Virtual Primary Care Article by Dr. Marshall Chin in New England Journal of Medicine

This video provides an in-depth exploration of virtual primary care (VPC), drawing insights from a New England Journal of Medicine article by Dr. Marshall Chin, an expert in chronic care. Dr. Eric Bricker, the presenter, begins by establishing the critical context that the COVID-19 pandemic starkly exposed the profound inadequacies and exclusionary nature of traditional, in-person-only primary care, particularly for chronic disease management. He highlights how this model disproportionately disadvantages vulnerable populations, including low-income individuals, hourly wage earners without paid time off, and those residing in rural or underserved areas, due to significant barriers such as transportation costs, childcare needs, and the sheer time commitment required for appointments.

The core argument, championed by Dr. Chin and echoed by Dr. Bricker, is that telemedicine, specifically in the form of virtual primary care, offers a vastly superior alternative when combined with a per-member-per-month (PMPM) reimbursement model, as opposed to the traditional fee-for-service approach. This hybrid model, incorporating both virtual and necessary in-person care, promises increased access to high-quality medical expertise, enhanced convenience for patients who can manage appointments without significant disruption to work or family life, faster and timelier care delivery, and substantial cost-effectiveness by reducing the need for extensive physical infrastructure associated with conventional clinics and hospitals.

However, the video pivots to a critical analysis of the major insurance carriers' recent initiatives to launch their own virtual primary care offerings. Dr. Bricker contends that despite the inherent benefits of VPC, these insurance-led models are fundamentally flawed and destined to fail due to five significant conflicts of interest and systemic issues. These include a pervasive lack of trust in insurance companies among both patients and doctors, the inherent conflict arising from insurance carriers owning Pharmacy Benefit Managers (PBMs) whose growth is tied to "script count" (potentially incentivizing over-prescription), the ethical dilemma of a doctor employed by an insurer having to fight their employer for prior authorizations, contractual restrictions preventing insurance carriers from "steering" patients to the highest quality providers within their networks, and the negative impact on employer flexibility when employees' primary care physicians are directly tied to a specific insurance plan.

Key Takeaways:

• Inadequacies of Traditional Chronic Care: The COVID-19 pandemic illuminated how the historical model of in-person-only primary care for chronic conditions (e.g., diabetes, hypertension) is inherently exclusionary, creating significant barriers for low-income individuals, hourly workers, and those in rural areas due to transportation, time off, and location challenges.
• Benefits of Virtual Primary Care (VPC): VPC, especially when coupled with a per-member-per-month (PMPM) payment structure, offers superior primary care by providing increased access to quality doctors, enhanced convenience for patients, faster appointment scheduling, and greater cost-effectiveness through reduced infrastructure needs.
• Critical Role of Payment Model: The video emphasizes that combining virtual care with a PMPM reimbursement model (rather than fee-for-service) is crucial for its success, aligning incentives towards proactive, holistic patient management rather than volume of services.
• Low Trust in Insurance Carriers: A significant impediment to the success of insurance-led VPC is the pervasive lack of trust: only 33% of patients and a mere 19% of doctors trust health insurance companies, which will severely limit patient engagement and adherence to medical advice.
• PBM Conflict of Interest: Insurance carriers' ownership of Pharmacy Benefit Managers (PBMs) creates a direct conflict, as PBM growth is often tied to "script count." This incentivizes insurance-employed doctors to potentially over-prescribe medications to maximize PBM revenue, undermining patient best interests.
• Prior Authorization Dilemma: The process of prior authorization presents an ethical and practical conflict for primary care physicians employed by insurance companies, as they would be forced to advocate for their patients' diagnostic tests (e.g., MRIs, CT scans) against the financial interests of their own employer.
• Network Steerage Restrictions: Many PPO contracts between major hospital systems and insurance carriers contain clauses that prohibit the insurance carrier from "steering" patients to specific providers within their network. This prevents insurance-employed PCPs from referring patients to the highest quality specialists, compromising patient care.
• Impact on Employer Flexibility: Tying primary care doctors directly to an insurance carrier reduces employer flexibility. If an employer wishes to change insurance providers, it would necessitate forcing all employees to switch their primary care doctors, creating significant disruption and resistance.
• Shift Towards Virtual Care: The broader healthcare industry is undeniably moving towards virtual care models, but the success hinges on addressing systemic issues and conflicts of interest rather than simply adopting the technology.
• Understanding Financial Incentives: The focus on "script count" in PBM earnings calls highlights a key financial incentive within the pharmaceutical supply chain that can influence prescribing patterns and patient care.
• Relevance of Corporate Practice of Medicine: The conflicts discussed, particularly around prior authorization and PBM incentives, underscore the importance and relevance of corporate practice of medicine laws designed to prevent undue influence on medical decisions.

Key Concepts:

• Virtual Primary Care (VPC): A healthcare delivery model that leverages telemedicine to provide primary care services, often combining virtual consultations with necessary in-person visits.
• Per Member Per Month (PMPM) Payment: A capitated payment model where healthcare providers receive a fixed amount per patient per month, regardless of how many services are utilized, incentivizing preventive care and cost efficiency.
• Fee-for-Service: A traditional payment model where providers are paid for each service they provide, potentially incentivizing a higher volume of services.
• Pharmacy Benefit Manager (PBM): A third-party administrator of prescription drug programs for health insurance companies, often responsible for negotiating drug prices, processing claims, and managing formularies.
• Prior Authorization: A requirement from health insurance companies that a healthcare provider obtain approval before prescribing a specific medication, performing a procedure, or ordering certain tests.
• Network Steerage: The practice of an insurance carrier directing patients to specific providers or facilities within their network, often based on cost or quality metrics.
• PPO Contract: A contract between an insurance carrier and a Preferred Provider Organization (PPO) network, outlining terms for patient access to providers and reimbursement rates.
• Corporate Practice of Medicine: Laws that prohibit corporations from practicing medicine or employing physicians, designed to prevent non-physician entities from interfering with medical judgment.

Tools/Resources Mentioned:

• New England Journal of Medicine (NEJM): A prestigious medical journal, where Dr. Marshall Chin's article on virtual primary care was published (October 23, 2021 issue).
• UnitedHealth Group, Aetna, Anthem: Major health insurance carriers cited as examples of companies announcing virtual primary care offerings.
• Sutter Health: Mentioned as an example of a hospital system that faced issues related to network steerage in California.