How VPC Can Help with Actuarial Decision Making

The evolution toward value-based healthcare is continuing, and actuary departments have to adapt to a changing data landscape in which new data streams are increasingly relevant.

Among the streams that have the potential to disrupt actuaries’ current models are the data generated by virtual primary care (VPC). As the industry moves beyond traditional telehealth urgent care to deliver a more comprehensive experience, VPC will create clinical and billing data that payers and providers will increasingly want to use.

Inevitably, actuary teams will also want to utilize this data. They will need to become familiar with the potential gains and challenges in the new virtual primary health care payment landscape.

Virtual primary care represents the future of healthcare delivery in the United States. VPC aims to deliver the traditional primary care experience from the comfort of patients’ homes by harnessing digital solutions, spanning a wide range of care modalities – urgent care, chronic care management, preventive care, and others.

The shift to a digital lifestyle experienced by many during the pandemic has accelerated patient demand for virtual primary care. The uptake of virtual appointments has increased 37-fold on pre-COVID levels, and as the quality of VPC advances that figure is set to rise further.

However, VPC often means the patient accessing primary care on a video chat with a doctor via tablet or smartphone. But this system has drawbacks: doctors are often reluctant to diagnose based on a low-grade video image alone, meaning patients often end up in the ER anyway in pursuit of a diagnosis.

Diagnostic tools that offer remote physical exams generate data that are stored within the patient’s Electronic Health Records to allow for continuity of care. In addition, these exams offer actuary departments a rich stream of data for analysis.

Historically, payers’ actuary departments have used their data to carry out their analyses, including reserve estimation. This has resulted in the standardization of the data held by payers across the board, making data access a straightforward affair.

The amount of data gathered by payers is often limited because the data they have access to is only that which is required to make a claim. To date, reserve estimation has focused on estimating the financial liability for claims that have occurred but have not yet been filed.

VPC enables broader visibility across the different remote and in-person transactions and events, which is important for risk scoring and understanding episodes of care. VPC also enables more longitudinal data on patients since VPC uploads health events into EHRs for each consultation with a patient, giving actuaries information about events far before they turn up in payer data.

Each EHR will also include more information than traditional telehealth data for the same encounter when working with remote physical exam platforms. Typically, no clinical data is available during video-only visits, whereas when key diagnostic exams are undertaken during the consultation, results are captured and logged on the patient’s EHR.

This additional data will allow for more accurate, innovative modeling by actuaries. For the payers and providers assuming more of the risk, this translates into a far greater degree of confidence in reserve estimation than previously possible.

As they move forward into the new healthcare data analytics landscape, actuary departments are free to create far more sophisticated models, collaborating with payers and providers to harness the more granular data made possible through access to EHRs and virtual primary care.

The availability of more robust clinical data, when used purposefully and with an understanding of the challenges it presents, can add significant benefits and value when approaching the actuarial model building.

Consequently, the advent of big data in healthcare will significantly improve the service that actuary departments can provide to payers and providers as they take on more risk in the move towards value-based healthcare.