Telehealth took on a new, enhanced importance with COVID-19 as a necessity to provide care and keep patients and providers safe.
Four factors that will affect telehealth’s continued adoption and staying power in the post COVID-19 world: use cases, payer barriers, regulatory changes and technology.
Telehealth embodies the old saying, it’s old wine in a new bottle. To be sure, telehealth has been around for decades in one form or another. It was rapidly gaining traction in the years leading up to the crisis associated with the illness caused by the novel corona virus (COVID-19). But the technology took on a new, enhanced importance with COVID-19 as a necessity to provide care and keep patients and providers safe.
While it’s too soon to know the full dimensions of telehealth adoption in the era of COVID-19, some revealing new statistics are emerging. Blue Cross-Blue Shield of Massachusetts announced it processed 250,000 new claims for telephone and virtual visits in March, along with 50,000 new claims for COVID-19 testing and treatment. Telehealth visits at the Dartmouth-Hitchcock Medical Center jumped from 3 per week to 2,000 each day–and climbing. Investors are betting heavily on current and future adoption. American Well raised almost $200 million in the middle of the pandemic. And there are estimates that telehealth could grow to a $250 billion revenue opportunity post-COVID-19. This is just the tip of the iceberg.
The question going forward is how to keep telehealth sustainable, building on the momentum that had been growing before and during the COVID-19 crisis. Here are four factors that will affect telehealth’s continued adoption and staying power in the post COVID-19 world: use cases, payer barriers, regulatory changes and technology.
Use Cases. Use cases drive adoption. The costs and benefits of telehealth were recognized pre-COVID-19. They are expected to continue post-COVID-19 and serve to propel the technology forward when the COVID-19 crisis subsides.
Cost savings.There is a growing body of evidence that suggests telehealth can result in considerable cost savings for patients and payers. For example, virtual visits typically cost $45, compared with $100 for an in-person visit at a doctor’s office or $160 at an urgent-care clinic. This is helpful for patients with high deductible plans. A March 2017 report by The Rural Broadband Association estimates telehealth use could result in annual savings of $20,841 per rural hospital. Telehealth created substantial efficiencies and savings at the Department of Veterans Affairs (VA), which has a huge telehealth footprint. The annual cost to deploy the telehealth program in 2012 was $1,600 per patient per year, compared to over $13,000 for traditional home-based care and over $77,000 for nursing home care. Telehealth also saves patients time and money in travel. A regional analysis in California found that telehealth visits saved individual patients four hours of driving time, 278 miles and $156 in direct travel costs.
Improved access to care. Telehealth expanded access to care for nearly all patients due to COVID-19. It created the means to reach vulnerable populations at risk for COVID-19, including the elderly, chronically ill and minorities. This could be a game changer for those with mobility and transportation issues. Telehealth became a lifeline to behavioral health patients. Not only will these use cases carry over into the post COVID-19 world, they indicate how telehealth will become an essential tool for patient engagement and population health management going forward.
Improved quality. Evidence was building pre-COVID 19 that telehealth provides quality care. Studies indicate that telehealth promotes continuity of care, decreases the cost of care, reduces readmissions and improves patient self-management and overall clinical outcomes. This is seconded by the American Medical Association. Another study found that telehealth services provided by physicians during off hours — specifically weeknights and weekend days — could result in 15 fewer rehospitalizations annually for individual nursing homes, which could save Medicare some $151,000 per facility each year. Such quality metrics are central to reimbursement under Medicare and accountable care organizations.
Medication management. Telepharmacy services had been making inroads before the COVID-19 crisis, primarily for patients and veterans in rural areas and in long-term care For example, remote pharmacists typically cover for hospital pharmacists during storm outages, vacations and off hours, providing substantial savings in labor costs. COVID-19 kicked it up a notch, with relaxed restrictions by federal and state agencies. This allowed pharmacists to practice top-of-license with face-to-face communication for hospital discharge management and medication management counseling. Expanded roles for telehealth pharmacists and lower costs will help drive post-COVID-19 adoption.
Changes in care models. Changes in telehealth care models will have staying power in the post COVID-19 world. An example is using telehealth to provide care outside of hospitals. That trend had already started with the advent of lower-cost ambulatory surgery centers and off-campus urgent care in drug stores and strip malls. With telehealth promising to become ubiquitous, hospitals could become virtual centers. It’s already happening today. An example is the Mercy Virtual Care Center, in St. Louis, which was designed specifically to support a range of telehealth services, from intensive care to telestroke to physician consultations. Some experts predict that telehealth could impact brick-and-mortar facilities “formerly known as hospitals.” While telehealth can’t replace all in-person care, it could change the need for large hospital campuses in another decade or so — much in the same way that on-line purchasing spelled the downturn of retail purchasing in malls.
There also will be changes in the care team resulting from telehealth. This includes an expanded list of care team members who can provide telehealth, many at lower costs. Many trained professionals can provide counseling, triage and care delivery, such as nurse practitioners, physician assistants, pharmacists, nurse midwives, and occupational, speech and physical therapists. At the same time, primary care could include a subspecialty (“virtualists”) and many primary care physicians will be working in newly-formed virtual care practices. Physician assistants and pharmacists will be working at top-of-license in virtual care settings. Telehealth could become a lifeline for solo practitioners or rural providers who may be having trouble weathering the drop in in-person visits and related revenues caused by the COVID-19 crisis.
Reducing payer barriers. Making telehealth sustainable going forward means changes by payers. Before COVID-19, payers limited telehealth adoption through usage and reimbursement restrictions. They include administrative barriers requiring the use of prior authorization, referrals and medical necessity reviews. At the same time, payers’ telehealth coverage and reimbursement were far below the going-rate for in-person diagnosis and treatment (although some of that was due to regulation).
Once the crisis has been tamped down, payers will be pushed to revisit their reimbursement rationales, methodologies and rates. Patient cost-sharing may become an issue, which could affect telehealth sustainability.
Then there’s utilization, which influences payers’ coverage and reimbursement decisions. There is some evidence that telehealth may increase utilization. Is this because patients are now seeking care for minor illnesses due to convenience? Is it because telehealth visits uncover conditions and medication adherence problems that previously were unknown and require additional treatment? Another point to consider is that as settings of care reopen, could a steady state be reached in which a person’s visits increase but use of telehealth services never goes away? This issue and its dimensions will need further exploration as payers weigh telehealth’s cost and benefits in the post COVID-19 world.
Regulatory changes. While telehealth had been around for years before the COVID-19 crisis, there were many federal regulations and State parity laws that limited reimbursement by Medicare, Medicaid and private insurers; curbed allowable sites of care; and placed licensure restrictions on who can provide telehealth services. Some of that changed pre-COVID-19 with bipartisan support that recognized the benefits of telehealth. For example, telehealth became a standard benefit for Medicare Advantage plans as of January 1, 2020. Similar changes were being made by the states. Then the COVID-19 crisis hit. Both the federal government and the states relaxed or waived many remaining telehealth restrictions, which went a long way to promote its use. The Drug Enforcement Administration (DEA) is temporarily giving providers the ability to prescribe controlled substances via telehealth for behavioral health patients. But will these relaxed requirements be scrapped after the crisis diminishes? Or can they be baked into the federal and state regulatory frameworks in a timely fashion to support enhanced telehealth sustainability? Many agencies, like the DEA, will have to take specific action to do so. CMS already is working on regulations to make permanent some of the relaxed restrictions.
Another issue is compatibility with the Health Insurance Portability and Accountability Act (HIPAA), which will be key to sustainability going forward. Myriad telehealth platforms were stood up or expanded in a hurry during the COVID-19 crisis. The government waived potential enforcement actions concerning HIPAA compliance. Many, like Face Time and Skype, are not necessarily HIPAA compliant. Zoom appears to be as long as business associate agreements are in place. However, its security breaches have been concerning. Will the government be pushed to revisit its HIPAA guidance to address telehealth compliance in a post-COVID-19 world? If so, how fast will that happen?
Technology Innovation. Telehealth platforms exploded in response to the COVID-19 crisis. This variation is akin to the early days of electronic health records (EHRs). There were hundreds in the marketplace with varying degrees of interoperability and sophistication, but the number has significantly decreased due to market consolidation. There is likely to be a similar a winnowing of the telehealth market once COVID-19 is over. But what will be needed to ensure sustainability? Standards and interoperability will head the list. Added to that will be workflow integration. Currently, many platforms require manual entry of patient data, both pre- and post-visit. This opens the door to errors and creates provider frustration by adding more “clicks” to the care process, which can serve as a barrier to adoption.
Integration of artificial intelligence (AI) also will add value and promote telehealth sustainability. AI paired with telehealth had been on the rise before the COVID-19 crisis, creating increased clinical and administrative capacity as well as facilitating diagnosis and remote patient monitoring. It gained ground in telehealth use with COVID-19, such as by identifying patients at risk for COVID-19 and candidates for clinical trials.
Conclusion. It is clear that telehealth is here to stay, now that the “genie is out of the bottle,” as a UnitedHealthcare executive so aptly stated. Now that providers and their patients have experienced the benefits of telehealth (time savings, better access for patients with transportation challenges, more productive clinicians), it’s going to be difficult for payers to dial-back. And the pressure on regulators to catch up to the technology with licensure requirements will intensify. Point-of-Care Partners (POCP) can help your organization understand the impact of telehealth, both now and in the future. Reach out to us at michael.solomon@pocp.com and tricialee.rolle@pocp.com. POCP also is monitoring telehealth legislation and implementations. For information on legislation, please contact our regulatory team at keith.fisher@pocp.com and michelle.soble@pocp.com.
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