HIMSS’19: Real Value in Telehealth and Virtual Care

This is the second in a series of blog posts recapping HIMSS’19; you can read all our coverage here.  

My primary purpose at HIMSS’19 was gathering information and ideas for our upcoming report on the front door to care. This report will take a close look at the evolving ways patients first enter the healthcare system. Whether from retail health, telehealth, remote patient monitoring, or remote care apps, HIMSS was full of changing ideas and approaches. The conference had a utilitarian focus, looking less at generic or abstract buzzwords to get people excited, and more at what can be done right now to engage providers, payers, and ultimately patients.

My biggest takeaways:

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them.

Health systems have invested a lot into controlling referrals and leakage. While the PCP remains the central organizing hub of most healthcare, the growth of retail and remote health could lessen the PCP’s centrality in traditional referrals networks.

Unlike the Teladoc model, which employs contracted providers to provide a turnkey outsourced telehealth service, newer entrants offer operational platforms and back-end systems so HCOs can staff and run their own telehealth programs. This allows them to retain control of the patient experience. It’s an easier model for an HCO to understand and use, but whether they adopt such solutions before their competition is an open question.

Behavioral health might finally get its due through Virtual Care apps.

Between shrinking reimbursements and scarce providers, behavioral and mental health care have been the first service line on the chopping block for a while now. PCPs have become the go-to provider for too many behavioral health needs, occupying increasing amounts of time and stretching their expertise thin.

Several of the telehealth and remote health platforms I saw last week had behavioral health components. There were a few well-executed apps dedicated to mental health and wellness, mainly with a CBT/DBT focus and some with solid clinical results. Helping PCPs manage this care and mitigating the effects of comorbidities on patients is an important part of addressing PCP workload and job satisfaction, as well as patient engagement. These virtual care offerings can help struggling PCPs get their patients the help they need, while still working within tight budgetary and scheduling restrictions.

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them. The question is whether health care systems will recognize that in time.

Performance improvement services are becoming a core component of analytics products

With my background in healthcare performance analysis and improvement, I wanted to see how analytics is evolving to become more effective and efficient.

The future of analytics platforms looks less like pre-built dashboards or reports and a lot more like what Visiquate offers. Its embedded employees work directly with customer end-users to execute Agile-inspired improvement sprints supported by their analytics and reporting. Vendors are coming to grips with the challenge of operationalizing analytics for value and performance improvement. The value proposition behind both improved reporting software and process improvement is pretty well understood. Figuring out how to fit it all into an annual budget in an era of shrinking margins is the real hard part here.

Leveraging data to produce specific, actionable recommendations remains a challenge.

A fascinating conversation about AI at the Geneia booth on Tuesday afternoon summed up the current state of AI and machine learning in the clinical world. While access to existing and new kinds of data is increasing and the ability to integrate it is getting more sophisticated, AI and ML still aren’t the clinical tools many expected them to be. Only imaging, an area where the datasets are complete and the challenges are well understood, has really begun to heavily leverage AI/ML. Everywhere else, the barriers to gathering appropriate context and rendering predictive clinical recommendations have yet to be overcome.

Stay up to the minute.

Did You Know?

2019 Predictions: M&A, Big Tech, and the Fate of ACOs

The Meaningful Use gravy train finally came to an end in 2018. As the strongest EHR vendors struggle to define new revenue streams, weaker ones faded from view through acquisitions or leveraged buy-out. Meanwhile, funding for ‘digital health’ start-ups continued to increase, though it likely hit the high water mark in 2018. And lest we forget, Amazon, Apple and Google continue their forays into the healthcare sector as the market is simply too big to ignore.

So what’s in store for 2019?

We brought together our analysts’ brain trust and came up with the following baker’s dozen of 2019 predictions. Over the near decade of making these annual predictions, our batting average has consistently been well above .500, so don’t ever say we didn’t give you an advanced warning on the following:  

 

Revenue cycle management M&A picks up; Optum acquires Conifer

Revenue cycle management M&A activity will continue to pick up with the most notable acquisition by Optum as it doubles down on its Optum 360 managed revenue cycle business and acquires Conifer Health Solutions from Tenet.

Alternative primary care clinics remain a side-show

Despite the hype and media attention around alternative primary care clinics (e.g. Oak Street Health, Chen Med, One Medical), the actual number of physical locations serving patients will remain paltry at less than ten percent of the number of retail health clinic locations. 

Humana finds a life partner with Walmart 

Walgreens will likely make the first move to acquire Humana in 2019, but Walmart will outbid Walgreens to win Humana over.

Regulatory approvals for artificial intelligence-based (AI) algorithms accelerate, tripling the number approved in 2019

The number of FDA approvals for algorithms in 2018 was impressive and shows no signs of abating. Additionally, 2020 will see a further tripling of regulatory approvals for AI.

Choose wisely: 2019 sees the first major shake-out of DTC telehealth vendors

Consumers’ use of telehealth will continue to see rapid growth and rising competition leading to significant consolidation among the plethora of vendors. By year-end, a major non-healthcare-specific consumer brand will join the mix, and the market will be down to five direct-to-consumer (DTC) nationwide brands.

Data science services see extraordinary growth, nearly doubling in 2019

By the end of 2019, every major healthcare analytics vendor will provide a cloud-hosted offering with optional data science and report development services.

In 2019, healthcare organizations (HCOs) adopt a cloud-first strategy

Cloud offerings have become far more robust, concurrent with HCOs’ struggles to recruit IT talent and control costs. Amazon’s AWS and Microsoft’s Azure will be clear winners while Google’s own cloud infrastructure services will remain a distant third in 2019.

New rules from ONC about data blocking have little effect because the business case does not change

Laws and regulations to-date have not compelled providers to freely share data with patients. ONC’s information blocking rule, which will be released before the end of 2018, will make it easier to transfer data to other organizations but will do little to open the data floodgates for patients, clinicians, and developers.

Big tech companies’ intentions in healthcare do little to disrupt the delivery of care

  1. Despite high-profile hires, the Amazon/Berkshire/JPM initiative will make no substantive progress.
  2. Amazon will focus only on the DTC supply chain, payer, and employer—staying away from anything substantive in the provider space.
  3. Apple’s Healthkit and sensor-laden smartwatch will remain sideshows in 2019 awaiting a more actively engaged healthcare consumer.
  4. Google [Deepmind] will never break out of clinical research and drug discovery.

Majority of MSSP ACOs stay and take on risk; hospital-led ACOs lead exits

Despite loud protests, the vast majority of provider-led MSSP ACOs will take on downside-risk as CMS shows flexibility in waivers. However, hospital-led ACOs, who continue to struggle with standing up a profitable MSSP ACO, will exit the program in 2019.

Closure of post-acute facilities shows no signs of slowing

Continued changes in post-acute care reimbursement, especially from CMS, combined with the migration to home-based services, puts further economic strain on these facilities. Nearly twenty percent of post-acute care facilities will shutter or merge in 2019.

2019 Health IT IPO market fails to materialize

The warning signs are there over the last couple of months that the stock market has become skittish. This will extend well into 2019 (if not lead to a mild recession). It will hardly be an ideal time to do an IPO, and those planned by Change Healthcare, Health Catalyst and others will wait another year.

Elon Musk reinvents healthcare

Elon Musk will have a nervous breakdown leading him to reinvent the healthcare system from his bed during his two-week recovery at Cedars-Sinai.

Webinar – Telehealth 2018: Healthcare Beyond the Exam Room

In this webinar, Chilmark President John Moore presents key findings from our report, Telehealth 2018: Vendor Assessment and Market Impact. Afterward, he discusses broader telehealth opportunities and challenges with special guests Ann Mond Johnson (CEO of the American Telemedicine Association) and Dr. Brian Zack (Medical Director of Telehealth Services at University Hospitals Cleveland).

Key topics addressed:

  • Drivers and challenges to telehealth adoption
  • Greatest opportunities for telehealth to impact care delivery and outcomes
  • Current market segments
  • Potential disruptions to the telehealth market

You can also read some of the report’s findings in our blog post on provider adoption of telehealth.

To access the slides, please enter your email address in the video form or at the bottom of the page. To learn more about the report or to purchase it, please click here.



How will Proposed Changes to CMS Telehealth Reimbursement Affect Adoption?

Key Takeaways

  • CMS-proposed rule changes extend Medicare Advantage and Part D plan coverage for telehealth services starting in 2020
  • Proposal includes enhancements to the Star Ratings methodology, which include updating the cut-point determination methodology as well as adjustments for Star Ratings in times of uncertainty, such as hurricanes.
  • Under the proposed changes, starting in 2019 in Medicare FFS, CMS will reimburse for virtual check-ins, evaluation of patient submitted photos, and prolonged preventive services regardless of patient location and care facility.

What the Rule Changes Mean

doctor cares for medicare patient via telehealthOn Friday, October 26, the Centers for Medicare and Medicaid Services (CMS) announced several rule changes that affect how telehealth services will be covered under Medicare Advantage (MA) and the Medicare prescription drug program (Part D). These changes are in direct response to the Bipartisan Budget Act of 2018, which eliminated historical restrictions on telehealth reimbursement, and are intended to “improve quality of care and provide more plan choices for MA and Part D enrollees.”

Also included in the proposed rule changes are adjustments to methodologies and processes that should improve access to care, as well as recover funds from payments improperly applied to insurance companies. We view this as a positive development, especially as it relates to current and projected physician shortages. Greater reimbursement should allow for providing some basic services through telehealth applications, it is going to equip providers with the ability to “do more with less.”

Our recent report, Telehealth Beyond the Hospital, provides a detailed analysis of the telehealth market as a whole, but we felt it prudent to prepare a supplemental post to give a brief examination of how these rule changes could potentially impact the provision of healthcare services.

Easing Reimbursement via Classification

Telehealth services have previously seen limited implementation by MA plans because they have been traditionally classified as services covered by “supplementary medical insurance.” These new rule changes shift the classification of telehealth services to the “basic benefits” category. We have witnessed lagging adoption rates of telehealth technologies over the last several years, and view the inclusion of these services into the basic benefits category as a necessary step to increase their rate of use.

CMS expects that the inclusion of telehealth services in the basic benefits category will spur more MA plans to offer these benefits beginning in 2020, and increase their support of these services in subsequent years. This isn’t happening in a vacuum, and is in line with the broader push to promote telehealth services as viable alternatives and supplements to traditional care options. The move towards parity between physical visits and telehealth services has shown to increase reliance on telehealth services before: Michigan has seen a “77.5% increase in Telemedicine encounters after supporting service parity in telemedicine.”

This isn’t happening in a vacuum and is in line with the broader push to promote telehealth services as viable alternatives and supplements to traditional care options.

Driving Near-Term Adoption: Patient Satisfaction and Ease of Access

Recent surveys have shown that patients are growing more and more amenable to remote care options, especially if it reduces their out-of-pocket costs. The opportunity cost of non-reimbursed care is one of the primary barriers to provider adoption of telehealth services, and by removing this barrier we will hopefully see further alignment between providers and patients on this issue.

We see this alignment as a part of the greater industry shift towards value-based care (VBC). As we noted in our Patient Relationship Management (PRM) Market Scan Report, engagement was one of the areas where adoption of these new technologies for VBC was exceeding expectations. Increased reimbursement for telehealth should continue this positive trend and hopefully allow for the realization of some PRM benefits.

We predict that the CMS rule changes will encourage diversified managed care organizations (MCOs) to expand their current commercial telehealth contracts to their MA business and also potentially drive the adoption of telehealth offerings among that trend.

Impact on Providers and Vendors

These new rule changes have a large potential upside for all players in the telehealth market, but it is important to note that telehealth adoption has been incremental over the last several years and there is no reason to predict a stark diversion from that trend.

We predict that the CMS rule changes will encourage diversified managed care organizations (MCOs) to expand their current commercial telehealth contracts to their MA business and also potentially drive the adoption of telehealth offerings among that trend.

Vendors looking to capitalize on this incremental market growth are going to have to navigate the differing needs of commercial and Medicare providers. For commercial providers, telehealth is seen primarily as a cost-savings and efficiency tool. For Medicare providers, they are looking most closely at telehealth as a way to promote post-acute care management and patient engagement. To effectively sell to Medicare providers, vendors are going to have to tailor their tools and pitches to hit on the appropriate pain points.

Conclusion

As the costs of chronic condition management skyrocket, looking for innovative telehealth solutions is of paramount importance.  Reclassification as basic services and simplification of the reimbursement process will certainly help vendors supplying these solutions overcome potential buyer uncertainty on the ROI of their products.

The most important takeaway from these rule changes from an HCO perspective is that the future of value-based care is arriving quickly. HCOs need to prepare for this future by refreshing their care delivery strategies, especially as it relates to primary care. The primary care environment is changing, and HCOs need to closely examine what they need to provide in terms of physical locations, providers, and services for their patient populations. They then need to craft strategies to meet these evolving requirements.

How Health Systems and Health Plans Are Leveraging Each Other’s Strengths Through Telehealth

By Mike Baird, President, Customer Solutions, American Well

 

telehealth consultationThere are over 5,000 hospitals in the United States, each caring for the country’s growing population of more than 325 million people. Aside from integrated health systems, many of these organizations are operating independently from health plans or other health systems. This type of siloed care has become the norm in the healthcare industry, and while EHRs have improved care continuity over the years, health organizations are still largely operating on their own.

The same can be said for these organizations’ telehealth programs. More than half of healthcare executives say they have implemented some sort of telemedicine service into their organization. Many health systems and health plans launch with a direct-to-patient urgent care telehealth service, before expanding to other service lines including behavioral health, specialty care, chronic care management, follow-up appointments and more. These telehealth programs leverage the healthcare organizations’ provider expertise, clinical services, technologies and unique ties to their communities. While telehealth is helping these organizations deliver more convenient and affordable care, their programs, too, have been historically siloed. Until now, that is.

Today, some of the top health systems and health plans in the country are utilizing their telemedicine programs to connect and exchange services instantly online. Health systems or hospitals who supply healthcare services are partnering with health insurers who generate consumer demand to leverage each other’s strengths.  This sharing of patient demand and provider supply is key in driving telehealth and patient success.

Two of the nation’s top healthcare organizations provide a perfect example of this type of telehealth care convergence. Cleveland Clinic, one of the largest and most well-respected hospitals in the country, offers its telehealth services on Anthem’s telehealth platform, LiveHealth Online. Consumers in Ohio, West Virginia and Pennsylvania who use Anthem’s telemedicine platform can connect with Cleveland Clinic physicians and nurse practitioners through the LiveHealth Online mobile or web platform for live on-demand video consults.

For Anthem, this collaboration offers its members unique access to providers from one of the nation’s leading institutions, and for Cleveland Clinic, it allows the health system to extend its telehealth service visibility to Anthem’s 38.5 million members — ultimately increasing usage and attracting new patients.

health plan health system shared telehealth platform

New-York Presbyterian offers another innovative example of care collaboration and integration through telehealth. New-York Presbyterian is one of the nation’s most comprehensive, integrated academic healthcare systems. The system has ambitious goals for telehealth and has already integrated virtual care into its emergency rooms to provide effective behavioral health treatment and to triage non-urgent patients to reduce wait times. Through its direct-to-consumer telemedicine program, New-York Presbyterian makes its providers available on the Samsung Health Ask an Expert app, which is preloaded onto Samsung Galaxy smartphones. Through this telemedicine exchange, a consumer with a Samsung phone can have an urgent care video visit with a New-York Presbyterian provider from within the Ask An Expert app. For New-York Presbyterian, partnering with Samsung gives their telehealth program unprecedented exposure to consumers across the country, while Samsung can offer consumers access to New-York Presbyterian’s renowned providers.

New-York Presbyterian, Cleveland Clinic and Anthem are the trailblazers for this type of virtual care collaboration, and more healthcare organizations are following suit as focus shifts from fee-for-service to value-based care.  These partnerships help accelerate telehealth adoption through greater platform utilization, increased healthcare specialty choices for patients, and expanded access to care.

Recent regulations have also helped make telemedicine collaboration more appealing for healthcare organizations. The Interstate Medical Licensure Compact allows expediated multistate licenses for physicians, which means health systems wanting to extend their services over state lines can expect expedited, multistate licensure for their physicians.

Health systems and health plans have their own unique strengths; by lifting the virtual barriers of telehealth care delivery, they can leverage these strengths through thoughtful telehealth collaborations.  In turn, this is transforming the way care is delivered and received for the benefit of both patients, providers, and health systems.

This post originally appeared on September 5, 2018, as the first in a series of sponsored guest blog posts on our Convergence conference blog. 

How Healthcare Leaders Adapt to the Evolving Front Door to Care

by Brian Eastwood and Paul Nardone

When today’s healthcare consumers have questions about their health, they are no longer limited to phone calls to the doctor’s office or visits to the emergency room. Technology has enabled and supported the creation of numerous new “front doors to care” – including but not limited to telehealth, chatbots, digital therapeutics, retail health, urgent care, and community-based clinics – that threaten to disrupt traditional care delivery models.

We recently interviewed two leaders at organizations leveraging telehealth to meet patients where they are and complement existing clinical workflows:

  • Joseph Brennan, Senior Director, MedNow at Spectrum Health
  • Chris Johnson, Vice President and General Manager, Landmark Health

Excerpts of these interviews appear below. They have been edited for clarity.

Briefly describe the solution or service you offer and how it opens a new front door to care for patients.

Brennan: MedNow is Spectrum Health’s direct to consumer (DTC) telehealth program. It has been in place for four years. It lets patients see a provider on their device for low acuity primary care conditions. Custom-building a mobile app that integrates with the EHR enabled us to enhance the patient experience and complement all of the other digital tools that Spectrum Health offers.

Johnson: We describe Landmark Health as a leading-risk medical group. We contract primarily with payers but can also contract with anyone who takes on risk. We focus exclusively on patients with 6 or more chronic conditions and are available to them 24/7/365 telephonically or in their home. We have physician leaders who take care of patients and are supported by interdisciplinary teams: Case management, behavioral health, pharmacists, dietitians, social worker, and non-clinical healthcare ambassadors who help build relationships with patients in between clinical visits and help them with education.

Was the motivation to adopt a solution that would open a new “front door to care” driven by clinical, financial, or operational needs?

Brennan: All of the above. The primary driver for us creating a great patient experience is that it is quickly becoming an expectation of patients who want convenient access to care. In addition, as healthcare transitions to value-based care (VBC), cost reduction is paramount.

Johnson: The hospital business model isn’t designed to provide longitudinal care of patients with complex conditions. We designed a model from the group up that could provide care for patients when they need it (24/7) and where they need it – in the comfort of their home. Patients with complex chronic conditions have a generally steady high medical spend year-over-year, so intensive longitudinal models to improve their long-term health work well. There are also psychosocial elements, including depression, dementia as well as addiction. This can be impacted by the interdisciplinary approach – specifically the incorporation social work and behavioral health – of our clinical model.

Hospitals state outwardly that they don’t want inappropriate hospitalizations. We are not taking away their core business treating patients in need of acute care.

How did you make the case for implementing a front door to care that has the potential to adversely impact another part of the business?

Brennan: Throughout development of our program, we were very conscious of cannibalization. Telehealth takes visits out of the emergency department and replaces it with something much less expensive. In preparing our health system for the future, we would rather get ahead of reducing healthcare costs than react to it. We need competencies in virtual care for the future and chose to build it now, rather than trying to catch up later.

Johnson: Hospitals state outwardly that they don’t want inappropriate hospitalizations. If there’s a readmission, they don’t get paid the second time, so we partner with them on discharge planning. Conceptually, they’re aligned. We are not taking away their core business treating patients in need of acute care.

Which stakeholders did you need to engage when first making your pitch – and who was the hardest to convince?

Brennan: We emphasized both clinical and operational benefits. Many health systems focus on one or the other; our strategy was to focus on both. The primary resistance came from physicians who were not convinced this was an appropriate standard of care. Four years into our telehealth journey, some physicians still don’t believe that virtual care is part of the future. We can attribute much of our success to the buy-in and support of executive leadership.

Johnson: We’re something that not a lot of people have seen before. It takes a bit of time to explain who we are and assuage fears that we will be competing for members with primary care physicians. We’re not a PCP, and we encourage strong relationships with a PCP. When we enter a market, PCP visits stay the same, or even increase a little bit. Once PCPs see the effects, they realize it’s really only a small number of their panel – and it’s usually the ones they find the hardest to manage, who have a lot of barriers to care.

When we are measuring the growth of our encounters, we are thinking of it as a convenient front door to the system, so it makes sense to measure how many people come through that door. Other important metrics include new patients to the system, cost savings to payers, avoided ED and Urgent Care visits, and patient miles saved.

What KPIs or other metrics are most important to measuring the success of your front door to care initiative? Are you focused on raising awareness, boosting business, or adding revenue?

Brennan: For us, it’s the number of encounters. With virtual care, the only way to scale is through increasing volume. When we are measuring the growth of our encounters, we are thinking of it as a convenient front door to the system, so it makes sense to measure how many people come through that door. Other important metrics include new patients to the system, cost savings to payers, avoided Emergency Department and Urgent Care visits, and patient miles saved.

Johnson: Our service significantly reduces the medical expense reimbursement for a patient and improves the medical loss ratio for that covered population – from north of 100% to something quite profitable. Health plans can take a segment of members that used to be challenging and bring it in line with the rest of their book of business. This allows our plan partners to keep premiums lows and invest in additional services for their members.

How does your new front door to care reduce the friction that often makes it difficult for patients to seek the care they need?

Brennan: First and foremost, it’s access. Our average wait time for a visit is 12 minutes and we are available 24/7. MedNow sees patients regardless of having a relationship with a Spectrum Health provider and we are available to everyone in the state of Michigan.  We have created a patient experience that is easy to use so that we can provide care where and when a patient needs it.

Johnson: The patients we serve often have frequent inpatient stays, or discharges to skilled nursing or post-acute care facilities. It’s often inappropriate and ineffective care; patients leave in worse condition than when they came in. If we can manage or control these patients more effectively prior to an incident, working with their existing PCP and specialists, we may prevent a hospital visit and stabilize longitudinal health.

What do you think will be the most disruptive front door to care in the next 3-5 years?

Brennan: It’s the digital health ecosystem. Similar to Google’s digital ecosystem, it is a suite of products, not just one tool.  We will get to a point where the expectation of patients becomes that health systems will meet their needs digitally like other industries, such as banking and commerce.

Johnson: For us, it’s literally the front door. Our mission is to bring healthcare to people when they need it, where they need it. It’s simple but profound. It also allows us to bring family in. A lot of the barriers to care are around families and education and getting people on the same team. We have clinicians who can build great care plans, but also think through the barriers to care and how to ensure the patient can follow that care plan. “How can we implement this? What are the barriers? What is the family alignment that we need?” Being able to do it in the evening, on the weekend, allows us to have better conversations.

A version of this blog first appeared on the Convergence 2018 blog on September 27, 2018. 

Telehealth’s Ongoing Efforts to Support Care Beyond the Hospital

Key takeaways:

  • Providers are adopting telehealth only when it directly contributes to revenue with a proven business case. This will not change for two or three more years.
  • Vendors are positioning telehealth as a complement to care, not a direct competitor to care, to address increasing competition for low-acuity care.
  • Whether telehealth does in fact complement clinical workflows will depend on whether the technology avoids becoming yet another silo of care delivery and clinical data creation.

Where are we on the hockey stick trajectory?

The growth of telehealth adoption has embodied the classic hockey stick graph. For decades, organizations such as the American Telehealth Assoc. (ATA) and a few market forecasters have touted telehealth as the next big thing in healthcare. Nothing, nada outside of a few, very limited use cases and what the Veterans Administration has been able to accomplish.

It’s not that other use cases didn’t emerge, or that other patient populations would not have benefitted from telephone- or television-based care. Rather, several obvious factors stood in the way – the cost of technology acquisition and maintenance, the opportunity cost of providing care that is not reimbursed, the complexities of licensing and credentialing across 50 states, and the difficulty of scaling what was, in many cases, a cumbersome if not fly-by-night program. Above all, it represented “A New Way of Doing Things”, and we all know how well received these are in healthcare.

Providers will not invest in telehealth technology unless there’s a clear indication that it will add revenue or generate savings in a value-based care model.

Today, of course, hundreds of vendors offer a range of technology solutions to support telehealth, both in the hospital and in the home. The cost of such technology has dropped; in the case of many direct to consumer (DTC) telehealth apps, it’s essentially free, as many consumers already own a smartphone and/or laptop and pay for Internet access and/or data plans. The difficulty of implementing and scaling programs has dropped as well. Reimbursement parity is not universal, but barriers are slowly falling – Medicare Advantage plans can start covering telehealth in 2020, and restrictions on telestroke coverage end in 2019.

The key question, though, is where on the hockey stick are we today. Is the market at the tip of the stick’s blade, with adoption destined to remain at its current level in the single digits (according to multiple metrics)? Or is the market still at the beginning of the blade, near the shaft, with adoption poised to peak at a much higher rate?

At the risk of answering questions with more questions, figuring out the exact spot that telehealth occupies on the hockey stick graph means asking two key questions:

Chilmark Research’s forthcoming Market Scan Report, Telehealth Beyond the Hospital, addresses these underlying questions as part of a greater focus on the state of telehealth adoption and the potential for telehealth market growth over the next 10 years. We examine the impact on providers as well as payer, employer, and patient stakeholders.

Providers catch up, where there’s money

Provider organizations are warming up to telehealth. Efforts to support acute care within the hospital are expanding, especially amid growing demand and shrinking supply for key medical specialists. Efforts to augment low-acuity care are also expanding, partly in a nod to improved customer service / patient satisfaction and partly to beat back the rising tide of retail health and urgent care competitors.

Not surprisingly, providers’ warm feelings towards telehealth are directly proportional to the amount of money to be made.

  • Interest in telehealth for outpatient care is tepid and limited to scattered pilots for high-acuity remote patient monitoring (RPM), condition management, and orthopedic procedures covered under bundled payments. Without proven value-based care (VBC) reimbursement models, most providers are not willing to take their chances.
  • DTC telehealth is pitched primarily as a tool for patient acquisition and retention so providers do not lose (or stop losing) business. While the benefits of improved care coordination and data-sharing are implied, the marketing message for DTC services typically centers on the low cost and high convenience of care.

Expect this trend to hold firm for at least the next two to three years. Most providers will not invest in telehealth technology unless there’s a clear indication that it will add revenue or generate savings in a VBC model. It clearly makes business sense to avoid such financial risk, especially in times of tight margins – but it leaves an opening for payers and employers, and their clearly defined financial risks, to fill in the blanks with their own telehealth programs.

Doors open up, where there’s a strategy

As hinted in the paragraphs above, telehealth is opening new front doors to care. This is true for the three broad types of telehealth technology defined and examined in our report.

  • DTC vendors can offer anytime access to care.
  • RPM vendors can support patients on care plans.
  • Acute care vendors can expand access to services, as well as expand the breadth of services available.

 

As for whether telehealth will create yet another care silo, our research suggests that vendors as well as providers hope to avoid this fate. Hospitals are increasingly centralizing telehealth operations, which brings consistency to the user experience but also allows executive leadership to pursue a clear strategy for telehealth implementation and expansion. Executed properly, this makes telehealth a complimentary service available across a system’s care venue, not an add-on available only in limited settings to a limited number of patients.

Meanwhile, vendors seem to be embracing the idea of telehealth as a complementary service, not a standalone one:

  • EHR integrations are increasingly common among vendors of all types – and while a visit summary isn’t ideal, it’s better than no information at all.
  • DTC offerings are being added to those centralized telehealth departments, and most vendors are more than happy to white-label their solution on a hospital’s behalf.
  • Acute vendors are seeking to apply their experience supporting complex inpatient workflows to outpatient and in-home care coordination.
  • All stakeholders identify long-term, post-acute care and skilled nursing facilities as key areas of future growth, both for monitoring residents and for providing remote care that would otherwise require an emergency department transfer.

The challenge lies in the execution. It’s one thing to espouse a strategy of telehealth across business units; it’s another thing entirely to take the tactical steps necessary for that strategy to become part of the everyday practice of medicine. If execution falls short, the strategy rings hollow.

A complement to care, not a competitor

If we were to hazard a guess, we’d say that telehealth adoption today sits somewhere in the middle of the hockey stick’s blade. Providers remain risk-averse, taking action only when all barriers to success have been removed and the path forward has been nicely graded and paved. Payers and employers are more willing to stand up telehealth programs, but their struggles to members/employees to use telehealth benefits to achieve broader adoption is still very much a work in progress. As stakeholders keep waiting for national licensing, credentialing, and reimbursement standards to replace a patchwork of state regulations, expansion plans are put on hold.

All that said, interest is growing. Healthcare business models increasingly demand the shift of care to lower-cost care venues, and telehealth provides such an option. Patients appreciate the convenience of remote care, both to avoid a single ED visit and to prevent repeated trips to outpatient facilities for follow-up care.

Whether adoption reaches the tip of the stick’s blade, or whether it fails to move beyond the tape on the middle of the blade, will depend on the ability of stakeholders to position telehealth as a complement to care, not a direct competitor, and to position growth strategies accordingly. Telehealth will not serve all healthcare use cases, and it will not serve all patient populations, but mounting evidence suggests that it can support care beyond the hospital – and beyond the few use cases of yesteryear. Stakeholders that fail to take note can expect to fall behind no matter their business model.

By Opening a Front Door to Care, Telehealth Will Finally (Finally) Take Off

patient and doctor ina telehealth visitAnyone who has written about telehealth in the last decade has penned a January piece that begins, “This is the year telehealth technology finally takes off.” In keeping with the pattern, a second piece inevitably follows about 11 ½ months later, noting that telehealth didn’t quite take off as expected but, frankly, ought to in the year ahead, often for the same reasons that held back adoption over the course of the year.

Admittedly, I’m guilty as charged. My first “telemedicine will take off” piece appeared in early 2013, only a couple months after my first “telemedicine is changing health IT” headline. (You can tell it was a long time ago because I still called it telemedicine.)

At the risk of sounding naïve, 2018 increasingly looks like The Year. But it’s not necessarily due to mergers and acquisitions, good earnings calls, or legislative progress. Yes, these matter, but they reflect outside forces pushing provider organizations. Such forces can only push heavyweight incumbents so far.

Providers are finally starting to flip the script, turning telehealth from something they compete with to a competitive advantage they exploit.

Rather, the evidence that telehealth is taking off comes from incumbents’ response to those outside forces. As last week’s World Congress Virtual Health Care Summit showed, providers have started to take matters into their own hands. The collective goal: Open a new front door to care that makes it easier for patients to access the services they need.

  • Providence St. Joseph Hospital is building on the success (and lessons learned) from its acute and direct-to-consumer (DTC) telehealth implementations to branch out into post-acute and follow-up care. When patients visit the system website, they have the option to book in-person, in-home, or online appointments.
  • The University of South Carolina offers acute care as well as chronic condition management (typically asthma) through telehealth services to more than 80 schools across the state. Future use cases include skilled nursing facilities (to provide after-hours access to care that otherwise results in an ED transfer) and DTC visits for patients covered under accountable care organization (ACO) contracts.
  • Spectrum Health saw demand for its homegrown telehealth program, MedNow, spike during a recent flu season. The Michigan system’s marketing team touted the virtual visit as a more convenient way to seek treatment – and providers bought in because it meant patients with compromised immune systems weren’t exposed to an influx of flu patients. Now more than 30 percent of MedNow users are new to the health system.
  • Ascension Healthcare, Intermountain Healthcare, and Spectrum Health all described taking a “platform” approach that made access to multiple telehealth services independent of the patient portal. The approach is akin to having a Gmail address but not needing to log into email to access Docs, Sheets, Drive, Hangouts, and so on.

The shift from telehealth to a “front door to care”

It’s important to distinguish between the front door to care and more traditional telehealth offerings. (While it feels odd to call any type of telehealth “traditional,” please bear with me.) The latter primarily provide phone, email, and video visits, with messaging and remote monitoring emerging as additional options. Kaiser Permanente notwithstanding, these modalities address one-off interactions, even for complex and high-risk patients. Care continuity takes a backseat to convenience. A door to care is opened, but it leads to a single room with no other doors. You have to go out the way you came in.

The front door to care, meanwhile, provides an access point to a much larger array of healthcare services. The enabling technology is largely the same, but the difference lies in the way that it is used – to provide convenience and care continuity, to lead to many other rooms that are likewise linked, to lead patients to the way out, as it were, that makes the most sense for their current and future care needs.

Admittedly, it takes substantial effort to erect a front door to care (and all the other doors behind it). In particular, speakers at the Virtual Health Care Summit noted the operational needs. The front line of patient care is impacted – and so is billing, legal, call center, licensing, collections, human resources, and so on. In other words, it requires a substantive change to the way a provider does business – and it explains why, until recently, providers have not been able to catch up with telehealth’s maturity.

The front door to care provides an access point to a much larger array of healthcare services. The enabling technology is largely the same, but the difference lies in the way that it is used.

Clearly the front door to care is not tenable in fee-for-service markets. (Think of all the parking, gift shop, and cafeteria revenue lost when patients and physicians opt for virtual care!) Nor is it tenable in states such as Massachusetts, which has yet to pass a law providing reimbursement parity for virtual visits. In the Bay State, providers essentially focus on small-scale bundled payment and ACO models while waiting for parity to open up additional opportunities.

Elsewhere, though, the tide is rising. Providers are finally starting to catch up – and it’s because they have flipped the script, turning telehealth from something they compete with to a competitive advantage they exploit. That’s why, as our upcoming Market Scan Report describes, telehealth increasingly has moved beyond high-acuity inpatient care and low-acuity DTC care to play a greater role “beyond the hospital” in order to provide more coordinated care. And that’s because, as the Virtual Health Care Summit discusses, providers know that the revolving door at the entrance to the ED is no longer the preferred front door to care.

Because if 2018 does, in fact, end up being The Year that telehealth takes off, smart providers want to be sure they don’t get left behind.

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