House Calls to Virtual Care:

How Telemedicine Serves the New Health Care Consumer

It’s seven thirty in the evening, and Stacy, a working mother of four-year-old twins, is finishing bath time. She notices that one of her children has a large, bright red, and raised rash on the back of her thigh. There’s no fever and no other symptoms, but this doesn’t look good, and Stacy begins to think about trying to get a drop-in appointment at the pediatrician’s in the morning.

If her daughter can be squeezed into the doctor's already packed schedule, she'll have a long wait with two active toddlers in the officer waiting room, both kids will be late for preschool, and if the appointment takes longer than expected, she may have to take the day off.

Stacy and her kids really like their pediatrician. But unfortunately, their situation is not uncommon. And for others like Stacy, options for getting timely care often seem limited and time consuming. At least, that's the way it used to be.

Today, telemedicine has evolved into a growing and well-received delivery channel of high quality care. Certainly, there are limits to what types of care can be delivered through telemedicine, but for people like Stacy, the value is tremendous.

With roots in the old-fashioned house call, Carena—a Seattle-based company—has evolved the high-quality experience found in the traditional office visit into virtual care. Today, the company provides care to self-insured plans covering more than 500,000 lives and has a hospital-system coverage area in six states (expanding to four more in 2015) with more than six million lives covered.

“We are always focusing on the patient experience,” says CEO Ralph Derrickson. “This is part of our core mission. We want to change how customers and consumers access health care, providing medical care on their terms.” Those terms are based largely on a growing health care consumer base that wants different things than they have had in recent years.

The evolution of health care, stemming from the Affordable Care Act and the Triple Aim (Berwick’s model of care quality, population health, and reducing costs), is changing not just the delivery systems and provider practices but also how patients see themselves. Cost transference in the form of highdeductible plans is changing care-seeking behaviors. “The health care consumer today is now asking if they even need to see a doctor, and if so, what kind of doctor is the right choice both in terms of care and economics. Patients today are looking for buying advice,” notes Derrickson.

But these are not the only changes impacting the new health care consumer.With more and more services being investigated, reviewed, and purchased online, these consumers are looking for the Amazon online equivalent to their health care. This goes beyond just offering online appointment scheduling and portals to view a medical record. It has to do with transparency—what does something cost, what are other consumer reviews, what is the refund policy? And it has to do with speed of delivery.

“When someone contacts Carena, we average about twelve minutes to get them connected to a provider. The visit lasts about twenty minutes. So the total time is less than one hour from the time someone decides they need care to the completion of their patient visit,” says Derrickson. This is compared to the hours, days, and sometimes even weeks of waiting to see a provider for a ten-minute visit. “Seventy percent of the time, we can take care of your issue in that one virtual visit. Thirty percent of the time, we refer you to other resources.”

And it’s in those referrals that Carena’s model is finding physician and employer support. By contracting with employers and health systems, Carena knows when someone calls who their insurer is and what in-plan resources are available. This keeps patients connected to their primary care provider as well as other in-plan options. “We work hard to ensure that the patient’s primary care doctor knows we delivered care. We’ll send them a report of our interaction with their patient, describing the care we provided,” notes Derrickson. “We approach the virtual visit from the PCP perspective. We want to get you back to your PCP so that everything we are doing is fully integrated and supports the continuity of care.” Derrickson believes this model can actually help physicians and their practices stop patient leakage away from clinic panels.

The care that Carena provides follows clinical practice guidelines. In fact, Carena is the only virtual care provider that is certified by Washington State’s QAIP Program—a continuous quality improvement program for clinicians that tracks quality measures and is granted to those entities who regularly perform above and beyond the average. This third-party credential is important to the virtual care model, so a focus on quality measurement programs (e.g., HEDIS) is only one tool to choose from. “We have metrics that tell us if care was delivered beyond the complaint, the total amount of care we actually delivered, and what our prescribing rates are (which are below the national average in several categories),” says Derrickson.

Carena's model is working. Companies like Microsoft, Costco, and Boeing are using Carena to supplement their selfinsured plans and to help keep costs down. Hospital and health systems like Catholic Health Initiatives (CHI) are using Carena as a way to support their own employee populations and as a means of extending the primary care arm of the system, as well as to market to new patients. “This model works for these types of organizations because we’re protecting the sanctity of the office visit. We’re not changing who patients see—just how consumers access their care,” says Derrickson.

And perhaps that is where virtual care makes medicine better. As Derrickson puts it, “If we combine one-third clinical, one-third technology, and one-third consumer orientation, we can create a total customer experience.” For patients, it is easy to see how they will become more savvy buyers of care who are looking for different models of delivery. If this is true, access to clinically appropriate goods and services will not be exclusive to the brick-and-mortar office visit. For providers, teaming with a virtual care provider extends their ability to care for patients without having to take two a.m. calls or pack more patients into an already full day.