The “Unvisit”:  Why Visits Are The Wrong Unit of Account

Over the last several  months, we have been really focusing on the details of operationalizing  true hybrid care. The complexity inherent in successfully delivering care that seamlessly transitions between in-person and online environments—and potentially with different teams delivering different services but which is experienced by members as integrated and consistent experience across the different “care channels”—is an often overlooked and certainly under-appreciated art form. 

In the new paradigm, a frequently asked question is, ”What constitutes a visit?” In the old days, this was pretty straightforward— a visit was a scheduled, in-person appointment. Today, the idea that a visit could only be defined in that way certainly seems anachronistic, if not archaic. However, even today, employers and consultants alike fall back on traditional utilization metrics, such as the number of “visits,” or “cost per visit” because they’re both easy to define and quantify, and because they’re familiar. But if we’re truly focused on health outcomes, it seem that this approach goes counter to the entire point of High Quality Primary Care as well as what “value based care” is supposed to be about. 

Taking a step back, one must ask, Is the notion of a “visit” even accurate in our new, hybrid world?

I was beginning to scratch at this three years ago when writing about the “tyranny of the visit,” in which I argued that this concept is an artificial constraint given to us by tradition but which is today being disrupted by technology. Encouragingly, despite the Icarus-like flight of many virtual firms and services since 2019, there is a greater willingness to look at new care delivery channels, different service concepts, and new ways to offer value to more targeted populations. Yet, despite all this innovation, we are still talking way too much about “visits” (defined as a time-bound, geographically constrained, in-person meeting). 

At Crossover, our Primary Health model is built on the premise of continuous, or streaming, care. It’s always on, building meaningful relationships with each member over time and through multiple interactions with our entire care team (from nurses and physicians to allied professionals to our coaches and navigators), and through multiple channels. As a value-based approach, the health and financial metrics that matter are those focused on engagement, satisfaction, and outcomes. Compensation has been modified to replace the visit as the unit of account and instead use measurements regarding the impact of the relationship (via therapeutic alliance, NPS, and other relational metrics) that tie directly into the clinical, financial, and other objectives achieved. 

However, even in situations where our clients have accepted the structure of always-on, multi-channel, team-based care, there often remains a desire to measure and assess our performance based on the number of member “visits.” This reminds me of the old days, when the telecom companies were transitioning from trying to bill on every single call or text (and becoming quickly overwhelmed as a result), and had to move to bundled payments and ultimately, to unlimited access.  Streaming care will go through the same process, with the laggards ineffectually trying to monetize the wrong units of value (much to the chagrin of their patients), and the leaders moving to bundled or capitated payments. Interesting how each industry has to go through its own growing pains. 

Trying to apply the criteria of a “visit” to this new multi-channel world of streaming care lands us in an unfruitful swamp of definitions. When is or isn’t a text exchange a visit? Are there certain actions that turn virtual communications like a text exchange into a visit, such as an initial diagnosis or prescription? Is everyone clear on the triggers for designating a text a “visit”? As a physician noted in a recent article in The New York Times: “We’re at an inflection point with messaging. How are we going to deliver care in the future as we continuously move away from all care being a discrete visit?” 

Exactly!  

Streaming of our entertainment has become the norm. All the content is there and always on, for a simple engagement fee or membership. Today, people would be aghast at having to pay for individual films or individual text messages. We need to learn from that experience and apply it definitively to a more modern and responsive form of Primary Health. The key insight will be the mental shift from a discrete “visit” to continuous “care” and this transition must also be accompanied by a new payment model that actually matches the new care delivery model. That’s why we have to focus on the “unvisit” as both a concept and mindset where the visit as the unit of account ceases to exist.