What! No Insurance Required? How SSM Health Creates Low-Cost, Operationally Efficient Virtual Care

The health system launches a $25-per-call service that dovetails operations into its existing Walgreens retail clinics, prescreens patients with an online questionnaire, and limits hours to maximize efficiency.

During an era when many health systems are exploring the best way to offer urgent care telehealth services, SSM Health has taken a low-cost, high-efficiency approach that dovetails with services offered through its Health Express Clinics at Walgreens.

The St. Louis–based non-profit health system's virtual visit program only charges $25 per call, doesn't file insurance, and limits service hours. One differentiating factor that boosts provider productivity: patients complete an online questionnaire that guides them through their history and symptoms before a nurse practitioner, who also works at the retail clinics, initiates the virtual visit.

Erin Powell, RN, system director for retail health at SSM Health, says this model meets multiple organizational strategies: to provide quality healthcare at an affordable price, grow patient volume, and direct consumers to the lowest cost care venue. She offers a look into five strategic and operational elements behind this approach that enhance efficiency for the health system, which operates 23 hospitals in four Midwestern states.

1. Strategy Combines the System's Mission With Growth and Cost of Care Initiatives
 

The primary strategy behind the virtual care initiative aligns with SSM Health's mission and values to "provide access to quality healthcare at an affordable price for our community," says Powell. "Number two, along with every health system, we are trying to grow volume and market share." To do that, Powell says, they must listen to consumers, providing access when and where they want it.

Another consideration behind the virtual service is SSM's cost of care initiative. To control healthcare costs, says Powell, the system wants to direct patients to the least expensive venue of care. This philosophy led to development of the Walgreens clinics, and was also a driving factor behind the telehealth program. When virtual visits and Health Express Clinics are available, she says fewer people will use the emergency department when they have a cold or the flu, for example.

The program initially launched in February with employees who are enrolled in the organization's health plan and was introduced to residents of Missouri and Wisconsin in May. Residents of southern Illinois and Oklahoma were eligible to participate in June. Powell says the slow rollout was intentional, enabling practitioners to become familiar with the process and workflow before the expected uptick in call volume when cold and flu season begins.

2. Dovetails Into Existing Retail Service
 

Rather than launching a new program and hiring additional personnel, SSM virtual care responsibilities are assigned to nurse practitioners who already work at one of the 23 Walgreens clinic locations. When taking calls, the responsible nurse is devoted to that task for the day and another nurse covers the clinic visits. For the time being, only one nurse provides virtual care each day.

"This really complements the service that already exists," says Powell.

Both programs fall under the auspices of the health system's retail health platform. Nurse practitioners are employed by the SSM Health Medical Group. The nurses and primary care physicians have collaborated to ensure all protocols use evidence-based practices, she says.

3. Low Consumer Price Point
 

SSM virtual visits cost only $25, payable by a credit or debit card or a card associated with a Health Savings Account (HSA). Callers do not need insurance, although those who have it may be eligible for reduced rates through their insurer. Medicare does not reimburse for these services.

SSM Health does not file insurance claims for virtual care, reducing workload and administrative responsibilities for the system.

"Obviously, the price point is low, and it was very aggressive," says Powell. "Our goal was not to make revenue off of these virtual visits, but rather to serve more people within the community and draw more patients into our system." In addition to resolving callers' immediate issues, new patients may be referred to SSM's primary care physicians, as well as inpatient and outpatient services. This is how the system expects to gain market share and see revenue growth.

Powell says SSM Health is aware that the low cost will be attractive to the uninsured and "underinsured," which is consistent with the organization's mission to provide affordable care for all. In addition, it helps control costs by reducing ED utilization.

4. Limited Hours of Operation
 

In an era when many consumers expect service around the clock, SSM Health launched its virtual visit program with limited hours of operation, from 9:00 a.m. to 7:30 p.m. Monday through Friday and 10:00 a.m. to 4:30 p.m. on weekends. The approach is designed to control operational costs, although the hours may change in the future.

"The vast majority of our patients don't emergently have a sore throat at one in the morning," says Powell. "They're going to call when they're awake or when they get home from work. You have to look at what makes sense operationally. Do you run a 24/7 operation with high overhead to get [a few] calls during the night? Our strategy at this point would be no. Now if the day comes that we are getting overwhelming volume [after hours], we will absolutely consider extending our hours."

5. An Online Questionnaire that Produces Provider Efficiencies
 

While limited hours, no insurance claim filing, and dovetailing the virtual service into an existing retail platform save the system money, SSM Health creates further operational efficiencies through its "dynamic questionnaire."

Before a patient speaks to a provider, he or she must fill out an online questionnaire. It takes five to 15 minutes to complete and asks a series of questions driven by algorithms to deliver the provider exactly the information he or she needs to make a rapid diagnosis. In addition, the caller may be asked to submit photos.

The nurse practitioner responds within an hour of the submission or within 60 minutes of opening if a questionnaire was completed overnight.

The tool was designed by Zipnosis, a Minneapolis-based virtual care platform company that SSM Health partners with for its virtual care technology.

"The questionnaire arms the provider with as much information as they can passively get on that patient before moving forward with a diagnosis or pushing a care plan to that patient," says Powell. "It really does a good job of getting a full picture. By the time that provider does a video visit or a phone call with that patient, they've got a thorough view, and it shortens the length of the visit."

After a decade of working with health systems across the country, now totaling nearly 50 integrated delivery systems, Zipnosis CEO Jon Pearce, says the "the average work time for a clinician to treat these very simple conditions is about two minutes." The questionnaire not only mimics the interview experience a patient would have with a physician, it also captures "99% of the documentation for the provider," he says. "This powerful combination creates a ton of efficiency."

What's Next?
 

Powell reports that SSM Health is pleased with the early performance of the virtual care program, but due to the incremental rollout, she says, "It is a bit early in the process for any real metrics." Next February they will measure how the program has impacted volume across regions, referral patterns from the service to other SSM care sites and physicians, and quality metrics. In addition, they will examine Net Promoter Scores "to understand how our consumers perceive us and what is the likelihood that they will recommend us to someone else."

The system is also exploring other uses for telehealth. SSM Health operates other virtual care services outside of retail health including telestroke, teleneurology, and telepediatrics, and is exploring the use of the medium for mental health services and primary care visits. Meanwhile, the urgent care initiative is the only one offering a direct inbound connection for consumers.

"Obviously, telehealth is the wave of the future," says Powell. "We continue to have a task force that is dedicated to how we grow telehealth, [and determine] what services we need to invest in first and foremost. One of our priorities is to grow and get more physicians who are willing and interested in this technologically advanced way of practicing medicine. I don't think there's an organization out there that doesn't see telemedicine as a priority."