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Recent CMS Changes and New Models of Care Delivery: Direct Contracting, Distributed Care and Virtual Care

by Alex Lennox-Miller | January 13, 2021

John Moore III: [00:00:23] Today, we’ll be joined by Alex Lennox-Miller, one of the senior analysts here at Chilmark Research. His current focus is on virtual care and we’ll be discussing exactly how the recent announcements from the Centers for Medicare and Medicaid Services will impact the adoption and the shift towards more virtual care modalities into 2021. So without further ado, Alex.

Alex Lennox-Miller: [00:00:44] Thanks, John. It’s great to be here. This is a really exciting topic. It’s one I am very interested in. This is one of those topics that we’ve been discussing for probably 10 to 15 years now and the amount that we’ve seen it change in the last six months has probably been the most growth that we’ve seen in the field for the whole period.

John Moore III: [00:01:06] So one of the big announcements that came out of CMS recently was the removal of seventeen hundred specific procedures from the inpatient only list. What impact will this have on care delivery?

Alex Lennox-Miller: [00:01:18] We started to see CMS emphasize care at home and hospital at home treatments at the beginning of the covid pandemic, and it made a lot of sense. They wanted to move patients, especially vulnerable patients, out of hospitals. That’s something that’s a trend we’ve seen for years with focuses on trying to reduce hospital acquired conditions and hospital acquired infections. One of the big questions was how much are they actually going to push it? They talked about it, but we didn’t know what the actual muscle behind the suggestions was going to be. And this is really showing that there’s a lot of commitment to this. Moving these procedures into the home, into an outpatient facility really gives a lot of flexibility to health care organizations and health care systems. It allows for much more treatment, much more reimbursement, and is going to drive a lot of the technology that’s required not just to provide the treatments, but to provide the monitoring and the support that patients need in order to maintain their health conditions outside of the hospital.

Any vendors that are trying to build this kind of technology need to make sure that they aren’t losing track of that really central focus that they’re offering and supporting [provider-patient] relationships, because those are the things that really drive the best clinical outcomes for their patients as well as the attendant lower costs.

John Moore III: [00:02:25] Ok, sounds pretty important.

Alex Lennox-Miller: [00:02:28] It is. I mean, this is one of those areas that has really been up in the air. Historically the reimbursement is very hospital-based. By moving care out of the hospital. You aren’t just moving individual treatments. You’re moving that whole suite of monitoring, that whole suite of devices that patients need that has real significance for post-operative care, post acute care, and also for a whole set of conditions that really don’t need to be inpatient. They need monitoring, they need care and commitment. But as long as that can be provided adequately at home, the health outcomes are generally pretty good. One of the most interesting things about this is that CMS is not looking at this as a purely virtual or purely technology driven operation. They’re integrating the the health care provider, the in-person relationship and really interesting ways, building on some of the changes that were made to remote check ins and remote appointment reimbursement codes over the past couple of years and leveraging home care nurses, home health aides and mobile EMS personnel in order to actually visit some of these patients at home to do some of the treatment that some of the activity that requires real in-person activity.

John Moore III: [00:04:02] So how does the announcement about the geographic contracting affect the shift towards the hospital at home, scope of practice, virtual care and other telehealth and remote initiatives that have been in play for the last five to 10 years, as we’ve seen a shift towards value based care overall across the industry.

Alex Lennox-Miller: [00:04:20] So the biggest impact there is that this direct contracting model really requires cost reductions. It requires reductions in the ability to provide care, but it also requires reductions in readmissions and and complications. And this is really where virtual care technologies come into play when they are used well, when they are used correctly, and especially as the technologies become more advanced and the data analytics move from simply describing the patient condition to potentially projecting or predicting when patients are going to move from a low risk or moderate risk category into a high risk category and allowing providers and clinicians to prevent that movement that allows costs to remain low. And when that happens, the ability of an organization with a direct contract payment. Model to recoup money remains high. I think that’s why you see a lot of private equity funded organizations and clinics that have emerged over the past couple of years have focused on Medicare Advantage and capitated Medicaid, where their ability to deploy virtual technology, virtual care and technology solutions allows them to keep those costs low.

John Moore III: [00:05:47] That makes a lot of sense, getting things out of the hospital or getting things into specialized providers that can really hone in on their own operational excellence. And their one workflow.

Alex Lennox-Miller: [00:05:56] Honestly, more than anything else, is about keeping people out of the hospital in the first place. Those are the biggest costs come into play when someone needs to go to the E.R. or needs to be admitted to the hospital. The more you can avoid that, the lower their costs are. When you’ve got somebody who is relatively healthy, somebody in our age bracket who doesn’t have serious chronic conditions, they see a doctor probably twice a year. And that’s really all they need. Primary care panel of two thousand patients leaves a provider with about two hours per patient per year. On the other hand, when you have a patient with really significant chronic conditions, two hours per year doesn’t cut it. They need seven to 12 appointments per year just to maintain their health status. And their providers don’t necessarily have that time when technology can support providers in giving patients the care and the attention that they need, it prevents patients, even patients who need that attention from regressing and declining and needing that more expensive treatment.

John Moore III: [00:07:03] Point of clarification for our viewers right now, because not everybody is going to necessarily know this. What is the difference between virtual care and telehealth?

Virtual care essentially is offloading a lot of that unnecessary work from providers and from staff and pushing it on to technology. You don’t want to remove the provider entirely. You want to make sure that patients still have that good relationship and that trust relationship with their health care provider. But a lot of that can be mediated or assisted with technology.

Alex Lennox-Miller: [00:07:12] Well, that’s a really good question. And it’s one of the questions that has become really significant as we’ve seen this expansion since the beginning of the pandemic. Telehealth is that remote appointment. It’s a direct communication between a patient and a provider, and it’s done remotely for the purposes of the pandemic that’s been essential. It’s allowed patients to continue to see their provider, to continue to get the health care that they need. Unfortunately, from an efficiency perspective, from a time saving perspective, it doesn’t offer a whole lot. The provider spending exactly the same amount of time during the appointment, the documentation and the follow up requirements are the same. It allows patients to access care in a more convenient way, which is great, but it doesn’t really cut down on the amount of time or effort on the behalf of the provider. Virtual care is that larger suite of solutions that includes telehealth, but also includes remote patient monitoring, asynchronous communication between patients and providers. So something like a triage bot or a symptom checker, it includes a lot of patient engagement and patient communication technology, things like patient reported outcomes.

Alex Lennox-Miller: [00:08:35] So collecting information from a patient on side effects of their medication or whether or not treatments are working. It also includes interactive tools that might be helping patients exercise or giving patients training in something like cognitive behavioral therapy so that they have the ability to do things that normally would require an appointment, would require going to a provider’s office or having a provider directly there talking to them. But they can do it in any location at any time when they feel the need or when they have the opportunity. So the difference is pretty substantial. Virtual care essentially is offloading a lot of that unnecessary work from providers and from staff and pushing it on to technology. You don’t want to remove the provider entirely. You want to make sure that patients still have that good relationship and that trust relationship with their health care provider. But a lot of that can be mediated or assisted with technology. And especially as we start getting into broader data aggregation from disparate tools, as we start applying more sophisticated analytic techniques, we can really start seeing a lot of value.

John Moore III: [00:10:02] I can imagine that’s got a lot of attention with the covered pandemic and all the shift that we’re seeing towards people just not wanting to go to care centers and not wanting to leave their home to be potentially exposed in these medical facilities.

Alex Lennox-Miller: [00:10:16] You know, this is something that patients have been asking for, probably for five to 10 years. Patients want more convenience. Patients want easier access to care. And historically, the barrier to adopting these technologies has been the provider organizations. It’s been reluctance from providers to offer them because they’re concerned about it impacting the quality of care. It’s been a concern from organizations which haven’t necessarily had the reimbursement or the revenue opportunities. Some of the changes in the last couple of years support that better. We’ve seen new CPT codes be released that allow more of that interaction and allow provider organizations to see reimbursement and payment for some of this activity. Some of it was literally new with the pandemic, as CMS offered a lot of waivers and states offered a lot of changes to their reimbursement strategies. But the biggest change has been that now providers and provider organizations have been willing to make that leap, have been willing to adopt this technology deployed at scale and really see that it isn’t just a gimmick, it isn’t just a toy. It really can, first of all, help their patients really significantly and second of all, really help them in.

John Moore III: [00:11:43] A lot of this ties into the primary care for the twenty first century report that you published towards the end of 2019 brings it all back around to. I mean, we kind of predicted back then that we would see these massive increases in interest with covid coming through in March. The timeliness of that was pretty onpoint.

Alex Lennox-Miller: [00:12:01] It was one of the big questions when we released that report was that even when we were talking about skyrocketing deployment and acceptance of, for example, telehealth, we were still talking about a tiny fragment of the overall appointment population.

John Moore III: [00:12:15] It had been crawling at a snail’s pace for years, like you said.

Alex Lennox-Miller: [00:12:18] The growth had been significant percentage wise. When you looked at the actual numbers, it was still tiny, the ability to suddenly go from less than one percent of total appointments to 40 percent, which is what we were seeing in April and May, is incredible. And it’s a real tribute to the health care providers that they were able and willing to make those changes when they had to. As much as you can say that there’s a silver lining, the silver lining is now that they’ve experienced it, now that they’ve seen that there’s real value to this, it’s significantly less likely that we’re going to revert back to the peak that we saw in April and May was obviously unsustainable. And when you look at what providers said, a lot of them felt like they were seeing too many of their patients virtually. They they were using this too much and they didn’t have a choice.

Alex Lennox-Miller: [00:13:10] As we start to have more in-person appointments as the as the option to either bring patients in in person or see them remotely becomes more viable, we’ll probably still see twenty to twenty five percent of all appointments happen virtually. The other interesting thing will be seeing which appointments or which interactions, which encounters. Don’t need to be done, hands on anymore, you see a significant amount of work that is manual that doesn’t need to be whether it’s staff reaching out to patients, doing check ins, bringing patients in to check their vitals or check the their chronic care status.

[00:13:56] If you can deploy tools and technology to their home, that can help them, that can monitor them there. They can still have in-person appointments when it’s required, but they don’t need to be contacted and don’t need to be bothered if they’re doing fine.

John Moore III: [00:14:12] That’s a good segue into the next clarifying question, which is can you just explain a little bit more about what exactly is distributed care versus virtual or telehealth?

When we talk about distributed care, that’s the core of what we’re talking about, is that we’re not looking at virtual care to replace providers. We’re not looking at virtual care to deliver all care remotely, we’re looking at virtual care as a tool set that providers can use for patients in the right circumstances.

Alex Lennox-Miller: [00:14:20] So as we’ve been talking about, it’s really essential if you’re going to retain people’s interest, if you’re going to keep them adherent to programs, and especially if you’re going to keep them performing long term, that they not just have access to the tools, but that they trust the provider and that the tools are the right thing for them. Their personal relationship with their health care provider, that trust relationship that’s so essential to build is a key part of that. And the best way to do that is by retaining some in-person appointments. And so when we talk about distributed care, that’s the core of what we’re talking about, is that we’re not looking at virtual care to replace providers. We’re not looking at virtual care to deliver all care remotely. We’re looking at virtual care as a tool set that providers can use for patients in the right circumstances. It’s essential in some cases to have that ability to visit an in-person provider. There are some tests that can’t be done remotely. There are some patients that need to be seen. There’s information that you can’t get from in and from a remote or an asynchronous appointment. Distributed care recognizes that looks at virtual care tools to provide care and provide access to care from a variety of locations in a variety of formats, including in-person care, when it’s necessary. Probably the most essential part of it is that ability to take multiple data sources from a variety of virtual care and in-person sources, whether it’s the HRR, whether it’s a diabetic management program, a care management platform, remote monitoring equipment, and tying them together into a single longitudinal view of the patient.

Alex Lennox-Miller: [00:16:20] That data then gives you the ability to deploy really sophisticated analytic resources. And like we said at the beginning of the interview, transition from just describing the circumstances of the patient into potentially predicting and understanding before it happens, when they’re going to start having really important health transitions and giving them the tools and the care that they need before those become really seriously acute.

John Moore III: [00:16:50] Ok, I’m just going to insert a little plug now for the Analytics for Value-Based Care report that will be producing later in the year, which will very much tie into that predictive aspect of population health management and these distributed care models.

Alex Lennox-Miller: [00:17:03] The interoperability reports are a big part of that, too. Absolutely. Because interoperability standards and particularly the new standards that are being deployed are what really allow that variety of different solutions to all merge together into a single data source.

John Moore III: [00:17:19] So that’s another perfect segue into the next question, which is distributed care is going to be complicated because like you said, it’s working with different locations, different sites of care delivery that don’t necessarily all use the same platform. They’re not all in the same network. They’re not on the same night stack. As we all know, interoperability and health care is a massive problem. So what are the technologies that people are looking to use to actually start developing more effective, efficient, distributed care model?

Alex Lennox-Miller: [00:17:45] I mean, unfortunately, right now that core technology doesn’t really exist. What we need is a data aggregation platform that can be that central point and unify all those disparate data streams. There are people working on it. Different vendors and different sides of the healthcare I.T. equation all have different ideas about who should be doing that.

Alex Lennox-Miller: [00:18:19] This is probably one of the biggest tasks confronting the modern EHR. Large EHRs like Epic and Cerner and athena are faced with the possibility that their central role, that central supporting pillar of health care, IT role that they’ve filled for so long might not be there, that they might have to transition to just being a source of clinical data as opposed to being that central resource for all health care. [John: It’s more of a spoke than a hub.] Exactly. If a really good hub gets developed, something that allows easy unification of data, easy normalization, because that’s one of the other big challenges and then really powerful analytics that can deploy communication, turn data into information really efficiently and really well. That’s going to be the new central pillar of health care I.T. I think the would love to be that I know they’re working on it, but there are other companies that are working on it, too. And who ends up filling that role, I think will be the central question of how distributed health care as a model progresses.

John Moore III: [00:19:31] Something else that we’ve been seeing in our coverage and in our research is some of these companies that are playing at that front office, that first touch point. They’re viewing themselves as being that nexus and that controlling factor for all of the patient money, because whoever controls the patient at the primary level, especially as we’re looking at direct contracting and other capitated models, they’re the ones that get to control the money. So when we look at the shift towards distributed care, where do you see some of these new pillars potentially emerging, these new players that might be that center point. Do you have an idea of which technologies may fit into that?

We’ve seen that patient demand, when it isn’t met by what providers can offer, transitions to more convenient modes. They go to urgent care, they go to the ED or they go to retail clinics. As we see more of those deploy, whether it’s by Walmart, CVS, or Amazon, small practices that aren’t offering the kind of care that their patients demand are going to be the ones that lose volume.

Alex Lennox-Miller: [00:20:08] That front door technology is really interesting and we have new players coming along that are trying to be that distinguishing point, trying to be the point where patient care gets distributed or allocated tools like asynchronous triage checkers or symptom checkers, which can. Take a patient’s experiences and translate them into clinical recommendations, you need to go to urgent care. We’ll give you an appointment with a PCP here. You just need a prescription. We’re going to send it to your pharmacy. Those have potentially a lot of ability to drive this and potentially have the ability to be that point that ties all of that data together. If they integrate scheduling, if they integrate payments, if they integrate some of the new payment transparency needs that are also coming down the pike in terms of shop ability. I’ve seen some vendors describe themselves as trying to be the Airbnb of health care, giving people that really broad, universal look at what their options are, where they could go and what fits best with what they need. Organizations or vendors that can do that are going to play a central role in this, but they have to have the ability to distinguish when patients need specific kinds of care, along with being able to direct them to the best places to do it.

John Moore III: [00:21:43] So as we’re thinking about that direction and this distribution and engaging these new stakeholders that have often been more on the fringe of care delivery, who do you think will be the winners and the losers?

Alex Lennox-Miller: [00:21:55] I think honestly, potentially the biggest losers are going to be small health care practices and small health care organizations, independent practices, independent practices and small systems that aren’t able to leverage this technology quickly. And they’re probably already struggling to the problem. They’re absolutely already struggling. They’re overwhelmed. The problem is their patients are demanding this kind of thing. We’ve seen that patient demand when it isn’t met by what providers can offer transitions to more convenient modes. They go to urgent care, they go to the ED or they go to retail clinics. As we see more of those deploy, whether it’s by Wal-Mart, CVS, Amazon, small practices that aren’t offering the kind of care that their patients demand are going to be the ones that lose volume.

John Moore III: [00:22:46] They already have been. And they’ve already been struggling with the CMMI, different initiatives. OK, so looking out to the year ahead and looking into your crystal ball, what do you think we’ll see as far as changes that are being precipitated by these CMS announcements? Do you think we’ll see any real change in the next 12 months, or is this something that’s going to be more of a long tail change to the system?

Alex Lennox-Miller: [00:23:12] This is going to be a really long term change. Even when you look at the CMS announcements, especially in an election year where we don’t really know what the leadership and the direction of the government, federal government is going to be going forward. We can make some guesses, but we don’t really know. These are changes that will take at least a couple of years to fully propagate. What we can say is that remote care and I mean beyond telehealth, the telehealth appointments are great, but remote care that includes R.P.M. and includes chronic care management is going to be a major part of health care going forward. And that care at home, whether it’s direct hospital care, probably not quite yet. It’s going to take some time for that technology to really develop and mature. But home monitoring and that kind of home health care really is going to come very quickly because the technology has been mature for a number of years and it’s just been waiting for people to be willing to deploy it.

John Moore III: [00:24:13] Well, is there anything else that you’d like to add about this topic or do you feel like we’ve covered most of the bases that our audience would be interested in hearing us talk to?

Alex Lennox-Miller: [00:24:22] I do want to reinforce that no matter what you’re talking about, whether it’s primary care, post-acute, or behavioral health, the in-person relationship with your provider is essential. Any vendors that are trying to build this kind of technology need to make sure that they aren’t losing track of that really central focus that they’re offering and supporting those relationships, because those are the things that really drive the best clinical outcomes for their patients as well as the attendant lower costs.

John Moore III: [00:24:52] Well, thank you very much, Alex. This has been great. Clearly, there’s a lot of focus on how to enable the patient to get the care that they need, make it convenient for them, make it easy for them to actually access the resources that a lot of people don’t really have easy access to in this country. And as you’ve noted, those kind of smaller independent practices, they’re going to be struggling as we continue to deal with the pandemic and the results of how this is affecting our society and the socioeconomic status of many citizens here in America. And this shift is going to really help enable people to stay on track and keep getting the care that they need without having to. Deal with the inconvenience of the pandemic, completely taking them out of their hospitals.

Alex Lennox-Miller: [00:25:39] It’s really fortunate that we have this technology now and that we’ve been able to leverage it. How we can support that going forward. That’s going to be the big question in terms of what you mean by support.

John Moore III: [00:25:53] In terms of what?

Alex Lennox-Miller: [00:25:54] Because it’s not just a question of deploying, it’s a question of having the infrastructure that people can use to access it. It’s a question of government regulation and reimbursement processes that support it. Right now, most of our reimbursement and most of the technology designed to integrate is heavily encounter based. Yes, it’s based around appointments and the process of a patient coming in and being see most of this distributed care. Most of this virtual care is not reliant on that. It’s not encountered based. And we need to make sure that health care reimbursement, health care payment and health care structures are modified to not just support reimbursement for when a patient gets seen by a provider, but reimbursement for when health care is delivered because those aren’t going to be the same anymore.

John Moore III: [00:26:43] Well, thank you again for joining us today, Alex. This has been wonderful. And I’m sure our audience will agree that your insights and information you’ve provided will be very helpful. And thank you, audience, for joining us today. We know that time is precious. So we appreciate you sitting through this. If you’re new or lurking. Welcome to the Chilmark Research Family. If you would like to leave a comment or if you have any questions, please leave it in the comments below and someone from our team will get back to you. If you like the video, be sure to give it a like. And if you want to learn more about anything that we discussed today, please look in the video description where you can find links to additional resources.

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