At the Helm

10 takeaways: Covid-19 transformed telehealth overnight. What does it mean for the future?

by Christopher Kerns and Amanda Berra

With telehealth reimbursement finally seeing reimbursement parity with in-person visits during the public health emergency, providers of all stripes have begun investing heavily in a variety of platforms. In Thursday's session, Advisory Board's John League discussed the future of telehealth reimbursement, the technical needs that still need to be met, and how remote technology is poised to remake primary care.

Slide deck: Telehealth, Covid-19, and the watershed moment for digital health

1. Prior to Covid-19, telehealth adoption had been lagging

For many years, telehealth has not lived up to its billing:

  • Broad utilization never materialized: One pre-pandemic survey found that seven out of 10 consumers were interested in trying telehealth, but fewer than one out of 10 actually had; and

  • Awareness also lagged: While about a quarter of internal medicine or family practices reported offering video visits prior to the pandemic, fewer than one out of 10 consumers knew those visits were available from the practices they used.

2. Adoption is now through the roof

However, the pandemic completely altered the story of telehealth, with the use of virtual care and messaging skyrocketing.

The federal government played a major role here, working with regulatory bodies and payers to drop historical payment and privacy-related barriers. Between that and consumer behavior changes due to quarantine, statistics now tell a drastic before-and-after story:

  • The share of U.S. consumers using telehealth has increased from 11% in 2019 to 46% in April 2020;

  • Providers are reporting 50x to 175x the number of telehealth visits compared with pre-Covid-19 levels; and

  • 57% of providers view telehealth more favorably now than they did before Covid-19.

Providers have kept the momentum going by quickly transforming the delivery system. For example, NYU Langone Health recently added 1,300 physicians and other care providers to deliver care through its telehealth platform.    

And based on anecdotal evidence, while telehealth use appears to decline as a Covid-19 surge passes, rates in those places are still considerably higher than before the pandemic.  

3. When people try telehealth, they like it

Pre-pandemic research consistently said when people try telehealth, they tend to like it—and that positive experience has continued in the Covid-19 context.   

  • Recent consumer surveys found patients rate the care they receive and their interactions with clinicians just as highly via telehealth as they did via in-person visits; and

  • Clinician surveys are also positive, with more than half reporting that, once they tried it, their opinion of it became more favorable, and two-thirds being more comfortable with how to use the technology.

4. Investors like telehealth most of all

With huge increase in demand and favorable response from both providers and consumers, it is perhaps not surprising that investments have been flooding into telehealth. 

  • In the first quarter of 2020, telehealth companies raised almost $800 million in investor dollars;

  • Public market investors are just as enthusiastic; Teladoc—one of the few publicly traded telehealth companies—almost doubled in value last week. Meanwhile, privately held Amwell is filing for IPO; and

  • McKinsey estimated that in coming years, $250 billion in health care spending in the United States could be diverted to virtual care.

However, not all industry observers are so bullish. Observers cite two main factors for their skepticism: First, the immediate transformative impact of disruptive technology in health care is often oversold, and second, many of the recent regulatory and reimbursement conditions currently enabling telehealth adoption are temporary.

5. It's not whether temporary accelerants like deregulation and improved reimbursement will stick around—it's which parts

The telehealth spotlight was on CMS Administrator Seema Verma last week, as she provided comments that served as preliminary indicators of CMS' position on ongoing payment and regulation for telehealth.  

Advisory Board drew three tentative conclusions from reading between the lines of Verma's statements:

  • There is no going back. Verma provided a general endorsement for telehealth, saying that Medicare and Medicaid beneficiaries are recognizing its value and should not be forced to give it up. This comment seems like a general signal that CMS will cover more kinds of services, for more patients, via telehealth in future.

  • Telehealth from home, and more types of provider sites, is a regulatory change that seems likely to stick around. Verma said telehealth access needs to be made easier from homes, nursing homes, and hospices. And while Congress—not CMS—would need to change the law to make these particular changes permanent, Verma's comment signals that CMS will do what it can via its regulatory power to ensure that these types of requirements will be relaxed.

  • Reimbursement parity may not remain. Verma said the concept of parity (paying the same rate for a virtual visit as an in-person visit) needs further study. But she also said she does not necessarily perceive a one-to-one relationship between a telehealth and an in-person visit. While this does not necessarily mean that no types of visits will continue to be paid at parity, it did not sound as if universal parity will be a cornerstone of CMS' future approach to telehealth reimbursement.

6. With or without reimbursement parity, providers looking for a sustainable telehealth path think about total transformation

The gap between investment and likely reimbursement for telehealth returns providers to their ongoing business case dilemma: Telehealth's transformational potential is obviously huge, but for providers, achieving ROI has long been a struggle.

To solve this problem, Advisory Board recommends providers consider telehealth in the context of a larger set of business case possibilities. Simply substituting a digital interaction for an in-person can be valuable, but it's not the only way to connect providers and patients digitally. 

Asynchronous communication and remote patient monitoring also offer tremendous value—but these use cases will require patients, providers, and payers to think about using and paying for telehealth in different ways. For instance:

  • Providers should consider telehealth business cases beyond (only) patient acquisition or engagement. For example, AI-powered telehealth—such as message functions that use symptom checkers or preliminary diagnoses to streamline patient intake and interactions with providers—represent bets that telehealth can generate ROI in the form of increased clinical productivity.

  • Payers and providers should create telehealth arrangements that incentivize activities that drive specific patient, providers, payer, or purchaser objectives. For example, if a purchaser believes behavioral health is under-utilized, it could provide reimbursement parity specifically for tele-behavioral health, so that patients can receive more of that kind of care.

Providers should also consider what ROI data they will be willing to share to illustrate the value and quality that all stakeholders should be able to reap value from telehealth to secure ongoing support for its use.   

7. Don't push telehealth overall—identify and push the best clinical use cases  

Medical groups and health systems often ask Advisory Board's telehealth research team, "What should my total proportion of virtual visits be?" John said, "I understand the desire to have a goal. To make plans and build platforms and design incentives for physicians to get a certain volume—that all makes sense. But I think that focusing on a single top-down number is misplaced."

Instead, providers should take a step back and look critically at which interactions in a care pathway—and which patients in the broader population—most need telehealth.

Interactions that require hands-on care, or in-person counseling, should not default to virtual—but other types of interactions, such as pre- or post-op visits and receiving routine lab results, possibly should. Each different provider type will have a different mix of opportunities.

And when it comes to specific patient populations, providers should look at seniors as a focus area for supporting telehealth adoption:  

  • Seniors are the biggest consumers of care generally;
  • Seniors, like most patients, tend to have favorable views once they do try telehealth—not as positive as younger age groups, but surveys indicate they think it works and they would do it again;

  • Telehealth can protect seniors from exposure to Covid-19; and

  • For seniors with polychronic conditions, telehealth represents a more effective care management approach compared with frequent in-person visits.

However, research shows that seniors still have consistently lower utilization of telehealth compared with other patient groups.  "Providers must find ways to encourage older patients to embrace telehealth for the right kind of interactions. Doing that will create a tailwind for telehealth adoption generally," John said.

8. There are no 'silver bullet' platforms or services—but there are no-regrets investments 

All provider CEOs, CIOs, and CSOs are keen to know if there is a list of no-regrets telehealth investments.  According to John, "There is no silver-bullet single platform or service—those decisions depend on your organization's objectives, goals, your clinicians, and which patients you are serving."

"However," he said, "there are some things you can do to make sure whatever investments you make will pay off." For instance:

  • Make the platform secure and integrate it into clinician workflow;

  • Ensure scheduling is seamless. A recent Press Ganey survey found that while consumers report that their experience with telehealth was good overall, scheduling was more difficult;

  • Invest in provider training and communication, including not just how to use the platform, but how to deliver positive patient experiences virtually;

  • Create messaging and awareness campaigns for patients;

  • Make it easy for patients to use the technology. For example, Advisory Board researchers increasingly find providers using clinic staff to "room" patients for a virtual visit--calling ahead of time, making sure they are ready, and set up on the telehealth platform, so the visit can begin right away when the provider enters.

9. Take steps to close patient access gaps 

Not all patients are benefitting from telehealth. A comprehensive telehealth strategy should prioritize overcoming barriers, especially for underserved populations. Disadvantaged populations are using telehealth less than the U.S. population overall, likely due to lower access to health care generally, as well as to lack of devices, technology, and digital literacy. Millions of Americans lack access to high speed internet [FCC study, Microsoft study].

To combat access barriers, providers can:

  • Help patients obtain devices, either through renting or reduced rate programs, and notify them of the newly free broadband Internet expansion through the CARES Act;

  • Ensure alternative care paths are in place if there is no way for patients to access the needed technology—for example, audio phone calls instead of video visits;

  • Develop training and tutorials, or dedicated call lines to do test runs of virtual visits, to raise patient comfort with the technology; and

  • Proactively reach out to support disadvantaged populations specifically.

All telehealth stakeholders should also advocate for long term change: More funding for equipment, connectivity, and reimbursement parity (where it makes sense clinically).  

10. Don't reinvent the wheel—take advantage of lessons learned the hard way

One upside of telehealth's long, slow adoption to this point? A wealth of lessons learned about the pitfalls and best practices for boosting the odds of telehealth success. Don't reinvent the wheel—learn from the experience and insight available through existing and upcoming research. 

Slide deck: Telehealth, Covid-19, and the watershed moment for digital health

In last week's webinar, Advisory Board's John League discussed the future of telehealth reimbursement, the technical needs that still need to be met, and how remote technology is poised to remake primary care.

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