MedCity Influencers, Health Tech

Breaking Down Barriers for Payer Adoption of Virtual Care Providers

As we navigate the complex terrain of virtual care integration, it is imperative to recognize the significance of payers as catalysts for change. By addressing the technological, procedural, and regulatory roadblocks head-on, payers can position themselves as champions of innovation and value

Today, virtual and in-person healthcare providers working together within hybrid collaborative care models are increasingly demonstrating their ability to improve outcomes and accelerate the industry’s shift towards value-based care.

By offering access to specialized care teams virtually across geographies, virtual specialty care has gained considerable traction in the past few years. In fact, virtual care now accounts for 14–17% of patient visits compared with approximately 1% in February 2020 – despite being artificially constrained by many technology, procedural and regulatory roadblocks. These hurdles impede payers from fully embracing and endorsing virtual care providers within their networks, despite its potential and a growing desire by patients.

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A Deep-dive Into Specialty Pharma

A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.

With 76% of physicians citing a lack of insurer coverage as the foremost barrier to effective telehealth delivery, payers stand at the epicenter of this transformative healthcare landscape. As such, they play a crucial role in driving the adoption of virtual care providers and bridging the gap between innovation and patient access.

Barriers hindering payer engagement

Payer organizations face a number of specific challenges that make it harder to integrate virtual care into their networks and products, all of which must be addressed to foster integration and adoption.

  • Outdated Systems Based on Zip Codes

The policies and systems of health plans were built around a fundamental concept that healthcare is delivered in-person in a brick-and-mortar clinic or hospital.  The pandemic has reshaped care delivery to bring care into the home or wherever someone wants to receive it via telehealth.  As health plans now look to integrate virtual-first provider organizations into their networks, they are finding that their technology infrastructure and legacy systems pose a significant hurdle.

One example of the need to overhaul systems is helping members find providers or providers refer to other providers.  The use of zip code-based ‘find a doctor’ tools for members does not work well when a virtual clinic can serve an entire state’s population on day one. Payers must rethink how they help members find providers now that the primary criteria is no longer zip code or location of an office.

This challenge also applies in Health Maintenance Organization (HMO) plans, which require members to obtain referrals from their primary care physician to see specialists. While this referral process was designed to better manage and coordinate a patient’s healthcare within a defined network of providers, the systems provided to primary care providers often were built to exclude virtual care providers who traditionally only provided urgent care services.  Now that virtual-first specialty care providers are blooming and growing, these systems must be adjusted to show virtual clinics to primary care providers to enable the referrals needed for HMO members to receive specialty care.

  • Regulatory and Policy Constraints

Virtual care enables specialized providers that are in short supply to support patients needing their services, regardless of whether the provider and patient are in the same zip code or even state.  This has massive potential to address provider shortages and health equity issues by connecting patients to very specific providers that can best serve their needs.  However, providers and payers face regulatory and policy barriers to capturing these benefits.

Healthcare providers are required to comply with state licensure requirements and state regulations, which contain a high degree of variability despite the services and providers being the same across states.  Providers must navigate the time delays, redundant paperwork and expense of getting licensed across states.  Payers then must update their credentialing policies, processes and systems to support a growing pool of providers that are licensed across many states.  While all well-intentioned, this variation adds administrative cost and avoidable barriers to scaling care to people in need.

Furthermore, regulatory policies such as network adequacy have not been updated to reflect the power of virtual clinics to provide high quality specialty care across entire states and all zip codes without needing a brick-and-mortar location.  Health plans that want to add virtual clinics to meet member needs in rural or underserved areas cannot count these specialty virtual clinics toward network adequacy requirements.

  •  Network Abrasion & Steerage Concerns

When introducing virtual care providers to their networks, health plans must be careful to avoid large health systems and provider groups (on which they rely for network coverage) viewing virtual care as a threat. These concerns require proactive and intentional communications for health plans to show local provider practices the benefit of augmented support from virtual care that is built to partner with them, not compete.  Virtual-first clinics can support bi-directional referrals and hybrid collaborative care that improves outcomes for their members and the economics of their practices. Endorsements and recommendations from governing medical associations also go a long way towards changing this perception.

Meanwhile, complex anti-steerage clauses in health system contracts limit health plans’ ability to build awareness among their members of newly-added provider options to the network that could benefit the member.  While some work is being done to restrict such provisions, only four states have successfully passed laws, hindering competition and innovation within the greater healthcare system.

Progress and innovation on the horizon

Amid these challenges, the industry is witnessing promising initiatives aimed at dismantling roadblocks and fostering payer engagement with virtual care providers.

A number of insurers are establishing digital front doors for members, enhancing accessibility to care and leading the way in offering personalized, technology-driven and value-based healthcare. These strategic collaborations emphasize the importance of not merely locating care through zip codes but ensuring members can find providers based on sub-specialties, demographics, and other preferences that can help them achieve great outcomes.

Others have announced significant investments in virtual care, with one recently announcing $5 billion for enterprise-wide investments in data, technology, research, and innovation. That provider also committed to a $0 out-of-pocket expense benefit for virtual urgent care visits, meaning eligible members will pay nothing for round-the-clock virtual support.

Another is setting a precedent by credentialing virtual care providers from outside their geographic coverage area, a move that better reflects the realities of modern telehealth solutions. This has already enabled the insurer to grow its mental health provider network by 50% over the past five years to help ensure access to high-quality, affordable care options for members.

At the same time, notable players in the industry are actively pushing for regulatory and policy advancements. The Blue Cross Blue Shield Association has put forth policy recommendations aimed at reducing healthcare costs, a move that could foster an environment conducive to virtual care provider integration. The recommendations include improving competition, lowering prescription drug costs, and prioritizing high-quality care.

Charting the path forward

While challenges persist, the momentum towards payer adoption of virtual care providers across specialties is undeniably gaining traction. Forward-thinking payers are investing in technology, reimagining processes, and advocating for regulatory reforms to overcome these barriers. As these pioneers blaze a trail, their peer health plans are taking note, committing to investments, and setting the stage for incremental changes.

The future of healthcare lies in the convergence of technology, collaboration, and patient-centricity. As we navigate the complex terrain of virtual care integration, it is imperative to recognize the significance of payers as catalysts for change. By addressing the technological, procedural, and regulatory roadblocks head-on, payers can position themselves as champions of innovation and value, unlocking the full potential of virtual care providers for the betterment of patient health and outcomes.

Photo: temniy, Getty Images

Sam Holliday is CEO of Oshi Health, where he combines his passion for redesigning healthcare around the needs of patients with a mission to increase access to the high quality, whole-person care that two of his family members have needed to manage their digestive conditions.