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How to advance telehealth with evidence—not assumptions

By John League

February 18, 2021

    Many health care leaders seem to view Covid-19 as exceptional, not transformational. That is, it's a bump in the road. They believe that once the Covid-19 pandemic has been contained, we can go back to how we did things before—especially for telehealth.

    Our take: Why providers must embrace telehealth now

    Now, I don't mean to suggest that health care should sustain every stopgap measure and regulatory flexibility from the public health emergency. But telehealth adoption has been beholden to a lot of largely untested assumptions about use, cost, and quality. We've learned a lot as an industry over the past year about how to deliver care outside of traditional in-person interactions between clinicians and patients. 

    The question is: How do we know what to sustain beyond the pandemic? The answer: Evidence. 

    We have more data on telehealth than ever before—which extends far beyond the lockdown-driven, virtual-care-only days of April-May 2020—and more federal dollars to study that data. Across the final six months of 2020, virtual visits in the U.S. consistently made up 15% to 20% of all visits on a weekly basis, a baseline that was not correlated with spikes in Covid-19 infection or hospitalizations. That steady utilization can provide the data we need to inform decisions about how to deploy telehealth going forward.

    Unfortunately, I see two obstacles to making constructive use of this hard-earned evidence. The first is simply ignoring it because it may not align with entrenched, pre-pandemic perspective on telehealth. The second is holding telehealth to a higher standard than other modes of care delivery. I am especially worried because I see these obstacles not only at individual provider organizations but also in recent meetings of the Medicare Payment Advisory Commission (MedPAC).

    Health care can't ignore 2020 data

    MedPAC can have an outsized influence on the future of telehealth. As an independent advisor to Congress on Medicare, MedPAC's recommendations have far-reaching impact on what all payers, including both government and private health plans, will prioritize and reimburse. So, it is disappointing that some MedPAC commissioners and staff seem to be stuck on pre-pandemic assumptions about telehealth.

    In each of the three most recent public MedPAC meetings, commissioners and staff consistently assert that virtual care "should" cost or "probably" costs less for providers to offer. There's no evidence given for this, but in a staff presentation at the commission's January 2021 meeting, it was listed first among reasons that CMS should reimburse for telehealth at lower rates than in-person care. Another orthodox but largely unproven assumption rounds out those reasons: That payment parity will "distort prices" as clinicians steer patients to virtual instead of in-person visits.

    I want to be clear: Reimbursement parity alone will not make telehealth valuable for patients. At the same time, denying parity without looking at actual data on cost, use, and downstream affects of upstream telehealth doesn't help patients, either. We can't continue to be satisfied with assumptions about what works and what doesn't.

    Some health systems have already shared data that debunks long-held assumptions that telehealth would surely increase use and ultimately cost more than in-person care. For example, Stanford Health's utilization data indicates that telehealth has been a substitute for in-person visits, not simply an add-on service.

    If your organization is unsure about what data to collect or analyze—or what to do with it once you have it—I have a suggestion. The Alliance for Connected Care has an open call for telehealth data. It's asking providers to submit data on recent telehealth use to answer questions on utilization, no-show rates, post-discharge care coordination, skilled nursing facility transfers, and imaging. This is a strong first step in understanding how telehealth is being used and its impact on care.

    Telehealth is different, but the standard of care is not

    If that evidence is to guide our industry to constructive choices about telehealth, we can't hold telehealth to an unnecessarily higher standard. The prevailing approach to something new in health care tends to be that if it isn't demonstrably better than what we already know or do, then we won't change.

    You can see that in the adoption of tele-behavioral health. Even before Covid-19, clinical research consistently indicated that tele-behavioral health was comparable in quality and outcomes to in-person behavioral health. Still, most behavioral health providers resisted connecting with patients virtually. In January 2020, only about 3% of all psychiatry visits were virtual. The perceived limitations of virtual platforms (including difficulty reading body language and making eye contact) outweighed the potential benefits (including patient convenience, provider visibility into a patient's home, and increased ability for patients to terminate a session) for most providers, even though the quality of care was the same.

    But just because telehealth can't do everything, that doesn't mean it can't do anything—which behavioral health providers seem to have realized in 2020. In December 2020, virtual visits accounted for two-thirds of all psychiatry visits.

    Unequal standards for dealing with fraud, waste, and abuse (FWA) also undermine a consistent, location-agnostic standard of care. Both MedPAC presentations and media headlines consistently have tarred "telehealth companies" as participants in unnecessary orders for durable medical equipment, genetic tests, and prescriptions. This is simply unfair. There is no evidence that vendors who provide legitimate telehealth services were involved in any of these abuses. And one of the proposed remedies—requiring in-person visits to order specific kinds of testing and medical equipment—is willfully blind to the fact that, unfortunately, FWA occur throughout Medicare.

    Clinicians have made heroic efforts to integrate telehealth into practice. The Taskforce on Telehealth Policy put it best: "We should trust clinicians providing telehealth services to triage patients needing a higher level of care or in-patient care, as we do in other care settings."

    How can health care stakeholders advance telehealth adoption?

    4 key takeaways from our 2020 Executive Cross-Industry Telehealth Summit

    Telehealth adoption skyrocketed during the early months of the pandemic. But the initial experience of telehealth under emergency use and the sharp decline in virtual activity that followed put a spotlight on our current system's structural fragmentation.

    To address these concerns, Advisory Board convened health care executives from across the industry to discuss stakeholder roles in advancing and sustaining telehealth adoption. Read on to learn the four key takeaways from our Cross-Industry Telehealth Summit.

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