"New Models By Patrick T. Courneya, Kevin J. Palattao, and Jason M. Gallagher doi: 10.1377/hlthaff.2012.1157 HEALTH AFFAIRS 32, NO. 2 (2013): 385–392 INNOVATION PROFILE ©2013 Project HOPE— The People-to-People Health Foundation, Inc. HealthPartners’ Online Clinic For Simple Conditions Delivers Savings Of $88 Per Episode And High Patient Approval Patrick T. Courneya (patrick ABSTRACT The delivery of health care online is relatively new. However, .t.courneya@healthpartners .com), a family physician, is early indications suggest that it can improve the experience of care for the medical director of patients and the health of populations, along with reducing per capita HealthPartners Health Plan, in Minneapolis, Minnesota. health care costs. HealthPartners in Minnesota launched an online clinic called virtuwell in late 2010. After more than 40,000 cases, we report an Kevin J. Palattao is vice president of clinic patient average $88 lower cost per episode compared with care received in care systems at traditional settings, strong indicators of clinical effectiveness, and a HealthPartners Clinics and vice president of virtuwell at 98 percent “would recommend” rating from customers. The possibility of HealthPartners. extrapolating such savings to larger volumes of cases is compelling.We Jason M. Gallagher is a senior suggest a need for regulatory reform, particularly around state-level director of health informatics statutes that create barriers to the expansion of online care delivery, such and population health analytics at HealthPartners. as those that require clinicians to be located in the same state as the patient and those requiring clinicians to have had a previous face-to-face visit with a patient. Such reforms would encourage further innovation and lead to cost reduction and improvements in access and convenience for consumers throughout the health care system. nlinehealthcaredeliveryisarel- experiencessatisfying?Cananonlinecarebusi- atively new care option. Recent ness model deliver compelling cost savings? In studieshavecomparedqualitybe- short, can e-visits work? tween online and face-to-face Our organization, HealthPartners, is a 1 O clinicalcare, e-visitusebyphysi- Minnesota-based, consumer-governed, non- 2 cians, and cost comparisons between e-visits profit organization that provides health insur- 3 and care received in traditional settings. ance through a health plan and care through a Within these studies, findings include compa- largeintegratedhealthsystemthatincludesfour rable quality between online and face-to-face hospitals and more than seventy medical and care for selected conditions and indications of dentalclinics,aswellasanetworkofcontracted costsavings.Otherfindingssuggestlesspositive providers.In2010welaunchedanonlineclinic outcomessuchasslowuptakebyphysiciansand calledvirtuwell.Twoyearslater,virtuwell’searly possible increased use of antibiotics. resultssuggestthatonlinecarehasthepotential Several fundamental questions drive such in- tomeetthe“TripleAim”goalsofabetterhealth vestigations. Can online care be performed care experience for patients, improved popula- 4 safely, securely, and in compliance with regula- tion health, and more affordable health care — tions? Will consumers accept care delivered via especially for conditions typically associated these new channels, and will they find their with primary care. February 2013 32:2 Health Affairs 385 Downloaded from content.healthaffairs.org by Health Affairs on February 17, 2013 by Rachel McCartneyNew Models Examining virtuwell as a case study, this ar- provisionofalabtest,imagingstudy,orphysical ticle reports on the cost savings, clinical effec- exam. In the case of urinary tract infection, for tiveness,andcustomersatisfactionthattheser- example,wefollowInstituteforClinicalSystems vice has so far demonstrated. We do not posit Improvementbest-practiceguidelines,whichdi- these results as generalizable findings, but we rectthatalow-riskpatientwithatypicalconstel- do suggest that they are relevant to providers, lationofsymptomsmaybesafelytreatedwithout payers,employers,regulators,andconsumersas an exam or lab testing. This guideline has been online care continues to emerge. thestandardofpracticeintheTwinCitiesmarket for nearly twenty years. To date, more than 40,000 customers have About virtuwell received treatment plans from virtuwell, and To help put our findings in context, we first some 56,000 others with symptoms beyond briefly describe the service and the consumer the scope of the service have been referred to 7 experience of virtuwell. appropriate in-person providers. Patients to The Model Now available to residents of date have been 78 percent female, 22 percent Minnesota and Wisconsin (and newly intro- male, and most ages 24–45. Sinusitis, urinary duced in Michigan), virtuwell combines rigor- tract infection, conjunctivitis, and viral upper ous clinical protocols with a carefully designed respiratory infection are the most commonly onlineuserexperienceandserviceguarantees.It treated conditions. is accessible at http://virtuwell.com around the Weattributethepreponderanceoffemaleuse clockandofferstreatmentforaboutfortysimple to several factors, including the fact that about conditionssuchasurinarytractinfections,sinus 29 percent of our overall case volume is from 5 infections, and conjunctivitis. female-only conditions such as urinary tract in- The service uses sophisticated interviewalgo- fections and yeast infections. Because women rithms; makes patient- and clinician-initiated are the “chief medical officer” of most house- telephonic interactions available around the holds, we also expected to see higher trial use clock; and incorporates review by nurse practi- bywomenintheearlystagesofvirtuwell’soper- tionersorphysicianassistants,whothenprovide ation.Studiesalsosuggesthigheruseofprimary diagnosesandtreatmentplans,and,ifappropri- careclinicvisitsingeneralbywomencompared 8 ate, prescriptions. to men. Customer Experience To begin, the cus- Patient volume has been concentrated in the tomer visits http://virtuwell.com and answers Minneapolis–St. Paul metro area, where our questions abouthis or herconditionand symp- organizationisheadquarteredandwherewefo- toms and provides information about medical cused early promotion of virtuwell. However, history, allergies, and medications. A certified virtuwellhastreatedpatientsinall159counties nurse practitioner reviews the information and in Minnesota and Wisconsin. writes a treatment plan. The customer receives Theretailcostis$40pervisit,withinsurance notificationbytextore-mailwhenthetreatment coverageloweringtheout-of-pocketfeeformany planisready—usuallyinthirtyminutesorless.If customers per the terms of their benefit plans. a prescription is warranted, it is sent electroni- Approximately 85 percent of virtuwell cases to cally to the pharmacy of the customer’s choice. date have involved an insurance claim. In 2011 Customers may speak to a nurse practitioner at virtuwell was the first online convenience care anytimeduringoraftertheirvisit,andvirtuwell service to be authorized for Medicare coverage nurse practitioners also initiate outbound calls by the Centers for Medicare and Medicaid 9 to customers in about half of the cases. Services. Scope Of Service Theclinicalprotocolsused Space limitations here preclude discussion of forvirtuwellaretightlyalignedwiththosedevel- severalaspectsofvirtuwellthatmaybeofinter- 10 oped by the Institute for Clinical Systems est,suchasitstechnologicalscope andthede- Improvement, a nonprofit collaborative co- velopmentofthevirtuwellbusinessandpractice founded by HealthPartners with representation models, including testing, legal concerns, pro- from dozens of Minnesota-based care systems motion and marketing, investment levels, and and payers that has worked to standardize best staff recruitment and training. 6 care practices since 1993. Another measure worthy of further study but Conditionstreatedthroughvirtuwellarethose beyond the scope of this article is that of clini- generally associated with high diagnostic accu- cians’ satisfaction with online care delivery.We racy and treatment efficacy in both traditional observe, anecdotally, that physicians in Health- and online care venues. The service does not Partnersaregenerallysupportiveofvirtuwell,at offer treatment, for example, for conditions in leastin partbecausephysicians helpedcreateit which the standard of care suggests the and continue to participate in its operation. 386 Health Affairs February 2013 32:2 Downloaded from content.healthaffairs.org by Health Affairs on February 17, 2013 by Rachel McCartneyStudy Results comparisons of cost. Claims Costs Weexaminedclaimsdatatocom- Using the Wilcoxon-Mann-Whitney nonpara- pare costs for episodes of care delivered via vir- metric test, we found that on average, acute tuwell compared with care delivered in tradi- sinusitisepisodestreatedthroughvirtuwellcost tional settings including clinic, urgent care, $78.90lessthanacutesinusitisepisodestreated 12 and emergency department settings. Medical in our other settings (p<0:0001). For lower and pharmacy claims for HealthPartners’ com- genitourinary system infections, the cost was mercially insured members incurred and paid $127.61 less per episode (p<0:0001); for con- between May 1, 2009, and April 30, 2012, were junctivitis episodes, it was $69.00 less groupedusingtheSymmetryEpisodeTreatment (p<0:0001). When we looked at all episodes, Group(ETG)software,version7.5.Totalepisode wefound that perepisode treatmentcosts aver- costsweremeasuredusingtheamountspaidby aged$88.03lowerforvirtuwell-treatedepisodes HealthPartners to the provider, plus member (Exhibit 1). 11 cost sharing across the entire episode of care. Cost differentials observed for virtuwell are Comparedwithpatientsusingtraditionalcare highly dependent on access to and availability settings,virtuwellpatientswithinthisstudypop- of different venues for care. To understand the ulationofHealthPartners’commerciallyinsured cost differentials per specific setting, we exam- 13 members were slightly younger (37.3 years ver- ined the origination of the episode. sus 40.9 years), and a greater percentage were For each of the top three episode types listed female (83.4 percent versus 76.9 percent). But above—acutesinusitis,conjunctivitis,andlower the episode classification methodology we used genitourinarysystem infections—we found that establishedclinicalhomogeneityretrospectively virtuwell treatment cost $20–$30 less than con- by considering condition severity and patient- venience clinics (p<0:0001), $80–$142 less level comorbidities, thereby enabling valid than office visits (p<0:0001), $82–$124 less Exhibit 1 Claims And Cost Differentials Between virtuwell- And Non-virtuwell-Treated Episodes, By Condition, 2009–12 Treated episodes (claims) Average cost ($) Non- Non- Episode type (severity level) virtuwell virtuwell virtuwell virtuwell Differential Acute sinusitis, w/o surgery (1) 1,308 22,455 87.70 166.60 78.90**** Lower genitourinary system infection, not sexually transmitted, w/o complication or comorbidity (1) 943 10,236 74.36 201.97 127.61**** Conjunctivitis (1) 471 13,176 61.30 130.30 69.01**** Chronic sinusitis, w/o comorbidity, w/o surgery (1) 368 16,292 302.79 332.13 29.34**** Monilial infection of vagina (yeast) (1) 201 1,858 58.99 142.13 83.13**** Otitis media, w/o complication, w/o comorbidity, w/o surgery (1) 163 28,206 77.85 158.88 81.02**** Lower genitourinary system infection, not sexually transmitted, w/o complication, w/ comorbidity (1) 102 1,773 104.50 219.12 114.62**** Lower genitourinary system infection, not sexually transmitted, w/o complication, w/ comorbidity (2) 86 1,584 134.54 262.41 127.88**** Chronic sinusitis, with comorbidity, w/o surgery (2) 80 2,921 573.27 584.32 11.05 Otolaryngology diseases signs and symptoms (1) 74 17,322 67.46 128.32 60.86**** Acne (1) 66 9,485 178.03 361.20 183.17**** Allergic rhinitis, w/o surgery (1) 49 7,616 137.69 307.20 169.50**** Acute bronchitis, w/o comorbidity (1) 35 15,971 131.81 181.87 50.06*** Other infections of ear/nose/throat, w/o surgery (1) 32 6,296 113.98 195.59 81.61**** Other inflammation of skin, w/o complication, w/o comorbidity (2) 30 20,487 130.57 237.84 107.28**** Overall (weighted for virtuwell episode type distribution) 4,008 175,678 113.13 201.16 88.03 SOURCE Member claims data analysis, HealthPartners Inc., May 1, 2009–April 30, 2012. NOTES We approached this analysis by looking at overall comprehensive experience in and outside of virtuwell. We included all episodes not seen by virtuwell in the comparison group as long as the episode did not meet the outlier criteria. In this approach, we leveraged the clinical homogeneity of the Symmetry Episode Treatment Groups (ETG) software that enables a valid comparison considering the condition severity and patient-level comorbidities at play. We also conducted parallel matched case control studies in a 5:1 and 25:1 control to case ratio using the episode type, age, and sex of the patient. The results had the same statistical significance and no material difference in cost differential by episodetype.Intheend,weusedthepopulation-basedanalysisapproachasthebestrepresentationofthevaluestatement.Theweightingusedintheoverall cost differential was simply holding the non-virtuwell experience to the same distribution of care actually received by virtuwell. ***p < 0:01 ****p < 0:001 February 2013 32:2 Health Affairs 387 Downloaded from content.healthaffairs.org by Health Affairs on February 17, 2013 by Rachel McCartneyNew Models than urgent care visits (p<0:0001), and $159– Acute Bronchitis Discussions of online care $469 less than emergency department visits often prompt questions about clinical safety (p<0:0001)(Exhibit 2).Notonlydidvirtuwell andeffectiveness,particularlywithregardtopre- treatment for those three high-volume condi- scription medication. Virtuwell clinicians pre- tions cost less, but it also had an episode reso- scribeonlysimplemedicationssuchasantibiot- lution rate—that is, no face-to-face follow-up ics and antifungals—no narcotics or so-called 14 care was required —of 89–95 percent, a rate lifestyle medications, those that treat nonpain- similar to those of convenience clinics ful,non-life-threateningconditionssuchasbald- (Exhibit 3). ness. Even so, compliance with prescribing No Evidence Of Increased Patient Demand guidelines is as important in the online care We are sometimes asked if virtuwell’s around- venue as it is in any other setting. the-clock availability increases patient demand We analyzed all claims incurred at virtuwell forhealthcareservices,potentiallyerodingsav- between October 1, 2010, and June 30, 2012, ings realized by the lower per episode cost. fortheavoidanceofantibioticsinthetreatment According to the postvisit patient surveys we ofacutebronchitis.Thismetricofprocessqual- have conducted since 2010, at least 90 percent ity, included in the commonly used Healthcare ofvirtuwellvisitsdisplacein-personvisits.Only Effectiveness Data and Information Set, mea- about 6 percent of virtuwell cases to date have sures the avoidance of dispensing an antibiotic replaced a “watch and wait” or home care for patients who do not present with a comor- approach. bidityorinfectionthatwouldotherwiseindicate Giventhecostofavirtuwellvisit,weestimate aprescription.Misuseandoveruseofantibiotic thatthisslightincreaseinutilizationreducesthe treatment of adults with acute bronchitis is of cost differential between virtuwell- and non- clinicalconcernbecauseitcanleadtoantibiotic 15 virtuwell-treated episodes by about 10 percent. drug resistance. Avoidance Of Antibiotics In Treating Our study found that antibiotics were Exhibit 2 Claims Cost Differentials Between virtuwell- And Non-virtuwell-Treated Episodes, By Condition And Origination Of Episode, 2009–12 Range ($) Number of Average Differential to Median 25th 75th Condition/origination of episode claims cost ($) virtuwell ($) cost ($) percentile percentile Acute sinusitis without surgery Emergency department 77 373.33 293.49**** 357.28 218.11 538.83 Urgent care 2,483 167.59 87.74**** 135.82 115.97 187.21 Office visit 15,525 183.07 103.22**** 154.77 125.64 212.84 Convenience clinic 3,935 99.88 20.04**** 76.87 60.57 100.33 virtuwell 1,227 79.85 0.00 49.96 45.81 71.03 Other 516 150.59 70.74 102.42 44.70 214.36 Infection of lower genitourinary system, not sexually transmitted, without complication, without comorbidity Emergency department 424 537.34 468.70**** 517.17 377.75 698.37 Urgent care 1,866 192.53 123.88**** 159.22 128.63 211.87 Office visit 5,884 210.48 141.84**** 170.93 136.84 239.18 Convenience clinic 1,331 97.89 29.25**** 70.95 61.18 96.79 virtuwell 914 68.64 0.00 43.65 42.14 72.60 Other 760 156.43 87.79 71.45 29.56 219.20 Conjunctivitis Emergency department 100 218.58 158.57**** 221.96 151.56 278.47 Urgent care 1,878 141.54 81.53**** 129.45 109.01 154.89 Office visit 9,308 139.53 79.52**** 135.18 101.79 159.81 Convenience clinic 2,121 80.08 20.07**** 67.32 59.16 77.61 virtuwell 465 60.01 0.00 51.73 49.00 53.93 Other 775 130.50 70.49 111.93 85.37 165.00 SOURCE Member claims data analysis, HealthPartners Inc., May 1, 2009–April 30, 2012. NOTES The Episode Treatment Groups (ETG) software ensures that episodes between virtuwell and non-virtuwell visits are clinically homogeneous. Cost data are highly skewed even after handling outlier cases, so we used the nonparametric test to determine significance. Means and medians by location were provided to give insight into the distribution, and 25th and 75th percentiles have been added for a range description. ****p < 0:001 388 Health Affairs February 2013 32:2 Downloaded from content.healthaffairs.org by Health Affairs on February 17, 2013 by Rachel McCartneyExhibit 3 Episode Resolution Rate Comparison Between virtuwell And Convenience Care Venues No. of episodes virtuwell No. of episodes Convenience originating virtuwell resolution originating with Convenience careresolution Episode type with virtuwell resolved rate (%) conveniencecare care resolved rate (%) Acute sinusitis without surgery 1,227 1,099 89.57 3,935 3,598 91.44 Infections of lower genitourinary system 914 843 92.23 1,331 1,182 88.81 Conjunctivitis 465 439 94.41 2,121 2,023 95.38 SOURCE Member claims data analysis, HealthPartners Inc., May 1, 2009–April 30, 2012. appropriately avoided in eighty-one of the make multiple requests for feedback. eighty-six acute bronchitis episodes treated by Thesurveyresponsesfromthetimetheservice virtuwell, for an overall effectiveness rate of launchedhaveconsistentlysuggestedhighrates 94.2percent.Investigationintothefiveepisodes ofcustomersatisfactionacrosskeymetricssuch that did result in an antibiotic prescription aswhethertheserviceissimpletouse(93.5per- showed that the patients in question received cent“yes,definitely”;6.0percent“yes,kindof”; the prescription in another care setting sub- and0.6percent“no”)andwhetherthecustomer sequent to their virtuwell visit. In other words, would highly recommend the service to friends onlyasmallpercentageofvirtuwellpatientswith and family (94.2 percent “yes, definitely”; acutebronchitisreceivedanantibiotic,andthey 3.4percent“yes,kindof”;and2.4percent“no”). did so only via another venue of care. Other questions indicate similarly strong The rate of appropriate prescribing behavior acceptanceoftheservice,includingwhetherpar- for this condition in the virtuwell setting was ticipants received enough information in their significantly higher than in our commercially treatment plan (95.9 percent “yes, definitely”; insured population. It was also higher than 2.8 percent “yes, kind of “; and 1.3 percent any of the national benchmarks available “no”) and whether they have confidence and through the National Committee for Quality trustinthequalityofcarereceived(92.7percent Assurance’s Quality Compass, in which the “yes, definitely”; 5.4percent “yes, kindof“; and 2011 national average, for example, was 1.9percent “no”).Wealsoaskcustomerstoesti- 16 22.0 percent. mate how much time they saved by using virtu- Cautioniswarranted,giventherelativelysmall well;onaverage,virtuwellcustomersreportthat sample of cases we looked at, but this finding using the service saved them approximately suggests that a well-designed online venue can 2.5 hours per visit. provide appropriate care. Additionally, it may suggest that the online venue better supports providerstryingtouseantibioticsappropriately Discussion or that patients inclined to push clinicians for Again,althoughwedonotpresentthesefindings antibiotics may be less successful in doing so asgeneralizabletoallonlinecaredeliverymod- when treated online. els, in our view they suggest that thoughtful, Customer Satisfaction Each virtuwell cus- well-designed online care can save health care tomerwhocompletesavisitandreceivesatreat- costsandincreasepatients’accesstohealthcare. mentplanissentafollow-upe-mailwithinaset Thedisplacementofaprimarycarecasefrom period of time specific to his or her condition, othertraditionalvenuestovirtuwellhasresulted usuallywithinafewdays.Themessagesuggests in an average claims cost differential of $88.03 that the customer should be feeling better and and an estimated time savings to the patient of invites him or her to request a callback from a 2.5 hours. The possibility of extrapolating such virtuwell nurse practitioner or physician assis- savingstolargervolumesofcasesiscompelling. tant if not. Wefindthatlargeemployergroups,forexam- Inthissamemessage,customersareinvitedto ple, are particularly intrigued by the possible respond to an online survey about their experi- cost and productivity savings for their popula- ence with the service. Most questions ask for tions on aggregate, if more of the simple cases simple yes-or-no answers, although we also in- withintheirpopulationsweretobedivertedtoa viteopen-endedcomment.Theoverallresponse service such as virtuwell. Even though employ- ratetothesurveyhasbeenapproximately11per- ers’ cost concerns tend to focus on the preven- 17 cent. We do not connect customers’ responses tion and management of higher-cost chronic to their cases or health information, nor do we conditions such as cardiovascular disease, February 2013 32:2 Health Affairs 389 Downloaded from content.healthaffairs.org by Health Affairs on February 17, 2013 by Rachel McCartney"