Summary

Costco has partnered with Sesame to offer its members affordable virtual healthcare services, including medical and mental health consultations, which has implications for the broader healthcare system and patient expectations.

Abstract

Costco has introduced a new service for its members in partnership with Sesame, providing access to virtual healthcare appointments for a flat fee of $29. This service aims to address the long wait times for doctor appointments and the increasing number of primary care physicians leaving insurance plans. While telehealth has been shown to be effective for managing chronic conditions, acute care via virtual visits often results in more emergency room referrals. The service also raises questions about the quality of care and the role of non-physician providers, such as Nurse Practitioners (NPs) and Physician Assistants (PAs), in the face of physician shortages and the controversial issue of "scope creep." The American Medical Association has expressed concerns about scope creep, including increased costs and potential overprescribing by non-physicians. However, patient preferences and the need for accessible care may outweigh these concerns, and services like Costco's could provide valuable data on healthcare outcomes.

Opinions

The author acknowledges the potential benefits of Costco's virtual healthcare services for its members, particularly in terms of cost and accessibility.
There is a cautious optimism about the effectiveness of telehealth for chronic condition management, but skepticism regarding its suitability for acute care needs.
The author points out that the use of non-physician providers in virtual care settings may lead to an increase in emergency room visits due to limitations in assessment and treatment capabilities.
Concerns are raised about the accuracy and ethics of advertising these services as being provided by "doctors" when in fact they may be delivered by NPs or PAs.
The author highlights the issue of "scope creep" and its implications for the quality of care, noting the American Medical Association's stance against expanding the scope of practice for non-physicians.
Despite concerns, there is an acknowledgment that the demand for accessible healthcare and patient preferences may drive the acceptance of non-physician providers in primary care roles.
The author emphasizes the importance of transparency in the provision of healthcare services, suggesting that Costco could conduct its own studies to demonstrate the effectiveness of its virtual care platform.

See a Doctor, Get a Hot Dog

Costco now offers both

Society rejoice! Costco has made medical visits cheap and accessible. They have partnered with a company called Sesame to provide their members with cheap virtual appointments. For $29 you can see a provider, which is often as much as a copay even with insurance.

They also offer mental health counseling and even virtual dentistry! That is a new one which will require a flashlight and a very good computer camera.

From a numbers perspective, giving this type of access is a great thing for Costco members. There are 127 million Costco card holders and this is big business.

Couple this with the fact that the average wait time to see a new doctor is 21 days and up to 16 hours in the ER, at least in my state, and we can all clearly see a need for faster access. With more primary care doctors leaving insurance plans and medical systems, these types of solutions from private companies will be needed.

Is the quality of the care the same?

The research shows that for management of chronic conditions, telehealth is about equal as in person visits. This makes sense. If someone has had diabetes for 5 years, is on the same meds, and is being monitored for their glucose control, it is simple to follow them virtually.

This is harder for acute visits that usually require touching, listening or doing some sort of testing (like neurological sensation or strength). JAMA found that acute virtual visits led to ER follow-ups more often than an in person visit.

The reasons for this are obvious. Chronic conditions are predictable more often than an acute concern within a 30 day window, for example. That is why virtual visits will come with so many disclaimers by providers in order to CYA (cover your “tush”). An after visit summary starts to sound like a pharmaceutical commercial:

If you experience chills, fevers, diarrhea, changes in your bowel habits, vomiting, chest pain, numbness, weakness, pain of any kind, lightheadedness or any other concern, please follow up in the Emergency Department

That is the only way this can work as the visits offered by Costsco and every other virtual provider are not done in a medical setting. That means no vitals, no physical assessment beyond what can be seen on camera. And my experience with these types of visits is often a questionable internet connection or the inability of the patient to show you a clear view of their issue.

That is why more of these patients end up in the ER than someone who saw a doctor in person. Long ER wait times therefore get longer.

The “doctor” will see you now

If you go onto the Costco/Sesame website it clearly says “Doctor Appointments as low as $29” but when browsing the options, there are few doctors.

It is obvious that with the massive shortage of primary care physicians in this country, we will need to start utilizing NPs and PAs to meet patients’ needs. But there is a concept called “scope creep” which is important to discuss.

Scope creep is when someone outside of a particular specialty will perform things that are “out of scope.”

Here are three specialties pushing against scope creep:

1. Ophthalmology: Ophthalmology organizations are fighting efforts to allow optometrists to perform eye surgeries.

2. Anesthesiology: Several states, including New Jersey and West Virginia, have proposed legislation expanding the scope of practice for certified registered nurse anesthetists, allowing them to work without physician supervision.

3. Psychiatry: This year, there was a nationwide push for Medicare to define psychologists as physicians, allowing them to prescribe medications without reporting to an attending primary care physician.

The American Medical Association gives reasons against scope creep (clearly with their own biases). Expanding non-physicians’ scope of practice increases costs. For example:

X-ray ordering rose 441% among non-physicians.
Patients were 15% likelier to get an antibiotic from a non-physician.
6.3% of NPs prescribed opioids to more than half of their patients, compared with 1.3% of physicians.

And patients prefer physician-led care, with:

95% saying it’s important for a physician to be involved in their diagnosis and treatment.
91% agreeing that a physician’s education and training are vital for optimal care.
75% saying they would wait longer and pay more to be treated by a physician.

I will take this time to say I have worked with some amazing NPs and PAs who I would trust with my own care and the care of my loved ones. I am neither advocating for or against scope creep and understand its need in our medical system in order to get access for those who need it. And if patients vote with their wallets to access care from non-physicians, then it does not really matter what the AMA says.

But the issue is more that when we are okay with scope creep, we will see it across the spectrum. The motivation for these companies is maximum throughput of patients. The motivation of patients is to be healthy. Whether these two goals mix is yet to be seen, at least with Costco/Sesame.

But there is already a concern I noticed. If you look under the “mental health counseling tab” some of the same providers show up.

https://sesamecare.com/service/online-mental-health-consult

Many visits in the primary care setting or ER are combined with mental health issues. Clearly chronic disease and behavioral concerns go hand in hand. ER physicians and primary care physicians are accustomed to dealing with mental health concerns, and can prescribe medications just like a psychiatrist when necessary.

However, that being the case, those physicians are never paid to be behavioral therapists. It would be disingenuous to say that seeing a primary care doctor is the same as seeing a psychologist. While they can provide a temporary solution to a patient’s problem, they still need to establish care with a specialist.

In my area, when searching for a psychologist on the site, there is one available. But she is a nurse practitioner. And when searching online, she has no training in mental health, only primary care experience. Again, this is very deceptive.

Get the care you need

Services like this from Costco/Sesame are necessary. It is great to see innovation in the space because ultimately people have to be able to access care when they need it. Having a medical question and being able to see someone within 2 hours for $29 is remarkable.

It is just important to look up the person you are seeing. If you are being told you are seeing a doctor, and you are not, that is not the right approach to get people to trust you for health needs. If a non-physician gives you the care you need, and answers all your questions, then why do you need to see a physician?

It depends on your needs as a patient. While I do not agree with the “false advertising” aspect, and the obvious scope creep, I do want people to have the fastest, safest access to care.

Costco can even do their own study to counter the AMA. They can gather useful data on outcomes from this platform and can use it to help make the medical system more effective.

For all the positives they can do, I hope they just keep their customers in mind as they are now both members AND patients.