On Thursday, June 11, leaders at the Washington, D.C.-based Advisory Board, a division of the Minneapolis-based Optum, presented a webinar entitled, “Telehealth: How can providers make it sustainable beyond COVID-19?” The moderator was Christopher Kerns, Advisory Board’s vice president of executive insights; he spoke with John League, a senior consultant in the organization.
League told Kerns that as recently as January of this year, he and his colleagues were still predicting a very slow and gradual uptake in the adoption of telehealth for care delivery nationwide. Indeed, he cited a study by Amwell from earlier this year in which 66 percent of consumers had reported that they were interested in telehealth, but only 8 percent had tried it, and only 23 percent of the internists and family physicians were offering video visits at the beginning of the year.
“Then came COVID-19, and telehealth was perfectly suited for it,” League said, referencing the need to adopt telehealth during the pandemic, for a variety of reasons. “You can use it to assess patients remotely and use it to keep symptomatic patients at home, can use it to care for non-COVID patients, and can keep clinicians safer,” he noted. “Forrester estimates there will be 1 billion telehealth visits in the U.S. in 2020, which is enormous, considering that most physicians had been doing 1 or 2 telehealth visits a day prior to the pandemic,” he added.
League stated that “A lot of credit goes to Medicare, because of its policy provisions during the pandemic. The big change,” he said, “has been allowing patients to access telehealth from home, and no longer requiring that telehealth visits originate from healthcare facilities. In addition, allowing new patients to obtain telehealth visits; to allow telehealth visits using smartphones; to allow audio-only visits to be reimbursed; to allow all providers to provide telehealth visits, with no penalty for limiting or eliminating copays or deductibles.”
Importantly, Kerns asked him, “As the pandemic lifts, how many of these provisions will remain?”
“The only one of those that I’m confident will stick around after the public health emergency is over, is patients accessing telehealth visits from home,” League told Kerns. “The extension of eligibility for telehealth visits being extended to providers in nursing homes, etc., should probably stay. But I think the other provisions will be rolled back. The issue is the lack of security in terms of the platforms, like Skype. Most folks think that the FaceTime and Skype modalities are going to go away, as will audio-only telephonic visits. All of that said, these changes have still paved the way for the big national telehealth ‘trial’ that I mentioned at the beginning,” he added.
Among the statistics that League cited: Blue Cross Blue Shield of Massachusetts saw a 3,500-percent increase in telehealth claims between February and March 2020; and NYU Langone Health saw 4,345-percent growth in non-urgent telehealth visits from early march to mid-April. And, overall, nationwide, he said, the healthcare system saw a 50-175-percent increase in number of telehealth visits between February and April.
What about in May, once many patient care organizations had reopened in-person care delivery to some extent? “In most places, telehealth visits declined as much as 50 percent in May, as services reopened; however, there’s still a high level of utilization,” League reported. “And patients have continued to respond in the ways they always have. Advisory Board has found that when patients try telehealth services, they continue using them. Three-quarters of patients express high satisfaction. And Press Ganey compared overall satisfaction with telehealth visit satisfaction, and they’ve found that patients rate virtual visits as highly as regular visits.” Meanwhile, he noted, two-thirds of providers are comfortable using telehealth in their care delivery, and are expressing satisfaction with telehealth.
Strong investments being made
Turning to telehealth as a commercialized enterprise, League told Kerns, “It won’t surprise you if I tell you that telehealth is the segment of the industry where the money has really been flowing so far. In the first quarter of 2020 alone, telehealth companies raised nearly $250 billion in investment.” Among the telehealth services companies he cited: Amwell, TytoCare, K Health, 98point6, Doctor Anywhere, SonderMind, Medici, Bright.md, and SteadyMD.” Even as the healthcare market “overall is flat” in terms of capital-based investments, “In the first quarter of this year, investment in telehealth rose to $788 million, a 1,818-percent increase from 2019; and Amwell has filed for an IPO”—an initial public offering. Indeed, he said, McKinsey expects that $250 billion per year in U.S. healthcare spending will go to telehealth-delivered services.
“I have to say, I’m skeptical,” Kerns said. “We’ve heard this before about telehealth and about a lot of disruptive technologies. But I also know that health plans and CMS [the federal Centers for Medicare and Medicaid Services] haven’t tipped their hand as to reimbursement going forward.”
“This week, [CMS Administrator] Seema Verma said three specific things,” League responded. “She reiterated that there’s no going back; people recognize the value of telehealth. That’s a pretty strong endorsement. I think that means that we’ll see CMS covering telehealth generally. She also said that there needs to be more access to telehealth from the home, from nursing homes, etc. She did note that Congress will need to make changes to the law. She did say CMS will do what they can in their regulatory capacity. But also, she said pretty flatly that she did not see reimbursement between telehealth and in-person as being in one-to-one parity. It doesn’t seem like CMS will be operating based on a first principle of universal parity going forward.”
So, Kerns asked, what should providers be doing right now?
“I think your question points to a dilemma with telehealth that goes beyond reimbursement,” League said. “The problem is that simply substituting a digital interaction for an analog one is valuable, but not the only way to connect providers and patients.” There are asynchronous applications, he noted, including remote monitoring. “Both of those are valuable, but they require payers to think about reimbursing telehealth in different ways. So who’s using them, and who’s paying for them? That will tell us a lot. For example, if we see a lot of new AI-powered [artificial intelligence-powered] asynchronous capabilities, such as a message function built into streamline interaction with a patient around intake, such as with 98point6 or BrightMD—that kind of asynchronous interaction improves connection. We’re not focusing there on using telehealth as simply a replacement for an in-person visit that is driven by consumers’ preferences for one modality over another; we’re actually using telehealth to solve problems that go beyond consumer preference. We also need to be looking at different kinds of payer-provider partnerships, driving value around specific objectives on the part of patients, providers, payers, and purchasers. For example, if you’re a payer and you think that behavioral services are under-utilized, you’ll want to pay at parity or close to it, for behavioral care.”
Meanwhile, League noted, “Not every type of care can or should be made virtual. What kind of data will providers and payers be willing to share, to determine the quality, risk, and value of telehealth services going forward? Those will determine whether or not telehealth actually sticks in the industry.”
Questions around seniors’ adoption
“A lot of the focus has been around chronic care,” Kerns noted. “When you think about the staying power of telehealth, will seniors continue to use it?”
“Absolutely, seniors are our biggest consumers of care, and if they can take to telehealth, it will drive its long-term durability,” League replied. “The reality is that the results are kind of a mixed bag. Seniors, like everyone else, are responding favorably in surveys; not quite as favorably as younger people, but favorably. And we want them to use it, in terms of preventing infection, etc. Unfortunately, a lot of them haven’t used it.” He cited a number of recent surveys. Only 24 percent of seniors in Medicare Advantage plans have used telehealth,” according to a survey by the Better Medicare Alliance); 81 percent of consumers 55-64 and 84 percent of consumers age 65 plus have not had a virtual visit, according to Sage Growth Partners.
Still, League noted, “Medicare Advantage seniors rank their telehealth experience as favorable—53 percent. And 78 percent of those who have used telehealth are likely to use a telehealth service again in the future,” according to a Better Medicare Alliance/Morning Consult survey. And, he added, “Pre- and post-procedure visits work particularly well with telehealth. The follow-up visits in particular. I understand the counseling and personal interaction that often go along with providing lab results. But there are other ways to connect people digitally, that really add value to the entirety of the care pathway. Where along the care pathway does it make sense to replace an in-person visit with a virtual one? There is a ton of work here to be done. But it is one of the ways to make sure that we are using telehealth appropriately.”
Investments that should be made now
“What are the ‘no-regrets’ telehealth investments that providers should be making?” Kerns asked.
“There’s not a single ‘no-regret’ platform; it all depends on the various elements involved in your situation,” League said. “But there are four steps that make sense in any environment. The first thing is to implement a secure telehealth platform; we’re going to have to implement secure telehealth platforms; the waivers permitting the use of FaceTime and Skype are probably going away, and we need to integrate telehealth platforms with EHRs and physician workflow. Second, we really need to take this opportunity to get scheduling right. The Press Ganey survey found that one of the biggest gaps they found was around how easy it was or wasn’t, to schedule; many patients reported that it was harder to schedule virtual visits than to schedule in-person. We need to streamline this both for patients and for providers.”
Meanwhile, League continued, “The other element that I think is particularly important, as we think about the potential for a resurgence of COVID, or sadly, some other sort of pandemic that we haven’t anticipated yet, is to train all of your providers to use a telehealth platform. This will be essential if we do have to go to virtual-only visits again. Get everybody involved; we’ve got to have everybody training on it just like on any other platform. And we really need to help a lot of providers do virtual visits. How do you do that How do you create an engaging virtual experience for patients?”
What’s more, League said, “Finally, and this is big for patients in general, but certainly for our older patients: we really need to support patients who use telehealth. And that means that we have to continue to promote telehealth use through patient portals and outreach. Prior to COVID, providers told us that one of their biggest challenges was creating awareness among patients of telehealth as an option. As we roll into late 2020, and we stop seeing as much in the news about virtual care, providers will have to develop patient awareness efforts. That is essential in making any f your telehealth investments. The second part of that is thinking about how we can help patients use the technology.”
In terms of what’s happening right now, League said that “I’ve spoken to a few providers in the past few weeks; many are already providing patients with tablets, etc.; but one very simple thing that folks are doing now is using their staff to groom patients for a virtual visit, as you would do in an in-clinic visit. So instead of doing that live intake, bringing the patient into the exam room, etc., these organizations are calling their patients in advance of the telehealth visit, preparing them before the physician comes in.”
Further, League said, “We also need to look at structural issues, including racism and access issues. Not all patients have equal access to telehealth. 21 million Americans lack access to high-speed Internet and 162 million Americans are not using broadband speed—a basic stumbling block. In terms of access to devices, providers need to help patients obtain devices, need to notify patients of subsidized broadband access, and find creative alternatives when necessary. In terms of digital literacy, they need to provide tutorials, need to set up walk-through trainings, and need to proactive reach out to underserved populations. They also need to advocate for change at the local, state, and federal levels, to fund equipment, broadband connectivity, and reimbursement parity.”
