The pandemic has created lots of twists and turns for healthcare delivery organizations, and for many hospitals, health systems and medical groups, an important key to surviving the crisis has been being adaptable to patients’ evolving needs.
For example, while telehealth delivery clearly surged as many in-person visits had to be halted, even within that virtual care realm, providers have an array of options to offer patients. Leaders at MemorialCare Medical Foundation, a physician organization in Southern California, for one, were ramping up their telehealth strategy in early 2020 and had planned for a phased-in roll-out approach. But then the pandemic happened, recalls Adam Solomon, M.D., chief medical officer of the MemorialCare Medical Foundation—which encompasses both the MemorialCare Medical Group and the Greater Newport Physicians IPA, and is a core element in the four-hospital MemorialCare Health System, headquartered in Fountain Valley, Calif.
So with the onset of COVID-19, previous plans were turned upside down and leaders at MemorialCare had to move much more rapidly. Part of that process was increasing the use of asynchronous telehealth, defined by the Office of the National Coordinator for Health IT (ONC) as "store-and-forward video-conferencing," which is the "transmission of a recorded health history to a health practitioner, usually a specialist." This option bakes in more flexibility compared to the more typically used video-based visit which requires patients and providers to be in front of the screen at the same time. In a recent interview with Healthcare Innovation, Solomon discusses how asynchronous telehealth has become a key element of MemorialCare’s broader virtual care strategy, while also sharing perspectives on his physician organization’s multi-layered journey into risked-based contracting. Below are excerpts of that interview.
Can you describe the work MemorialCare is doing around asynchronous telehealth and what has changed during the pandemic?
One of the priorities we've had is something called ease and access. We want to make sure that we have availability for our patients when they need something convenient, which is why we developed this MemorialCare Now concept: you can get what you need when you need it. There are a fair number of things that can be treated by video, but we also recognized that it's not always convenient to do the video, and being able to message or text is so much more prevalent in the rest of our lives. When you're going on a website, you can chat with somebody asynchronously, and there are a number of diagnoses that can be treated that way. It’s so much more convenient for a patient to get online, answer a bunch of questions, be guided, and then quickly get a response and/or treatment than it is to schedule a visit or call, or wait for an urgent care appointment.
What has the feedback to asynchronous telehealth been like?
The patients have been very appreciative of it. To be honest, initially when we rolled it out, we didn't do any marketing at all. We didn't know how it was going to be received. So we were just amazed at the rapid rise in the volume that came in without doing anything. That was pretty impressive; the patients found it, used it and liked it.
On the physician side, doctors are generally conservative in nature. So when we initially had broached the topic, many of them were a little hesitant to do it and took a wait-and-see approach. But fortunately, like everybody else, doctors are a diverse population. We had a few that were interested in checking it out, so they signed up and found that it’s easy, convenient, and that you can treat a lot of patients here without necessarily having to expend the amount of time that you would normally spend in an in office or even virtual visit.
You have given presentations and spoken about the organization’s move into two-sided risk and what that entails. What have been the biggest learnings in this area?
We have a large number of patients for whom we take risk, either frequently on the commercial side—professional risk in a managed care world—and in our Medicare Advantage plans, and then also in some of these PPO [preferred provider organization] ACO [accountable care organization] plans, we are taking risk for the total cost of care. This is a great and convenient way for patients to get care. Patients want to get care, and if you're not feeling well, you don't want to sit around and wait. But historically, physician offices have not been the most convenient: you call, you go through a phone tree, maybe you get through, but then they'll put you on hold. Eventually you explain what the issues are and then maybe you can get an appointment. If somebody is not feeling well, the first time that happens, they'll give up and go to the ER, and then the next time that occurs, they won't even bother calling.
We know the patient will get better care if they're able to access us easily and get the kind of care they need very quickly. This is one thing that I think people may or may not recognize. Even employers don't always recognize it—there are a lot of companies, startups, and even some of the health plans themselves developing or [deploying] video visits or some other kinds of remote monitoring or management of a disease state. But they're all one-offs.
An example of that was a company called Livongo, which had a product for diabetes management. They realized that they were a single tool that doesn't connect with anything. So then they merged with Teladoc, but in the end, a virtual doctor can't be your doctor; you need to integrate all of your care together. It may be that today you have a minor problem that can be addressed virtually, and then you can move on. But realistically, over the course of time, developing that relationship with a doctor and system that has your records, your history and family history, knows what medications you're on, knows your allergies, and can care for you in the right location in multiple different ways, is going to lead to a much better experience with better outcomes.
How has being affiliated with a large health system played a role in your value-based care journey?
If you look across the country, the percentage of physician practices that were independent used to be 60 to 70 percent. Now it's probably below 20 percent, as hospital systems have started to employ physicians. In California, hospitals can't directly employ physicians, but through the Foundation model, you can have an agreement with a physician group to provide services to the organization, so they become part of the organization without direct employment. Most of those other integrated healthcare systems have done so to have those physicians in the community direct care to their hospitals, because the charges that they can put in for services done in the hospital setting—whether it's imaging or outpatient surgery, or even physical therapy—they can charge much more for those services that could be performed on an outpatient basis. And that's what we see in this community—there are some hospital systems we compete with that direct everything back to the hospital.
Fortunately, the CEO of our system, Barry Arbuckle, and our system board, recognize that's not sustainable, and that over the course of time, the right thing would be to provide the best care in the most appropriate location. And oftentimes, that is going to be more cost effective. So, as part of our Foundation, not only do we have physicians and advanced health practitioners, but we also have surgery centers that are not on the hospital license. We have imaging centers in a joint venture with RadNet and are one of the largest, if not the largest provider of ambulatory imaging in Southern California. We've joint ventured with a physical therapy company, PRN, and have become the biggest provider of ambulatory physical therapy in Southern California. We've joint ventured with Fresenius for dialysis centers. The idea is that none of these things are on the hospital license.
So when patients go to [these places], they don't get those additional charges, it's more cost effective for the patient, it's more convenient for the patient, the outcomes are just as good if not better, the equipment that's used is the same, the staffing of physicians is the same, but the costs are less. And we did that somewhat to our own detriment—if you take a surgery out of the hospital where you can charge a hefty price and move it into a surgery center, you’re basically giving the same service but you're able to charge less. On top of that, we are joint ventured, so we get a portion of [the revenue] instead of all of it. But it was an intentional move, recognizing this is the direction that healthcare should be going in the U.S. That's how we bring down the cost of care, improve outcomes and improve the patient experience.
In that context, there is the challenge of straddling two very distinct payment environments, value-based care and fee-for-service, right?
It continues to be a bit of a struggle. There are some services that clearly cost a good bit of money to provide, and if it doesn't bring any additional reimbursement, it makes it hard to staff and provide those services—we're not getting paid to do it, because the funding is limited. The margins are also very small, and by making the choices we have, our margins are even smaller than they could be if we went in the direction that most other hospital systems have. But in the end, for many of these things, we end up saying, well, what is the right thing to do? And how can we facilitate that?
One example is through behavioral health. We were not happy with the fact that behavioral health, at least in California generally, has been a ‘carve out’ where the health plan is responsible for managing behavioral health, and physical health was cared for by the primary care physician. So if a patient had depression or anxiety, for example, they would need to call the number on the card, call the health plan, see if they can find somebody on the list, then call all those people on the list, and hope that there's someone available to see them. If by some miracle they do get into somebody, then there's no communication back to the primary care physician, so no one really knows what's going on. The physician doesn't know if the patient followed up, what the treatment plan was, or if they are getting better. We just weren't happy with that.
So we decided to implement something called the collaborative care model, where we have a behavioral health specialist integrated into our primary care office. So if a primary care physician notes that a patient has depression or anxiety, they can do a ‘warm handoff’ and have the patient assessed with standard metrics, and then follow up on the plan that the primary care physician has implemented to see if the patient is responding and improving. And there is also a psychiatrist who would work with that behavioral health specialist and the primary care physician, but not directly with the patient so that they can handle far more patients to support them and make sure things are on track, while also giving recommendations and suggestions for adjustments or additional treatments if the patient's not improving.
Well, that's all expensive to do, so when we initially rolled it out, we said we're only going to do this for our managed care patients, because it's been very clearly shown that patients who have behavioral health issues cost two to four times more than patients who don't. The feeling was that even though we're not necessarily getting paid additional money for managing their behavioral health issues, if we can improve them and we are at risk, then we'll save money on the costs for their physical issues, and it is better care for the patient. When we did that, we found that we weren't getting the volume we expected, because physicians don't necessarily differentiate by a patient's insurance for how they treat—so if they couldn't refer all their patients, they got in the habit of not referring any of them. We then realized that we just need to make this available; it's the right thing to do, and it will facilitate getting care.
At the same time, we also implemented a virtual experience for behavioral health called SilverCloud Health, which is a web-based application that patients are referred to, and it can be self-guided, or they can have a coach to help guide them to different modules to work on—for example, depression, anxiety, or even sleep disorders. So we also made that available to all our patients, even though it was a cost to us to have that service. And then with this pandemic, with what was going on in our community, we as a system decided to make it available for everyone in the community, even if they weren't our patients. Again, it's just the right thing to do. So that's the mindset of this organization.
