Dr. Erika Bliss of Equinox Primary Care in Seattle explains how she has been delivering virtual care during the COVID-19 crisis and how she has implemented policies around a virtual-only DPC membership. This webinar was originally broadcast on Thursday, April 2nd, 2020.

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Q: How has the COVID-19 crisis affected the way you implement your virtual care offering?

A: Virtual care has always been a large part of my practice. Before COVID-19, my standard approach was to start with an in-person visit where I would note patient history and conduct a physical exam. Once the relationship was established, and if the patient didn’t require future in-person visits, I would shift to virtual care. However, as a result of the COVID-19 crisis, I’ve shifted to more virtual care with my pre-existing patients. I’ve also decided to add a temporary virtual-only option which I’ll talk more about in this webinar.

Q: What is the composition of your practice and how does this affect your ability to deliver virtual care?

A: The age distribution of my practice is fairly normal, with a few very small children, a decent number of teenagers, a majority in their 40s-60s, and a lesser number of elderly patients. Other than age, though, the socioeconomic status of my patient base is widely diverse, and I’ve found that this tends to align with not only their tech-savvy (or lack thereof) but also their access to technology. Another factor that affects my ability to deliver virtual care is the location of my patients. For example, I have several who live in remote areas where service is inconsistent at best. Some of my patients, for whatever reason, struggle to handle the technology that is required for a virtual visit. These various obstacles, unfortunately, mean that I cannot offer virtual care to every patient.

Q: How did you determine what to charge for your memberships?

A: My pricing for monthly fee memberships is $60-$115 based on age. When I began considering a monthly fee membership for virtual care only, I wanted to set a price that would help defray the costs for delivering such a service, but I also wanted to remove financial barriers for those who needed care but couldn’t afford it. Therefore, I chose $25 per month for adults and $15 per month for children as my virtual-only fee. Since this crisis is ongoing and ever-changing, I wanted to make sure that I didn’t waste time coming up with complex pricing.

Based on their practice’s capacity, other DPC physicians can implement a similar plan if they so choose. Once they reach maximum capacity, they can always decide to suspend this option for any new patients. Of course, they can also choose the price point that works best for their unique practice.

Q: Do you recommend changing pricing based on the economy?

A: It’s totally up to each practice. The beauty of DPC is that you can make decisions about your pricing based on your market, your demographic, your feelings, your approach, and your offerings. Most practices start at $50 monthly, and I think that’s still a great deal. However, if it isn’t working, you can always update your pricing later.

Q: If your virtual-only membership costs less than your standard membership, how do you dissuade your current patients from switching to this lower-cost option?

A: When I sent out communication about this new offering, I was very clear that this virtual-only option was temporary. I also explained that it was created to be of service to the community during a crisis and that it was strictly for those who cannot afford a healthcare provider or cannot access theirs for whatever reason. Therefore, I would not be allowing current patients to change memberships.

I did have a few patients contact me directly about their inability to afford their full-DPC membership fees during this pandemic. In these cases, I just discounted or waived fees altogether instead of switching them to the virtual-only option. I did this to keep my books straight. If I were to move members from one membership to another, I would be unable to accurately track my membership losses. This is important to keep in mind at a time like this because DPC practices may be eligible for small business loans or grants depending on the extent to which their business suffers due to COVID-19.

Q: Do you offer one-time virtual visits? If so, what do you charge?

A: For the one-time telemedicine visit, I haven’t come up with a price yet. I’m currently working on opening up this option, but I’ve been focusing my time and energy on the monthly virtual-only option for the past two weeks.

Q: What kind of tools did you have to integrate to make your new offering work?

A: Since my practice staff consists of only myself and my medical assistant, I knew that my tools needed to be easy to implement. I chose Hint for my practice management program, Elation for my medical records system, IntakeQ for my scheduling system, and Skype for video visits. Before COVID-19 hit, I rarely used video chatting as part of my process. Unfortunately, I had put off completing my practice’s health history form on IntakeQ because we were having patients fill out a hard copy when they arrived for their first visit.

When COVID-19 forced us to go virtual, I had to finish that IntakeQ form so that patients could interact with us electronically. Now, this tool allows us to schedule patients and send them the intake form online. Then, IntakeQ not only tells us when a patient completes the form but also attaches it to the appointment where I am able to view it.

Q: Can you give us an overview of your workflow from start to finish?

A: The workflow starts with a landing page on my website where patients can see my new virtual medicine offering and click for more information. The patient is then taken to another page that explains how the offering works, gives him or her the option to sign up through Hint, and prompts the patient to provide a payment method up-front. Once the patient has signed up, we are notified, we call and set up for a video appointment, and we send the new patient our intake form.

For the actual virtual visit, I use doxy.me. It’s an encrypted platform that only costs my practice $35 per month. We simply text the new patient a link to doxy.me and he or she can click on it and video chat with me. During this visit, doxy.me allows me to share my screen, if necessary, with the patient. I document my notes on Elation and save them for future reference. For now, I block out a full hour for the intake visit. If my practice gets too busy to maintain such a lengthy first visit, I may shorten it to accommodate more patients.

Q: I am currently launching my practice, and I’ve decided to offer only virtual visits. What’s the best EMR to use in this case?

A: I love Elation’s EMR. It’s easy to use, intuitive, and provider-centric. It’s a great platform for a practice with a small staff. Elation’s document management features are great and the support team is attentive. If you need a system, however, that will allow you to work with a large support staff, it’s not as strong in that department.

Q: Does doxy.me integrate with Hint and Elation?

A: No, but Spruce does. If you’re looking for full integration, look into what Spruce has to offer.

Q: How did you launch new technology to existing members and new patients?

A: Before I communicated the technology changes to new patients, I walked through the new patient process myself -- utilizing each of the platforms that a patient would encounter -- to make sure that I didn’t run into any problems. This kind of familiarity with the patient experience also allowed me to help patients troubleshoot issues if and when they arise.

After I was sure that the new technology worked effectively, I sent out an email communication to all patients that explained the telemedicine-only option. The email included a link that I asked patients to share with others so that I could build awareness for people in need.

Q: Should we write a separate patient agreement for our virtual patients or just alter our traditional DPC agreement where needed?

A: We had a solid, workable DPC agreement in place already, so we just modified it to fit the new offering. Luckily, Hint allows you to upload a different contract for different memberships, so it was easy to implement a virtual-only agreement. As always, consult with your DPC attorney if you have legal questions about what should or should not be included in your new member agreement.

Q: Have you had any recent requests to support physicians or patients outside of the US?

A: No, I haven’t. I predominantly work with patients from the western US states.

Q: In addition to your virtual office, do you have a physical office as well?

A: Yes. I have a clinic in downtown Seattle.

Q: In this new virtual setting, have you maintained the same hours of service as your traditional DPC hours?

A: More or less, yes. Before the COVID-19 pandemic, I worked in the clinic on all weekdays except for Wednesday which was my off-site administrative workday. Now, I am open every day (telehealth only) from 10-6, and I allow all of my patients to self-schedule within these constraints. If patients need an in-person visit, they call me or my medical assistant and we decide how to proceed on a case-by-case basis.

Q: How many virtual patients do you currently have?

A: I have approximately twenty, but I’ve only met with about half. The rest have upcoming scheduled appointments.

Q: What do you do when you have a telehealth patient who needs to be examined in-person?

A: I arrange for them to go to another facility -- like their city’s emergency room, urgent care center, or testing center -- for examination. In some cases, I’ve faxed testing orders so that my patients could get the care they needed. I could do the same if the patient needed lab work or an x-ray, for example.

Q: How can DPC practices compete with Amwell or Teladoc in providing virtual care?

A: DPC is different from FFS virtual care because we offer a primary care relationship rather than a one-time visit with a randomly-selected doctor. This relationship is the heart of DPC and it could very well be the future of medicine. With DPC, patients can see the same doctor repeatedly, and that doctor can get to know patients and their needs in ways that a telemedicine platform cannot offer.

For more information on how your DPC practice can navigate the COVID-19 crisis, go to https://www.hint.com/virtual-care.