What is a “benefit-aware” doctor?

What if your company could hire doctors and arm them with services and partnerships that could support a higher quality and cost-effective practice of medicine?

What if, at any point in care, your doctor could be aware of health benefits available to you and leverage them to maximize the quality of your care and decrease your costs?

The biggest disruption we’ll see in healthcare is when people realize that “online-first” care, instead of “office visit-first” care is the most convenient, least expensive way to get diagnosed and treated. By going online first, 80% of health issues never need to be in-person. And a totally different fee-for-service claims profile along with drastically decreased raw number of fee-for-service claims emerges once people exhaust full-scope online primary care first before entering the traditional in-person fee-for-service world.

Let's face it. Doctors are the real “consumers” of healthcare.

They write the orders. And employees and employers pay whatever the bills cost.

That being said, what are the tools and services a doctor would need to deliver the broadest scope virtual primary care that helps them be the best “consumers” of healthcare?

Tools to allow specialists to review a patient’s situation online and then offer their opinion and care plan recommendations.

Many times, when PCPs refer a patient to a specialist, it’s because they have one to two questions from expertise they do not have. However, the answers to their questions do not need an in-person specialist visit ~70% of the time. Enabling a Virtual PCP to invite a specialist into an Episode of Care, read through the messages and the data, and then offer an opinion and treatment strategy would prevent ~70% of specialist referrals from PCPs.

This tool is already a feature of Sherpaa.

Tools to communicate with local specialists who are already working with an employee.

Here’s an example. You’re working with a patient who had a blood clot 9 months ago. Everything has been perfectly normal since but he’s still on blood thinners. If a Virtual PCP could message or call the specialist who first prescribed the blood thinners and ask if the patient still needs to be on the medication, this would prevent that follow-up specialist visit.

While there is not a tool for this, our doctors currently do this every day.

Tools for me to understand the one best specialist in a local area to refer a patient to, when necessary, who promises the best outcome at a reasonable cost. As you see above, about 6% of Episodes of Care eventually involve an in-person local specialist visit. I say eventually because, say we’re working with a patient who reached out to us for migraines. For the first month, we conservatively managed the migraines with typical primary care interventions, while also having the patient keep track of their headaches with a pen and paper or, for the tech savvy folks, an app like Migraine Buddy. After conservative management didn’t do the trick, we need to have this person seen by the best local in-network migraine specialist. If we don’t already have a migraine specialist in our own custom-built network, we can work with partners like Grand Rounds to help us find the local specialist with the best data and costs. Of course, when we do send you out to see a specialist, as the referring PCPs, we always get the specialist’s consult report digitally faxed back to us so we can execute the specialist’s plan and use specialists as consultants rather than ongoing primary care.

When Sherpaa shares a client with Grand Rounds, we can leverage their data to find the most appropriate and cost-effective local specialist.

Tools for me to get to the bottom of an issue when we identify a patient with an ongoing mysterious illness. Humans want a diagnosis. We don’t deal well with uncertainty. If we have a diagnosis, we can at least define and begin to wrap our heads around it. It’s the first stage we need to begin to accept a new reality. When we have a set of symptoms and no local doctor can figure out what’s going on, we need to help these patients get diagnosed. When they are not diagnosed, they are visiting local doctor after local doctor consuming a lot of time, money, and mental anguish. And no doctor can be expected to know nor have experience with esoteric, rare illnesses. There are services like CrowdMed that help me help the patient quickly get to the bottom of their mysterious issues without all the time and money invested in local doctors.

These tools exist today and are leveraged by Virtual PCPs.

Tools to help me order the highest quality, lowest cost lab test. Ordering lab tests today is a challenge. When patients need a test, they typically have 3 or 4 options— a local Quest, Labcorp, Mom & Pop lab, or local hospital network’s lab. Depending on the population density of the local area and the contracts the insurance company has typically with either Quest or Labcorp, many patients often have very little choice. And Quest and Labcorp, like all fee-for-service companies, are opaque about their prices. However, there’s a new solution arising with companies like Everlywell for the vast majority of tests that are not time-sensitive. Sherpaa doctors can either order a test at a local lab or they can order the test via Everlywell. Everlywell is adding new tests on a regular basis so keep your eye on this company as more and more tests come online, prices decrease, and more and more self-insured companies are covering the costs of these tests. Another perfect example of this is Cologuard. When Sherpaa doctors identify a candidate for Cologuard, instead of a colonoscopy (and definitely instead of a colonoscopy under general anesthesia!), they can simply order Cologuard to test for colon cancer. Tools to help me order the highest quality, lowest cost imaging test.

Amongst the healthcare cost-enlightened, it’s common knowledge imaging done at academic medical centers is far more expensive than free-standing imaging centers. The lowest hanging fruit is identifying the best local free-standing imaging center on a case-by-case basis and ordering the test there rather than at an academic medical center or hospital-based imaging center. Next, identifying the local testing center that offers the best-rated experience at the most reasonable price is the second stage of the tool.

This currently happens today with Sherpaa. When it’s unclear to a Sherpaa doctor at the time they’d like to order a test, Sherpaa medical assistants are tasked by our doctors to do the research and find the exact imaging center to order the local imaging test. Because we are not limited to time slots in office visits, we can say to the patient "You can expect to receive a message from us in an hour or so with your best option to get this test." Then, the test is ordered via Sherpaa’s EMR and the results are digitally faxed back to Sherpaa’s EMR when ready.

Tools for me to understand how much a medication will cost the plan and the employee.

When I’m ordering a test, I need to know how much the medication I want the patient to take will cost the patient and how much it will cost the plan. If I have the choice between a $4 medication and an $800 medication, I need to know this.

Today, Sherpaa doctors only have a rough estimate via tools like GoodRx and Blink Health. Ideally, the cost is labeled next to the medication name when our doctors are writing the e-prescription within Sherpaa’s platform.

Tools for me to order home monitoring devices (scales, blood pressure monitors, etc.) sent directly to the employee. If a Virtual PCP wants to monitor a patient’s blood pressure at a distance, a virtual PCP must be able to order an approved set of devices (for example, Qardio) to be sent to the patient’s home or office. And medical assistants should be available for tech support to help the patient set up the device.

Ordering seamlessly does not happen now, but could easily happen. We currently send links to devices on Amazon so patients can purchase them on their own. However, this is not seamlessly integrated into the plan. The patient must purchase the device on their own and hope for reimbursement.

Tools for me to manage and monitor chronic medical conditions like diabetes (connected glucose monitors), high blood pressure (connected blood pressure monitors), asthma (connected inhalers). Unless a chronic medical condition requires routine physical exams to manage the condition over time, a chronic medical condition can be managed virtually. For example, if I can prescribe One Drop or if a patient of ours with diabetes is already using One Drop and I have access to insights from their One Drop data, I can work with the patient to help them manage their diabetes. If I’m working with a patient who has high blood pressure, if the patient can share with me their readings from their home blood pressure device, I can adjust their medications accordingly and recommend the most appropriate lifestyle interventions. If I’m working with a patient who has high cholesterol and I’d like to follow their cholesterol levels and, based on those results, optimize their medication dose, I can order the test at Everlywell with the “subscribe & save” feature. If I’m working with a patient who has asthma or COPD and I can prescribe the Propeller Health inhaler sensor and get access to their data and insights within their Propeller Health profile, I can manage those conditions virtually. More and more of these kinds of products and services are coming online each day. But they can’t truly take off unless you have a primarily online relationship with your doctor.

These tools are being used today by Sherpaa doctors. We routinely recommend devices and patients can choose to invite us to view their information or simply share screenshots with us within Sherpaa’s platform.

Tools alerting me when a random doctor orders an expensive test or procedure for an employee in the group. Effectively, this enables me to serve as a pre-authorization partner and either approve or revise the order.

One of the main challenges we observe is when a patient gets care from a cost-ignorant doctor who orders tests and procedures without considering the cost of their orders. If a patient knew they could get an equal-quality MRI at one particular center vs. another at a quarter of the cost to them, there would be very little pushback. If a virtual PCP is pinged when something expensive, and avoidable, is happening to a patient they’ve taken care of, and that virtual PCP can dive in, understand the issue, potentially talk with the ordering doctor, and then either re-order the test at a far more cost effective center or simply take the patient down a different, more cost-effective pathway, we can prevent mindless, cost-ignorant orders.

This does not happen today, but I would love a tool that allows our doctors and care team to prevent mindless, inappropriate orders from doctors who aren’t playing on our team.

Tools for me to help coordinate surgical procedures at the most appropriate and cost-effective facility. Sometimes, people absolutely need surgical procedures. But, just like imaging, the cost of procedures varies wildly and cost does not correlate to quality. So, we need tools that can help me make decisions in partnership with the patient as to the surgeon and facility with the best outcome and the most reasonable price. If a patient we’re working with needs a knee replacement and their plan also partners with Sano Surgery, I can loop the Sano Surgery concierge into the conversation to arrange the procedure at the most appropriate surgical center and explain every single detail of the process to the patient.

This happens today and is an invaluable tool. Keep in mind, if we save $30,000 on literally one procedure, that buys unlimited virtual primary care for a year for over 100 members. That’s some serious low-hanging fruit.

Tools for me to help patients get their cancer treated at the most appropriate and cost-effective facility. About 2 years ago, we launched Sherpaa directly to individuals. Within an hour, we got our first patient. He created an Episode of Care and he described every red flag for testicular cancer. We ordered an ultrasound at the local imaging center and confirmed there was a mass. We immediately jumped on the phone with our trusted urologist here in NYC and arranged an appointment for the first thing the following morning. Over the span of 72 hours, this individual joined Sherpaa, we confirmed a mass, we arranged a specialist appointment who then arranged the procedure, and was home recuperating in bed. Since this was an individual with traditional insurance and we all know traditional insurance just does things the traditional way, we weren’t able to take some time and work with a group like Edison Healthcare to arrange care for him at a Cancer Center of Excellence. The number one rule for treating cancer is go to the specialist and facility who sees the most of the kind of cancer you have. Edison not only helps you understand exactly what you need, but has the financial arrangements in place to make this care cost-effective for the plan.

This happens today, but only when Sherpaa shares a client with Edison.

Tools for me to send a health professional to a patient’s home to connect in-person with them. If we have a complicated patient who maybe doesn’t like going to the doctor, but has a few chronic illnesses, and welcomes home visits from a health professional, I’d like to be able to arrange those visits and receive reports from them. This is via a company like Landmark Health. In partnership with Landmark and their team of local health professionals, I would like to manage complicated patients without them having to spend time and money on office visits that aren’t set up to handle multiple complicated issues. You often hear from patients with more than a few issues that their local PCP says to them “I don’t have time to handle all of these issues so let’s just focus on one or two and schedule another appointment for the rest.” This happens because traditional healthcare uses a scheduled block of time to communicate and problem solve. Health conditions, especially chronic ones, are dealt with every hour of every day and people need to be able to communicate with their doctor who can be a part of those issues alongside them. Giving virtual PCPs the ability to send a nurse or home health aide or health coach to a person’s home is a vital piece of managing complicated chronic health issues in our patients.

This does not happen today. However, this kind of service is a perfect Sherpaa partner.

Tools for me to identify the proper care pathway for a patient’s musculoskeletal condition to either order and monitor ongoing progress with physical therapy and medical management or a surgical procedure when warranted. Musculoskeletal disorders like low back pain and joint issues are a huge expense for a population. These patients often wind up enduring surgery when, by far, the most effective treatment for their condition is physical therapy and medication management. Ensuring each patient with a musculoskeletal condition gets the most appropriate treatment prevents many unnecessary surgeries and their complications. And honestly, nobody wants surgery if it’s not necessary. Unfortunately, patients often find themselves working with local doctors who make more money by doing more procedures. Working with partners like IMC, virtual PCPs can ensure every patient with a musculoskeletal condition is following the most appropriate treatment pathway— either physical therapy, or, in conjunction with Sano, helping patients get their procedure at a preferred surgical facility.

This happens today when Sherpaa shares a client with IMC.

Tools for me, with support from psychologists, to help patients get the most appropriate treatment for their mental health issues.

Stress, anxiety, and depression plague our population. Psychologists are best suited to work with patients through these situations. However, not every patient is the therapy “type.” And therapy isn’t the end all be all. Therapy comes in different ways to different people. Sometimes it’s deepening relationships with friends and family. Sometimes it’s having some sort of exercise outlet. A virtual PCP, in partnership with a virtual psychologist has four goals when working with patients with mental health concerns:

1 Is this a one and done situation that just needs a 15 minute phone or video conversation?

2 Is this a person in need and amenable to traditional therapy? If so, connect them with the most appropriate local therapist who specializes in their issue.

3 Is this a person who wants an online relationship with a therapist? If so, recommend services like AbleTo.

4 If this is a person who’s not the therapy type, what can we recommend? A book, a support group, an online forum, an app? We try to get super creative there, because therapy isn’t the end all be all.

Tools for me to medically manage, with support from psychologists, mild to moderate depression and anxiety. Mild to moderate depression is a condition often treated with expensive medications by local PCPs. In partnership with virtual psychologists who check-in with patients with depression on an ongoing basis, virtual PCPs can monitor progress and ensure the depression is treated with the most appropriate dose of the most cost-effective medication. This management does not depend on a routine physical exam, and is best followed by asking ongoing questions from standardized, evidence-based questionnaires like those found at Psychology Tools.

These mental health strategies are used every day by our Virtual PCPs.

As you can see, once people transition from office visit-first care to online-first care, it unlocks a whole new suite of tools available to doctors to manage health conditions in entirely new, far more convenient, and cost effective ways.