By Josh Gray
As is now well known, COVID has ignited the telemedicine industry, packing 5 – 10 years of industry growth into three weeks. As the pandemic picked up steam in March, many people relied exclusively on telemedicine for care. Medicare removed obstacles that had long limited growth, relaxing regulations that prohibited the provision of telemedicine across state lines, loosening HIPAA requirements, and providing equivalent reimbursement for physical and virtual care. Many private payers have also improved reimbursement. The results are impressive. In 2019, 11% of consumers had used telemedicine services; by 2020 46% had, and another 23% were interested in doing so.I n a typical pre-epidemic week, 13,000 traditional Medicare beneficiaries used telehealth services; in the last week of April, 1.7 million did, with 9 million seniors using telemedicine since March. A report by McKinsey suggests that telehealth could become a $250 billion industry.
More recently, the positive narrative around telemedicine has become murkier as evidence emerges that some physicians are already backing away from the modality. Phreesia provides patient registration and scheduling services to 50,000 physicians around the country. Physicians in Phreesia’s network provided almost no care virtually before COVID, but with the epidemic, telemedicine visits exploded, accounting for almost a third of all patient encounters by mid-April. From there, however, a surprising change happened: physicians in the Phreesia network cut back their telemedicine visits by about 46%, with even larger declines for physicians in smaller practices. The Center for Medicare and Medicaid Services (CMS) showed a similar pattern with telehealth accounting for over 45% of all visits for urban Medicare fee-for-service beneficiaries, declining to 20% of visits by early June.
What could account for this pullback? Ateev Morotra, one of the country’s most knowledgeable experts on telemedicine, speculates that part of the apparent disenchantment with remote care stems from basic hassles in using the technology, especially for smaller practices that lack technical support and have not invested in high quality telemedicine platforms. Telemedicine forces clinicians to assist their patients with technical issues and to learn new communication and scheduling workflows. In many practices, telemedicine platforms are separate from EHRs, at times making the documentation even worse than it usually is.
Perhaps most importantly, many physicians are increasingly concerned about getting paid for providing remote care. Reimbursement policies from some commercial insurers can be unclear, with physicians reporting confusion over reimbursement policies and unexpected denials and partial payments. Moreover, payers are still undecided on whether or not recent improvements to telemedicine reimbursement will be permanent. Anthem and United, for example, are committed to enhanced reimbursement through early fall, but are so far undecided on permanent reimbursement levels. Even though CMS head Seema Verma is supportive of telemedicine, enhanced reimbursement is technically tied to the COVID pandemic and uncertain thereafter. Until physicians can count on fair and reliable reimbursement, they will hesitate to invest in better telemedicine platforms that would make care easier and more effective, which will in turn constrain growth.
It is too soon to know where reimbursement will stabilize: poor reimbursement and resulting decrease in telemedicine volumes in the aftermath of COVID is certainly possible. But I am optimistic over the long term. For those providers being paid on a fee for service basis, insurers will find themselves under pressure by both physicians and patients (tens of millions of whom have now tried telemedicine for the first time and like it) to establish reasonable reimbursement levels. More importantly, as the health care system evolves away from fee-for-service and towards fee-for-value reimbursement, provider groups will find that telemedicine is a useful tool to manage care more effectively as well as a necessary step for earning and maintaining patient loyalty. It is noteworthy that Kaiser, the nation’s largest and oldest capitated health system, relies heavily on virtual care.
Beyond reimbursement, the pace of innovation will determine how fast virtual care grows. Most telemedicine volumes during COVID have been straightforward video or phone interactions which essentially mimic conventional visits. Yet virtual care has the potential to improve patient access and clinical outcomes through innovations in care delivery. In particular, I anticipate the following developments in the near to medium term future:
Fully Remote Physical Exams
Depending on a patient’s clinical concerns and available technology, conducting physical exams can be challenging. Physicians may have difficulty examining patients closely. One study for example, observed that physicians could not assess sore throats as accurately through remote interactions as they could through in person visits. In the future I expect that clinicians will be able to use wider and more reliable bandwidth, AI-enabled image enhancement, and remote digital sensors to conduct full, reliable physical exams. This will increase the comfort level of both physicians and patients in with remote care. The more technology can support easy interaction between physicians’ and patients, the less likely patients will put up with the inconvenience and risk of visiting physicians’ offices.
Integrated EHR-Telehealth Workflow
For physicians to fully embrace telemedicine, avoidable hassles for clinicians must be minimized, and few hassles are more pernicious than documentation. Telemedicine systems can force providers to toggle back and forth between electronic health record (EHR) and telehealth applications. Ideally, the telehealth workflow should be embedded in the provider’s electronic health record. At UPMC, for example, clinicians see a floating video connection with the patient (which they can move) from within the EHR, or they can look at the video on a smart phone or tablet. Patients can schedule virtual visits from within the patient portal, avoiding the need to set up a new account.
Multi-Channel Virtual Care Offerings
Rather than focusing exclusively on offering video and phone visits, forward thinking providers should be designing multichannel offerings responsive to the full range of patient needs and preferences. The current system relies largely on patients to initiate visits. Many visits probably do not need to happen (wasting the time of both physician and patient) while in other cases, patients who should be seen are not. A better approach is to deploy a variety of tools to monitor and interact with patients, calibrating outreach and interactions to patients’ underlying risk levels and clinical needs. Frequent, well timed touches, many of them digital, may yield better outcomes than occasional physical visits.
For example, consider a platform with the following components:
- A health care chatbot to help patients with administrative and clinical issues. A range of companies like Babylon, Buoy Health, and Your.MD, have attracted investment capital and are growing quickly. COVID has been a catalyst, with a number of health systems and public health departments using chatbots to answer questions about COVID and to flag patients with concerning symptoms for immediate follow-up.
The accuracy and usability of current products are improving as companies refine the user experience and apply AI to larger data sets to refine their algorithms. Some expect that as chatbots improve, they may become the first layer of primary care, answering basic questions, scheduling visits and tests, matching patients to the best specialists to meet their needs, and allaying anxieties for straightforward clinical problems.
- On-demand phone and video visits. These capabilities will increasingly be expected from most providers. Ideally, patients should have the option of a same-day (or immediate) visit with an available provider or waiting a reasonable period of time to interact with their usual provider.
- Synchronous and asynchronous text interactions. Patients with simple problems may prefer text interactions with their caregivers. Perhaps patients can have the option of texting immediately with a nurse staffed for that purpose or asynchronously with their regular clinician.
- Risk-based outreach. Give currently available data sources and AI tools, providers can now have substantial visibility into the risk levels of patients they serve. It is possible to identify the 10 or 20% of patients most at risk of an unplanned hospital admissions who have not accessed care recently and to reach out proactively to support these patients and prevent downstream events. Rather than relying almost exclusively on patients to initiate visits, providers will dynamically monitor the risk of their panels and reach out in a manner most likely to place the patient on the best possible trajectory.
Specialized Remote Disease Management
The ultimate challenge for telemedicine (whether for physicians, insurers, or patients) is improving outcomes beyond what is possible with in-person care alone. In particular, the integration of digital technologies with specialized disease management programs can allow substantial improvements in care.
A variety of devices to monitor patients’ health status and behavior are being used or are in development. Ambient passive sensors can monitor how well frail individuals are moving and interacting with others, and if there has been a decline in their physical activity levels. Digital pillboxes can remind patients to keep up with their medications and alert providers or family members of compliance problems. Inexpensive digital monitors can be attached to the skin to monitor heart rate, breathing rate, and body temperature. Other tools can be used to monitor blood glucose levels for people with diabetes or detect abnormal cardiac rhythms. Ideally, these devices should roll up into a dashboard that clinicians can review during sessions and trigger alerts that indicate a text, virtual session, or urgent/emergent visit is called for. The growing embrace of digital health will accelerate the expansion of these efforts.
There are already many examples where providers are using remote devices to monitor disease and virtually support patients. For example, the remote congestive heart failure program at Partners HealthCare uses wireless devices to monitor CHF patients’ weight, blood pressure, and pulse oximetry. Physicians set baseline ranges for these indicators at discharge and nurses are notified when values fall outside of the established ranges. The program has reduced hospital admissions 44% and saved over $10 million in six years. It also allows more effective use of clinical expertise: four or five nurses can cover 250 patients virtually, while in a home visit model, each nurse could only interact with four to six patients daily.
Specialized remote interactions have also proved to be effective for diabetes, depression, chronic obstructive pulmonary disease (COPD) and other conditions. As the COVID epidemic continues, I expect the number and effectiveness of these programs to increase, and to persist once the epidemic subsides.
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It is likely to take years before COVID is brought fully under control. As this begins to happen, volumes of telemedicine and other forms of remote care will begin to subside, but still at levels far above what we saw before the epidemic. What is important is that society’s mindset has changed and the pace of innovation has accelerated. As these innovations bear fruit, we’ll see more complex and more effective delivery of care, with remote services taking on a far more important role.