Virtual primary care: fragmentation or integration?

Virtual primary care (VPC) services, in which patients consult with a doctor or nurse via email, text, phone, or video are presumed to offer a number of advantages over traditional, brick-and-mortar general practitioner (GP) services, particularly in terms of accessibility and cost. However, evidence of their effect on clinical outcomes and quality of care is scant. Furthermore, if integrated poorly into existing care systems and payment regimes, VPC services will not create sustainable change, but will instead have the potential to contribute to the fragmentation of the health system. 1Panch T Mattie H Celi LA The “inconvenient truth” about AI in healthcare. Digital Medicine. 2019; 2: 77Crossref Scopus (126) Google Scholar A brief exploration of the economics of VPC services highlights the risks at hand. Although the focus of this Comment is on England, the questions raised are relevant wherever VPC services are in the process of being introduced. At the root of the issue is that VPC providers tend to serve specific populations. In England, GPs cross-subsidise care for complex patients with funding surpluses from those with lesser needs, and thus rely on diverse patient lists. However, data highlight that 53% of Babylon GP at Hand's users are male and 89% are between the ages of 18 and 39 years, and just 1% are older than 65 years. 2Bostock N GP online, in charts: how GP at hand pulled in 32, 000 new patients in 12 months. https: //www. gponline. com/charts-gp-hand-pulled-32000-new-patients-12-months/article/1518915Date accessed: July 22, 2019Google Scholar In Sweden, children and metropolitan residents are the main users, whereas people older than 65 years, people with chronic diseases, and rural residents account for only a small proportion of consultations. 3Blix M, Jeansson J. Telemedicine and the welfare state: the Swedish experience. IFN Working Paper, 2018. Google Scholar Although individual patient choice and technology literacy plays a major role, VPC organisations might also engage in risk selection, intentionally selecting or seeking to attract less complex patients. Furthermore, VPC services might be unsuitable for people requiring regular access to highly personalised or multidisciplinary services. When less complex patient groups deregister from their existing practices to register with practices that offer virtual services, as in England, the result is that brick-and-mortar GPs are left with increasingly complex patient lists. This segmentation of the patient population by risk is analogous to adverse selection in private health insurance markets, and might threaten the financial sustainability of traditional GP practices in a capitated payment scheme. For example, under the General Medical Services contract, most GPs in England receive a base payment of £87·92 per patient, with additions taking account of factors such as sex, age, rurality, deprivation, and turnover of patients, as well as measures of morbidity and mortality. GPs can earn additional income for achieving performance targets and for providing extra services, such as minor surgical procedures. Including these additions, the average income per patient, per year for GPs in England is £152, whereas Babylon receives, on average, about £90 per patient registered with GP at Hand. 4Babylon GP at HandHow we work. https: //www. gpathand. nhs. uk/how-we-workDate accessed: July 8, 2019Google Scholar This might partially account for the disparity in the complexity of patient lists, but given that a small proportion of patients with particularly complex needs accounts for the majority of health-care costs, 5French E Kelly E Medical spending around the developed world. Fiscal Studies. 2016; 37: 327-344Crossref Scopus (17) Google Scholar it likely still represents an overpayment of VPC relative to traditional GP services. VPCs might also introduce cost inflation and cost shifting, which is partly due to their high registration and turnover rates. 6PulseDigital practice patients three times more likely to return to prior GP surgery. http: //www. pulsetoday. co. uk/news/all-news/digital-practice-patients-three-times-more-likely-to-return-to-prior-gp-surgery/20038965. articleDate accessed: July 22, 2019Google Scholar, 7Ipsos Mori and York Health Economics ConsortiumEvaluation of Babylon GP at hand. Final evaluation report. https: //www. hammersmithfulhamccg. nhs. uk/media/156123/Evaluation-of-Babylon-GP-at-Hand-Final-Report. pdfDate: May 2019Date accessed: July 9, 2019Google Scholar Turnover is taken into account in the Global Sum Allocation Formula, on which GP payments in England are calculated, which will increase the per-patient payment and inflate costs for the health service. There is also a risk that patients who are unable to access the services they need from their VPC provider, or are simply dissatisfied with the service, might make heavier use of the National Health Service (NHS) 111 non-emergency phone line or walk-in services. For example, despite Babylon's running in-person satellite clinics for GP at Hand Users, in February 2019, its patients were reportedly waiting weeks for travel vaccinations, with many being redirected to alternative providers. This would have the effect of shifting costs to elsewhere in the system. Although a recent evaluation of Babylon GP at Hand's deployment by Hammersmith Clinical Commissioning Group did not find evidence of this effect, the patient population was not representative of primary care services in general, and the long-term effect is uncertain. 7Ipsos Mori and York Health Economics ConsortiumEvaluation of Babylon GP at hand. Final evaluation report. https: //www. hammersmithfulhamccg. nhs. uk/media/156123/Evaluation-of-Babylon-GP-at-Hand-Final-Report. pdfDate: May 2019Date accessed: July 9, 2019Google Scholar Overuse is also a potential issue: one study8Ashwood JS Mehrotra A Cowling D Uscher-Pines L 2017. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs. 2019; 36: 485-491Crossref Scopus (137) Google Scholar suggested that as many as 88% of remote consultations represented new activity, as opposed to activity replacing a traditional consultation. Finally, whether VPC services such as Babylon, which prioritise access, can adequately ensure continuity of care is unclear. This is a significant concern, given the growing evidence on the benefits of a long-term therapeutic relationship between a patient and a GP in terms of patient experience, outcomes, and cost. 9Barker I Steventon A Deeny S R Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ. 2017; 356: j84Crossref PubMed Scopus (217) Google Scholar On this basis, the economic case for simply adding VPCs onto existing systems without adaptation of payment models is weak. Over time, it will likely result in higher costs and less innovation in care delivery. One solution could be to increase the payment associated with particularly high-cost patients to ensure that either VPCs take on these patients, or in-person GPs are fairly compensated for their workload. Capitation formulae could also be adjusted to prevent cost inflation as a result of the high turnover rates associated with VPCs. However, these measures would not discourage the de facto creation of parallel systems for the young and the healthy, and the old and the sick. Meanwhile, a fee-for-service approach would likely give rise to a risk of VPC supplier-induced demand, particularly given the ease with which patients can access virtual services. A more sensible approach would be to create a unified system of physical and virtual primary care services. This would enable patients to access VPC services without foregoing access to their GPs, and the allocation of funds would reflect providers' actual contributions to their patients' health. The direction of travel indicated by NHS England's Long Term Plan is for greater integration of digital and physical services. It aims to provide all patients with access to digital services by April, 2021, by helping existing providers adopt digital platforms, and introducing a national framework for digital suppliers to offer access to their services on standard NHS terms. 10BMA and NHS England: investment and evolution: a five-year framework for GP contract reform to implement The NHS Long Term Plan. https: //www. bma. org. uk/-/media/files/pdfs/collective%20voice/committees/gpc/gpc%20england/investment-and-evolution-five-year-framework. pdf? la=enDate: 2019Date accessed: June 3, 2019Google Scholar There is also a welcome commitment to annually update contractual terms with digital providers, to reflect developments in technology and service delivery. There are numerous potential benefits to patients of being able to access online services while retaining access to in-person primary care services, providing those services are well integrated. Conversely, a brief examination of the economics of VPC services highlights the pitfalls of allowing services to develop in parallel to traditional ones. The implications are equally important in the UK as in other health systems that are in the process of adopting digital primary care systems, and could be even more significant in systems where primary care is funded on a fee-for-service basis, or where patients have a greater tendency to shop around. Even in an integrated system of virtual and physical primary care services, the technicalities of who gets what will need careful thought, and the optimal solution should incorporate measures to prevent risk segmentation, cost inflation, and cost shifting. This should be achievable, but it will require policy makers to be bold in their approach and sophisticated in their planning. We declare no competing interests. GAW contributed literature search, data collection, and interpretation, and wrote the majority of the Comment. HSS contributed to the development of the core arguments, identification of key sources, and provided extensive comments on and direct amendments to drafts of the Comment. AS contributed literature search, data collection and interpretation, and produced the initial draft of the Comment, and provided comments and amendments on later drafts. EM contributed to the development of the core arguments, identification of key sources, and provided extensive comments on and direct amendments to drafts of the Comment. 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