Betting Big on Telehealth: Should Healthcare Stakeholders Go All-In?
As the COVID-19 pandemic began to quickly unfold over a year ago, telehealth just as rapidly started to emerge as a viable solution to delivering care in many instances when in-person encounters were not possible. Hyped for years as a promising technology that had the potential to improve access to care and lower costs, the reality on the ground never seemed to match the industry buzz.
At the end of 2019, for example, just 10 percent of healthcare consumers had used any type of telehealth service and nearly three-fourths of Americans said they either didn’t have access or were unaware of telehealth options, according to research at the time from marketing services company J.D. Power. But then in April of 2020, telehealth visits skyrocketed, and accounted for nearly half of all Medicare primary care visits, as reported last summer by the U.S. Department of Health & Human Services (HHS).
Of course, the explosion in virtual care delivery was directly attributed to the crisis, as patient care organizations were forced to shut down non-essential in-person services last spring. As such, it would be unreasonable, and also impractical, to expect the volume of telehealth encounters to remain at such high levels, particularly as hospitals, health systems, and medical groups began to open back up.
At the same time, many assumed that the telehealth “trial” occurring last April would win over the court of public opinion and lead to more patients and physicians embracing it, and ultimately continued growth, industry-wide. The data, however, reveals that hasn’t been the case; a June 2020 report from the Commonwealth Fund found that the number of telehealth encounters that made up providers’ weekly baseline total visits already had been sliced in half from April’s peak.
Going forward, while it’s clear that a hybrid environment that involves a mix of telehealth encounters—at a greater rate than pre-pandemic levels—and in-person visits will take form, plenty of questions about the near-term still linger—perhaps none as important as how aggressive organizations will be in continuing to build out their telehealth infrastructures with new investments, despite real uncertainty around the future payment and regulatory landscape.
To build or not to build?
Throughout the public health emergency (PHE), Congress and the Centers for Medicare & Medicaid Services (CMS) have temporarily expanded coverage of telehealth services, aiming to give providers broad flexibility to furnish telehealth services to ensure that beneficiaries continue to have access to care and reduce their risk of exposure to COVID-19. For example, CMS last year added nearly 150 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that could be paid during the PHE when delivered by telehealth. Additionally, outside of the public health emergency, only doctors, nurse practitioners, physician assistants, and certain other types of practitioners could deliver telehealth services. During the emergency, a wider range of practitioners can provide telehealth services, including physical therapists, occupational therapists, and speech language pathologists.
Without legislative action, though, many of the changes will expire at the end of the public health emergency. Before the PHE, Medicare paid for a limited number of telehealth services and only if they were provided to beneficiaries in a clinician’s office or facility in a rural area. What’s more, most telehealth services were paid at the lower physician fee schedule (PFS) rate used to pay clinicians providing care in facilities, rather than the higher rate used to pay office-based clinicians, because the practice expenses associated with furnishing telehealth services were presumed to be lower.
Telehealth advocates have urged federal leaders to make these expansions granted during the crisis permanent; payment-focused telehealth changes are under the authority of Congress rather than HHS and CMS—but not everyone agrees. A recent report released by Medicare Payment Advisory Commission (MedPAC), an independent, non-partisan legislative branch agency headquartered in Washington, D.C., recommended that only certain elements of the government’s telehealth expansion during the crisis be permanently extended, and that “policymakers should temporarily continue some elements of the telehealth expansions for a limited duration of time—one to two years after the PHE—to gather more evidence about the impact of telehealth on access, quality, and cost, and they should use that evidence to inform any permanent changes.”
He notes that the cost of reorganizing a practice’s time, and adding staff to support care management capabilities to get the most out of these technologies “is quite complicated for anyone who takes it on, and it requires a fair amount of planning to get it right and to align with a business model that will pay for it.” As a result, “many practices have resisted that investment due to uncertainty about reimbursement,” says Gronniger.
Phil Hunsberger is the president of Alliance Health Professionals, a Michigan-based 36-physician group that’s part of Henry Ford Macomb Hospitals. From the very onset of the pandemic, Alliance shut down in-person activities entirely and converted all their visits to virtual. While the organization’s electronic health record (EHR) platform had telehealth capabilities, it decided to go with a simpler option that limited sign-ons and entering passwords, aiming to make it easier for patient end-users, recounts Hunsberger. So Alliance opted to go with solutions from Doximity and Doxy.me, which have some fees associated with them, but not at the level that would present hurdles, he notes.
As Gronniger alluded to, the challenge for Hunsberger’s practice was not the technology, but rather reassigning staff since patient encounters were dropping significantly. Hunsberger credits Alliance for being entrenched in value-based care beliefs, which allowed him to avoid furloughing staff by repurposing them to do things such as calling the highest-risk patients just to keep in touch and keep tabs on them.
“We found that to be very helpful and we heard from quite a few patients who were so appreciative during that time of forced isolation that they had regular contact with someone at the office. So we redeployed quite a few people to that,” Hunsberger says, adding that other staff were responsible for calling patients to set them up for their visit from a technology perspective. “We did lose a good amount of revenue, so our physicians took home less earnings as a result of that, but we did not make widespread furloughs,” he asserts.
Hunsberger’s experience, of course, represents that of a smaller physician practice. For a larger health system, having established IT teams, protocols and workflows leading up to the pandemic was a considerable advantage once stay-at-home orders were given.
MedStar Health, which operates more than 300 healthcare entities, including 10 hospitals in the Baltimore–Washington metropolitan area, had been using telehealth services vendor Bluestream Health to perform its virtual visits prior to the pandemic, and began to pivot from a business-to-business deployment use-case to a direct-to-consumer strategy that was jumpstarted by the crisis, recalls Ethan Booker, M.D., medical director of the MedStar Telehealth Innovation Center and MedStar eVisit. So naturally, in late February, when conversations among MedStar Health leaders on how COVID-19 would impact care delivery began to ramp-up, Booker’s team was able to fall back on the several telehealth use cases already established via the Bluestream platform as opposed to needing to reinvent the wheel. “Rather than trying to rebuild infrastructure from the ground up to respond to the new digital reality, we used the infrastructure that existed already and pieced it together in ways that made a lot of sense,” he says.
MedStar Health is still providing a lot of its care via telehealth today; in its primary care clinics, about 70 percent of visits are being done in person, with 30 percent done over video or phone. On the behavioral health front, the virtual care drop-off that took place across most other service lines never happened at MedStar Health ; Booker reports that in the organization’s behavioral health offices, less than 10 percent of ambulatory psychiatry visits are done in the office, and more than 90 percent are being done with the patient at home.
Booker believes one key reason MedStar Health has been able to continue providing so many telehealth visits is because it made the investment already. “We have invested in system platforms as well as in the integration of telehealth platforms into our EHRs and into our workflows.” But he notes perhaps the biggest investment that has been made has actually been in changing the culture. “Getting providers and patients to try telehealth has really changed the mindset of the providers and their willingness to do it. Instead of automatically thinking about the clinic and the in-person experience, they are now asking themselves, ‘What are the options here for my patient?’”
The payment ‘elephant in the room’
The question of how telehealth will ultimately be paid for once the PHE ends is a critical one, and one solution to avoid the uncertainty, from Gronniger’s perspective, is to join a risk-based payment model, such as an accountable care organization (ACO). “If Congress and CMS want to create real change in healthcare that leverages the improved access to care afforded by telehealth while also encouraging the highest quality of care, they will link permanent telehealth expansion to value-based payment models,” he asserts.
Gronniger adds that “the only logical, permanent step forward for telehealth reimbursement is that it must be tied to a provider’s willingness to access responsibility for the cost and quality outcomes faced by their patients. This approach would address most of the concerns that currently exist around a permanent expansion of telehealth. Clearly linking telehealth reimbursement to established value-based quality models would ensure that patients who receive telehealth services are receiving it because it is the best care for the situation, not because it is the most profitable service line,” he contends.
Booker acknowledges that many people probably thought telehealth and value-based payment would be much further along than they were in 2020 before COVID-19 started. Hopefully, he notes, “the advent of considerably more telehealth has begun to open folks’ eyes to the excellent fit between telehealth and value-based payment. And those places where health systems have populations at risk, either financially or via attribution models, means that it’s still very much worthwhile to make the investments in telehealth that we are making.” Beyond Medicare and Medicaid, there is also considerable energy from commercial payers in this space, Booker says, and that has been shown through the investment of their own platforms and processes.
Gronniger believes that those who are “least excited about telehealth right now” happen to be in Congress and MedPAC. As such, he says there is likely to be a lot less flexibility for people outside of value-based payment models because there’s a concern among public health and government officials that providing permanent parity between telehealth and physical office visits could encourage providers to abuse telehealth as a more profitable, time-saving service channel, even in cases where a physical office visit was warranted. Gronniger specifically points to the same case MedPAC referenced in its report, in which the Department of Justice (DOJ) charged 86 defendants last fall—including telemedicine companies—with submitting false and fraudulent claims worth more than $4.5 billion to federal health programs and private insurers.
Proving quality
As MedPAC noted in its report to Congress earlier this year, before deciding which regulatory levels to pull to permanentize telehealth expansion, more data must be gathered that illustrates the impact virtual care has on access, quality and cost. To that end, late last year, the recently created COVID-19 Healthcare Coalition, comprised of more than 1,000 healthcare organizations, technology firms, and nonprofits, set out to research several areas of telehealth, including the strengths and weaknesses of virtual care related to quality of care.
The group’s 48-question survey captured the opinions of 1,594 physicians and other qualified healthcare professionals last summer. One key finding from the research was that 60 percent of respondents reported that telehealth has improved the health of their patients. What’s more, 55 percent indicated that telehealth has improved the satisfaction of their work, and more than 80 percent of respondents indicated that telehealth improved the timeliness of care for their patients. A similar percentage said that their patients have reacted favorably to using telehealth for care.
Gronniger says that one way to look at the standard of quality would be to ask, “Are we doing as well as or better in taking care of patients with chronic conditions, and providing preventive care, through this modality as we were through in-person care?” For an ACO, the two core elements of demonstrating effectiveness to get a good quality score entails first providing the right services and care—and managing the conditions properly—and second, documenting it correctly, explains Gronniger.
“I would look at how we do on the key quality measures that are part of the ACO measure sets and the other program measure sets as the first indicator as to whether there’s been a big difference with telehealth,” he says. And some of those measures are better handled in person, so there may be some impact nationally, but I think it will require close parsing as the effects aren’t going to be huge,” he acknowledges.
Nonetheless, market researchers are already quite bullish on the future of this segment; last summer, consulting firm McKinsey & Company predicted that up to $250 billion of current U.S. healthcare spend could potentially be virtualized. Of that $250 billion—or 20 percent of all Medicare, Medicaid, and commercial outpatient, office and home health spend—the McKinsey analysts further broke it down by healthcare delivery segment. They asserted that 35 percent of home health services could move to virtual, as could 24 percent of office visits/outpatient encounters, with another 9 percent moved to “near virtual,” as well as 20 percent of ED visits that can be diverted to virtual.
Ultimately, until the uncertain regulatory and payment landscape clears up, just how big of a bet healthcare organizations will be making on telehealth probably will depend on a variety of factors such as each one’s size, resources and patient population. And for now, stakeholders are very much in wait-and-see mode. “Says Gronniger, “Hopefully, the next 12 months will be a period of more stability where we’re able to see that we’ve worked through some of the policy questions and know what the rules of the road are going to be. I do think that seems very achievable at this point.”
