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An open letter to telehealth patients: How the health system can avoid letting you down

By John League

April 19, 2021

    Dear patients,

    Many of you found that telehealth was the only viable way to receive care in the past year. Most of you also found that it was safe, convenient, and almost entirely free. And now that so many of you, of all ages, are ready to make virtual visits part of your new normal, the health care system is poised to disappoint you. Your out-of-pocket costs—in the form of co-pays, co-insurance, and deductibles—are set to return with the end of the public health emergency. Before then, health plans and Medicare seem likely to restore limits on how you can use virtual care and reduce financial incentives for your doctors to make it available to you. Even if you can access telehealth through a virtual-first or telehealth-only provider, you’ll probably have to change doctors.

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    But that’s not the way it has to be. If plans reimburse providers adequately for the virtual care they offer, and providers commit to consistently guiding patients to high-value, cost-efficient use of care, then they will create a sustainable framework for offering you convenient access to quality virtual care that’s worth paying for. Industry stakeholders can work together to preserve the benefits of telehealth utilization for themselves and keep you happy in the process. Here’s how:

    First, the low hanging fruit. Plans and providers all need to start examining the hard-earned evidence they accumulated in 2020 to determine where they can use telehealth in service of their strategic objectives. This is a true win-win. Telehealth had never been deployed at scale before 2020, so there are few reliable estimates of cost and limited (though compelling) data on quality and outcomes. There are far too many assumptions throughout the industry about what telehealth “should” cost to consume or “probably” costs to provide. More data will be available now and in the coming months on key stakeholder concerns such as total cost of care, unit cost for providers to offer telehealth services, overall utilization, and patient experience.

    But that’s not where the full solution lies. Each stakeholder group—health plans, providers, and yes, patients—has work to do.

    Health plans must narrow the difference between reimbursement for in-person and virtual visits that prevailed before the pandemic. My conversations with health plan leaders indicate that top plan priorities for telehealth—increasing the uptake of underutilized services such as behavioral health and preventive care, or directing members to more cost-efficient providers or sites of care—don’t require a wide payment differential.

    Reimbursement at or near parity is a concession to local physicians who are providing most of the capacity for virtual visits. A recent Rock Health survey shows that local providers did 70% of your video visits and 60% of your phone visits in 2020. Their businesses have largely fixed underlying cost structures that can’t easily or quickly pivot to an alternative payment model. If reimbursement returns to pre-pandemic levels, clinicians simply will not provide telehealth services. That will rob patients of a more convenient access point, and it will rob plans of valuable leverage in getting providers to steer patients to higher-value sites of care.

    Plans also need to simplify cost sharing on virtual visits for members. Cost sharing is complex and fragmented already, making it harder for you to understand your benefit or its actual cost. If plans want to use telehealth to reduce total cost of care, they must make it clear to you how you can use it, where you can access it, and how much you’ll pay for it.

    Providers need to take a more proactive role in directing you to appropriate uses of telehealth. Patients are already looking to them for guidance. In a recent Optum survey, 50% of patients who used telehealth said they learned about their telehealth provider from their doctor. Only 27% said that they found out from their health plan. Providers can use their influence to guide patients to visits that can substitute for in-person interactions rather than using them simply as triage. This is exactly the kind of help that plans want from providers in managing utilization. Most plans are still looking at telehealth on a unit cost basis. If plans agree to narrow the gap between payment for in-person and virtual visits, utilization becomes the most important factor in total cost.

    Providers also need to invest in a high-quality virtual patient experience. If patients are paying out-of-pocket for these services, they need to be as much like an in-person visit as possible: patients should be able to get it scheduled as they would an in-person visit, and get a diagnosis, treatment plan, prescription, or follow-up steps as appropriate. A recent survey from Cedar showed that 40% of consumers would consider switching providers if their current provider couldn’t offer a quality digital experience. That proportion is only going to get larger: four times as many consumers under the age of 55 said they would consider switching over digital experience as consumers over 55.

    But patients, you also have a role here. You will have to pay for telehealth in the same way that you pay for equivalent in-person care. This ensures providers get compensated appropriately for offering you telehealth services, and it helps plans push utilization toward higher-value scenarios. In return, you preserve the convenience and savings available to you through telehealth. Advisory Board consumer survey data shows that patients are impatient: three out of five patients would consider a virtual visit to shorten a wait of any length to see a clinician, even if it’s a wait of only a single day. And the Centers for Medicare and Medicaid Services estimated in 2018 that members of Medicare Advantage (MA) plans as a whole could save $67.5 million in travel costs alone if 2.7% of their visits were conducted virtually. It’s not unreasonable to assume that MA members will surpass that percentage by a substantial margin in 2021.

    That’s a lot of give and take for plans, providers, and patients. But there aren’t many incentives for any one stakeholder group to make telehealth viable for everyone. So, each group has to make concessions to other stakeholders. Without that compromise, no one will get what they want—or need—from telehealth.


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