it is incumbent on employers to stay informed about the risks, barriers and unintended consequences that have already emerged and may emerge in the future. While virtual services increase access to care, it is not a panacea. Virtual health can be an essential part of the new health care model when supported by best known practices and integrated within the health care ecosystem. However, adopting virtual health solutions without considering the broader impact on cost and each patient’s holistic care journey may end up doing more harm than good.

Below is a list of issues related to virtual health that can have a negative impact on care.

Fragmentation: The attempt to find solutions for the myriad care needs of a patient has not led to the desired improvement in care experience; rather, it has produced a complex and disconnected system. While there are numerous solutions, offering services that are not integrated can result in fragmentation of data and experience. The Future Health Index 2021 report found that two of the biggest barriers to the adoption of digital health technologies were difficulties with data management (44%) and lack of interoperability and data standards across technology platforms (37%).¹⁷
Data: Without an integrated patient data platform, providers will face challenges of data fragmentation, which increase the risk of treating patients and may create costly redundancy. Siloed data will impact continuity and personalization of care for patients and providers and potentially cause an increase in care gaps or allow existing care gaps to go unaddressed.
Point Solutions: If too many programs are engaging patients via different forms of communication, it can create frustration and confusion that ultimately leaves the patient with the additional complicated task of coordinating their own care. Overutilization and overlapping services resulting from fragmentation may create a fragmented care journey, costing many patients, their providers and their health plans more time, dollars and resources than initially predicted. A fragmented care journey can also be dangerous for patients who experience care gaps that can develop into acute medical events. One study examining trends in utilization and spending for acute respiratory illnesses estimates that net annual spending increased by $45 per telehealth user.¹⁸
Cost: With the health care system built on a fee-for-service model, any services provided virtually or through patient portal messaging may be billable. Many states allow for the reimbursement of certain telehealth visits to be on par with office visits. The expansion of virtual services may result in higher costs for employers and unexpected out-of-pocket costs for patients who may mistakenly presume that those services may be less expensive or free. In addition, even if a single telehealth visit for an illness may cost less, to the extent it needs to be supplemented by an in-person visit for more follow-up appointments and lab tests, overall cost may be higher. Liability concerns of a missed health risk may also prompt providers to recommend an in-person appointment for a patient after a virtual visit, which increases costs for their health plan and out-of-pocket for the patient.
Access: The pandemic also opened the door for states to waive their licensure requirements for telehealth services and allowed providers to practice across state lines. Employers with a national footprint may run into issues as more moratoriums on state licensing restrictions expire and patients can no longer seek care from an out-of-state provider. Patients most affected will be those near state borders. As a result, providers may have to scale back telehealth services and discontinue providing care to out-of-state patients. Patients who previously had trouble finding primary care or mental health providers may once again be left with no access to care, and care continuity will be affected in disciplines where the ongoing patient-provider relationship is linked to quality of care. If state licensing rules are not revised to allow virtual health providers to practice across state lines, patient access may be restricted.
Quality: As more providers move to the virtual space to deliver services, there is a risk that services will be lower quality if providers themselves are not adequately equipped and trained. One 2019 poll of older U.S. adults indicates that more than half perceived the overall quality of telehealth visits as less strong in comparison to in-person visits, as well as less effective at making the patient feeling well cared for.^{19, 20} Quality measurement to date has been anchored in provider licensure, and there are no regulations or quality measurement set forth for virtual solutions/platforms. Thus, services provided through the platform could be of lower quality since they are not subject to the same level of quality assurances as traditional providers. With new virtual options using unlicensed coaches or relying on computer algorithms, the current system has no existing mechanism to ensure virtual health quality. At present, there is not very much empirical research examining how rapid adoption of virtual care solutions during COVID-19 impacted the quality, safety and equity of care delivered over the long term.
Technology: Broadband-supported devices and solutions have made at-home care a more viable option for individuals living in rural areas, older adults, people with disabilities, those who have limited time or childcare issues, and those that just need a follow-up for chronic medical conditions. However, according to the COVID-19 Healthcare Coalition, the lack of access to technology and broadband internet are the most frequently cited barriers that physicians perceive as preventing their patients from participating in telehealth.²¹ Lack of knowledge of technology is a barrier for many older adults, and gaps in high-speed internet access disproportionately impact communities of color, those in rural areas and low-income households.^{19, 22} While audio-only telehealth services may be a solution, there are concerns about reimbursement and perceived quality of care.¹⁹
Equity: While technologically savvy patients can easily download and learn to use virtual health applications or navigate digital front-doors, some populations don’t have the ability or willingness to do so and are at risk of being left behind. Beyond a lack of usable broadband coverage, digital literacy, and specifically digital health literacy, continues to be an issue for patients who are older, low-income or have language barriers. Without an educational component for patients unable to grasp new technologies quickly, the shift to the digital age of health care can further marginalize the most vulnerable groups and exacerbate already existing gaps in health equity.²³

Leading HR and benefits leaders will want to remain abreast of best practices to avoid risks and address inequities/barriers by applying a culturally conscious lens to improve the patient experience (e.g., in terms of patient-provider communications) and outcomes with virtual solutions.

Employer Recommendations

An overly complex health care system presents challenges that could potentially hinder employers’ efforts to drive equitable transformation - but virtual health can make a significant difference if leveraged thoughtfully and intentionally. Listed below are some actionable steps that can help build a successful and comprehensive virtual care model.

Navigate employees to the right setting for their needs by actively planning and solving for potential patient confusion with the help of your navigators, care managers and communication teams.
Require data integration and exchange among all vendors and patient coordination whenever possible while maintaining necessary patient confidentiality.
Connect available point solutions to patients and their data, encourage consolidated reporting, and capture/share relevant data points with all vendors to the extent they can be actionable.
Utilize an aggregator to harness and coordinate data across solutions.
Seek to understand the barriers your employees experience in utilizing virtual health.
Assess the current vendor landscape and programmatic design to eliminate low-value services and those that have been replaced through more enhanced virtual tools. With each new virtual health solution considered, evaluate connection points that are possible within your existing vendor landscape.
Proactively address payment for all virtual services with your health plan and vendor partners, and begin the process of moving away from fee-for-service.
Assess your plan design and create affordability for patients with cost-sharing mechanisms that are transparent using virtual care.
Incorporate virtual care delivery into value-based care models and quality measures.
Redesign performance guarantees to incorporate metrics relevant to virtual experiences and care delivery.
Seek vendors that apply artificial intelligence that excels in proactively identifying members with existing or rising health risks and maximizes appropriate engagement.
Determine how clinical outcomes are measured and if the solution is evidence-based with a proper quality assurance program in place.
Monitor pharmacy benefit utilization to mitigate risk of negative drug interactions, overprescribing and patient confusion as a result of an increasing number of providers engaged in their care, including those who are part of virtual health offerings.
Engage health plans and navigators in ensuring a smooth transition for members between virtual-only programs and in-person care and ensure that virtual vendors are equipped to make referrals based on network offering and quality providers.
Engage in advocacy for the elimination of state and federal barriers to expansion of national virtual care solutions.
Use virtual capabilities to advance health equity by creating programs that remove rather than create new barriers.

Forging the Path Ahead

The pandemic accelerated virtual health and proved how quickly change is possible. Though the future of virtual care is clouded by uncertainties regarding reimbursement, state-to-state licensing rules and privacy issues, virtual health is here to stay. As more virtual solutions enter the marketplace, it is increasingly prudent for employers to think critically and creatively when implementing a virtual health model that improves employee engagement, experience and outcomes. The time is now for employers to successfully take advantage of the benefits of virtual care and leverage it in a way that addresses the challenges in health care cost, fragmentation and inequities.