Virtual Primary Care for PPO Members

August 9, 2022

Emily Kunisch

A Preferred Provider Organization (PPO) plan contracts providers and healthcare systems to encourage in-network use to lower healthcare expenses. PPO plans have higher monthly premiums and, compared to HDHPs, often provide richer benefits in the form of lower deductibles and out of pocket costs.  

All patients, regardless of plan design, benefit from a quality relationship with a primary care physician (PCP). However, over 60% of Americans either don’t have or don’t use a PCP.1 Personal barriers, doctor shortages and a confusing benefits environment are just a few things that contribute to deterring people from seeking care. A traditional in-network, primary care doctor that someone on a PPO plan might see (if they see one at all) operates in a fee-for-service environment. Patients typically only see that doctor once a year, for a few minutes for each visit, with very little follow-up in between. 

Even in a rich PPO benefits environment where a patient has little to no cost-sharing for visits, $0 virtual care and specifically virtual primary care, is a valuable alternative to patients in the following ways:  

  1. Removing Barriers: Issues around provider shortages, long wait times for appointments, logistical barriers around travel and inconvenient doctor schedules do not align with a patient’s free time and often deter people from seeking care. A virtual care option delivered by quality doctors offers convenience that patients on most plan designs can prioritize.  
  2. Fee-for-Service Reimbursement Model: Adding to the barrier of inconvenience, a misaligned insurance reimbursement model (fee for service) that incentivizes patient volume leads most primary care doctors to spend more time on paperwork and less time on preventive care. Virtual primary care removes the fee-for-service reimbursement model, allowing doctors to spend more time with patients and to ensure the best preventive care and management of chronic conditions.  
  3. Cost: Virtual care should be $0 for patients and their family members to use. In the telemedicine environment, patients are spared visits to the ER or Urgent Care, which are often substantial in cost even in a copay environment. No copays are required unlike most PPO plans. 
  4. Referrals & Care Coordination: Most doctors find it too challenging to figure out whether a specialty doctor is in-network for a given patient. In fact, 79% of them end up referring patients to out-of-network doctors.2 Virtual primary care provides steerage opportunities to in-network doctors when in-person care is needed. Care coordination consists of referrals to quality, low-costing specialists and facilities, which can help patients save money on expensive surgeries or treatments that will likely hit their deductible and ensure they receive the best whole-person health guidance.  

First Stop Health (FSH) Virtual Primary Care strengthens the patient-doctor relationship by operating in a value-based model. This means patients are spending more time (an average of 35 minutes) with FSH virtual doctors and are receiving continuous communication from our clinical team about adherence to care plans, medication support, follow-up visits and preventive screenings. Medication management and care coordination for chronic conditions are also a primary focus for some patients and their FSH virtual doctor. Patients can schedule a visit, complete the intake process and see a FSH virtual doctor in just 4 days on average.  

Learn more about our Virtual Primary Care solution

  1. https://www.advisory.com/en/daily-briefing/2020/02/18/primary-care 
  2. https://www.healthcaredive.com/news/physician-referral-issues-causing-more-out-of-network-care/530726/ 

Originally published Aug 9, 2022 6:07:16 PM.