According to Susan Dentzer’s article “Reform Chronic Illness Care? Yes We Can,” Health Affairs (Jan.-Feb. 2009), chronic illnesses account for 75 percent of total U.S. healthcare expenditures. Looking ahead, the challenge of caring for people with chronic conditions looms large. By 2020, the number of Americans with one or more chronic diseases will climb to about 157 million. That is when the shortage of physicians in the U.S. will reach approximately 200,000 and when the shortage of registered nurses could top 340,000, say David I. Auerbach, Peter I. Buerhaus and Douglas O. Staiger in “Better Late than Never: Workforce Supply Implications of Later Entry into Nursing,” Health Affairs (Jan.-Feb. 2007). The combination of more and more patients with increasingly complex care needs and a shortage of clinicians to care for them could be devastating for the nation. Something has to change.
According to Susan Dentzer’s article “Reform Chronic Illness Care? Yes We Can,” Health Affairs (Jan.-Feb. 2009), chronic illnesses account for 75 percent of total U.S. healthcare expenditures. Looking ahead, the challenge of caring for people with chronic conditions looms large. By 2020, the number of Americans with one or more chronic diseases will climb to about 157 million. That is when the shortage of physicians in the U.S. will reach approximately 200,000 and when the shortage of registered nurses could top 340,000, say David I. Auerbach, Peter I. Buerhaus and Douglas O. Staiger in “Better Late than Never: Workforce Supply Implications of Later Entry into Nursing,” Health Affairs (Jan.-Feb. 2007). The combination of more and more patients with increasingly complex care needs and a shortage of clinicians to care for them could be devastating for the nation. Something has to change.
Chronic Condition Care
We cannot increase provider supply fast enough, especially in view of the survey published in the Sept. 10, 2008 Journal of American Medical Association, which indicates only 2 percent of graduating medical students are planning careers in general internal medicine. Even if we could ramp up provider supply, we could not build the required hospital capacity fast enough, nor could we afford to do so. It is the medical management of chronic illness that has to change.
When patients with chronic conditions have office visits, they can get the routine care they need. When their conditions deteriorate and they are admitted to a hospital, they generally access requisite expertise and get the coordinated, continuous care they need, despite emergency department (ED) overcrowding. When they are discharged, they can get homecare to promote recovery. What’s missing? Ambulatory care remains episodic and fragmented. The system does not keep chronically ill patients connected to necessary clinical expertise in between office visits in order to avert medical crises that land them in the ED.
Connecting Patients and Clinicians
This is why telehealth is so important. With telehealth, regardless of where patients live or when they require care, they can connect and stay connected to providers with clinical capabilities matched to their care requirements.
Leading-edge telehealth systems feature patient stations that proactively prompt patients at home to answer health status questions by touchscreen and use integrated medical devices to take their vitals. These systems automate the basic sequence of questions that clinicians ask during an office visit. Health status questions, physiological parameters for monitoring, and multi-media and narrated instructions are all personalized for each individual patient. Via HL7 messaging using secure socket layer technology over telephone lines, or broadband connections, patient responses and data are transmitted to a server where the physiological measurements are date- and time-stamped for trending. Clinicians establish thresholds for each patient to red flag significant fluctuations. When readings exceed any pre-determined threshold, system software color-codes them so they stand out on clinical dashboards that are accessible on telehealth provider stations. Optimal telehealth systems also include video capability for televisits.
No matter which telehealth technology gets deployed, its use determines its value. Having primary care physicians’ offices on the provider end of a telehealth system is not sufficient. Primary care physicians do provide essential and efficient routine care to patients with chronic conditions; however, we cannot expect them to manage all patients with chronic illnesses without more support (especially those patients with the very highest levels of disease burden and most complex care needs). That’s why we need to use telehealth to supplement primary care with a new model of chronic care management.
We need to assemble teams of physicians and nurses who have demonstrated proficiency in caring for patients with the most complex chronic conditions. Telehealth technology is then used to establish and maintain ongoing care connections between chronically ill patients and their care teams. The teams maintain remote monitoring and conduct video visits to watch over patients’ medical conditions; carry out personalized care plans in coordination with primary care physicians; optimize each patient’s clinical and functional status outcomes; and, prevent re-hospitalization and other avoidable utilization and costs in between regular office visits.
Paying For Telehealth
Health plans have been reluctant to pay for telehealth and understandably so. Time and again payers have extended fee-for-service reimbursement for new technologies and procedures that promise to decrease costs only to see escalating demand and utilization instead increase their costs. Health plans could make telehealth a covered service with the hope of achieving savings by substituting lower-cost televisits for more costly office visits. But a tsunami of demand from patients who would value the convenience of televisits would sweep away any potential cost savings. If payment stays centered on units of service, using telemedicine to substitute $50 televisits for $100 office visits is a losing proposition.
Payment policies must ensure that telehealth is used for the subset of patients for whom it yields the highest value, by helping attain the largest possible improvements in clinical and financial outcomes. High-cost patients with the most complex chronic conditions are those in greatest need for telehealth-supported connected care. Rather than paying for telehealth as a convenience for all patients, we should pay for the results that telehealth can help achieve by rewarding high-value care systems that achieve superior outcomes in managing the care of patients with complex chronic conditions. Simply stated, we should pay for outcomes, not technology.
Share Real Savings
Telehealth care teams have proven to achieve 65 percent to 95 percent reductions in ED, inpatient and skilled nursing facility costs — achieved as care teams help primary care physicians monitor, improve and maintain the health of patients with complex chronic conditions.
How can we realize and share these savings? Payers must first segment their patient populations by identifying those with multiple chronic conditions, the highest complexity care needs and persistent patterns of highest-cost utilization. Health systems also must identify physicians and nurses who have proven proficiency in caring for such patients and organize them into telehealth-supported care teams. Payers can then contract to pay 95 percent of the expected costs for specific subsets of the segmented patient population. Additional savings above 5 percent are then shared 80/20, with 80 percent to the health systems whose care teams achieve defined clinical, health status and patient satisfaction outcomes goals. This approach, the essence of the “Independence at Home” Act for Medicare, aligns stakeholders’ incentives to reward positive health and financial outcomes for patients with the most complex chronic conditions — those who have the highest need for telehealth-supported connected care.
