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How to design a profitable staffing model for your telehealth strategy

April 4, 2018

    Medical groups deploy a range of strategies to meet consumers' demand for convenient access to care. One way to meet this demand is through retail clinics—the subject of our recent blog post. Another increasingly common strategy is offering virtual care options, which 83% of providers said they planned to invest in last year, according to a recent survey. When it comes to lower-acuity conditions, telehealth offers patients more convenient access to care, shorter wait times, and comparable quality outcomes, all at a lower cost.


    Unfortunately, most payers do not reimburse—at all or substantially enough—for telehealth visits. In fact, only 21% of providers report being highly successful in achieving financial return on virtual care. This means that it is incumbent on groups who want to pursue a telehealth strategy to develop a lean staffing model.

    Our research uncovered two ways medical groups can staff telehealth offerings to reduce provider concern and reap higher financial return. As you will see below, staffing needs depend on the type of virtual visit.

    Use APPs to respond to asynchronous visits

    Asynchronous visits involve the transmission of messages and/or images and require patients to wait for a response. These commonly come in the form of standardized email forms or online tools that ask the patient to answer a series of questions. Medical groups typically designate a preset list of conditions for which these exams can be used.

    One example of this type of virtual visit comes from Palmetto Health in South Carolina. Using their online SmartExams, patients complete a dynamic interview online that includes questions about current symptoms and medical history and are guaranteed a response within one hour. Through the tool, providers can diagnose and treat 80+ common medical conditions. It also involves acuity-adaptive triaging functionality, which filters patients out of the interview if their responses indicate they need to be seen in person. Their telehealth manager, Amelia Bischoff, describes the software as "an intelligent, diagnostic tool similar to sending your rockstar nurse into the exam room" to capture thorough information on the patient for the provider to make a diagnosis and supply a customized treatment plan. SmartExam assists providers in clinical decision-making, which improves efficiency.

    Palmetto Health exclusively deploys advanced practice providers (APPs) to reply to these SmartExams. They chose this staffing model because APPs can provide high quality care at a lower cost to the medical group than physicians. Specifically, four nurse practitioners (NPs) reply to the Smart Exams. These NPs all work at walk-in convenient care sites which tend to have excess capacity, leaving the NPs time to answer SmartExams at their convenience; however, one APP who answered SmartExams full time could treat up to 150 patients per day through the platform. The NPs are easily able to incorporate this into their days, with most providing responses within 10 minutes.

    Importantly, Palmetto Health had to work closely with their legal team to develop protocols and get legislation passed so that APPs were able to conduct these SmartExams. However, since state laws regarding APP utilization vary, medical group leaders should consult local regulations before adopting this staffing model.

    This model has been successful for Palmetto Health thus far. They are seeing approximately 10 patients per day via the SmartExam platform. Approximately 75% of these visits are for existing patients, so they are providing an additional access point for these patients and building loyalty. For the remaining 25% of new patients, if they do not identify a primary care physician (PCP), they are put in contact with Palmetto Health's Patient Experience Action Line to be connected to a PCP. This positions the SmartExams as a vehicle for system growth and population health management.

    Limit the number of physicians involved in synchronous visits

    Synchronous visits are live consultations with patients via phone- or video-based platforms. Some organizations prefer to staff physicians to these visits, due to local regulations and potential challenges with or hesitancies toward diagnosing patients virtually. To maintain a successful synchronous telehealth model, organizations should limit its impact on physicians. They can do this through outsourcing e-visits to physicians from external telehealth vendors.

    Another option is to use a limited number of in-house physicians, as Sentara Medical Group does to staff phone-based e-visits. Existing Sentara patients can schedule e-visits for a number of low-acuity conditions. Visits cost $30 cash or the standard office visit copay for those within Sentara's health plan.

    Since visits occur in real-time and disrupt physicians' traditional workflows, Sentara lets physicians choose whether and when to offer them. For example, one physician may decide to offer an hour of e-visits per month to try it out, whereas another may offer a few two hour spots each month. This opt-in model allows physicians to test out the program and scale up and to fit e-visits within their existing schedules. The model can also be leveraged to offer patients after-hours access, such as on evenings or weekends. In fact, most of Sentara's physicians want to offer these visits outside of regular hours. The hope is that eventually those offering these hours will also begin blocking off e-visit time during the middle of the day.

    To improve e-visit adoption, physicians are compensated for their time completing the e-visits, at 0.3 RVU credits each. In addition to this financial incentive, Sentara leverages physician champions to describe the benefits of the model and the ease with which they can complete e-visits. They find that once most physicians try out the e-visit platform, they like the flexibility with which it allows them to deliver care. Their physicians are now averaging nearly 30 visits per month—up from just five during initial pilots. Sentara plans to move their e-visits to a video platform once they have the appropriate technology built into their EHR.


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