What’s really slowing the adoption of telemedicine
A 5-year-old child, in medical distress at a rural emergency room in northern California, is stabilized enough to avoid having to be rushed 50 miles to a pediatric critical care unit at a regional tertiary hospital. A video intervention in the rural setting saves hours of diagnostic delay, the costs of the trip and a high-intensity hospital stay.
In a quite different setting, a geriatrician talks to the nurse on duty at a skilled nursing facility in Pennsylvania about a sudden change in an elderly resident’s condition, reassuring her remotely that the situation doesn’t call for the once-standard reaction of calling for transport to an ER. The SNF keeps the resident in place, retaining revenue and preserving a comforting routine. The hospital avoids a Medicare penalty for a too-soon readmission.
At the opposite end of the care spectrum, relatively healthy adults in the San Francisco Bay Area who were seeking treatment at an ER instead of a physician’s office start using a telemedicine service for much of their primary-care needs. Established to provide more convenient access to suit those adults, the service gives a provider-sponsored health plan a way to cover that population comprehensively.
These are common scenarios in locations around the nation that are deploying telemedicine to solve specific problems. Hospital systems are elevating the technology to a vital place in their care continuum, to not only gain better clinical outcomes but also to manage costs in a fixed-revenue business environment.
Nine years after Pittsburgh-based UPMC initiated telemedicine with a remote stroke response program, it now operates 62 telemedicine-related services, in specialties as varied as maternal fetal medicine, endocrinology, and colorectal and breast surgery. Satisfaction is high; quality levels are no different from in-person interaction, says Andrew Watson, MD, vice president and medical director of telemedicine, who has done 500 tele-consults himself. “It just absolutely works, and it makes sense.” A second generation of initiatives, launched within the past year, is pointedly targeting cost avoidance.
Telemedicine’s traditional purpose was to increase access to care for isolated, underserved people. “That’s good,” says James Marcin, MD, director of the pediatric telemedicine program at University of California-Davis Medical Center, “but now it’s much, much more than that. The business case for that original approach may not have been as strong as it is now.” UC Davis has 32 specialties using telemedicine to some degree.
The emerging business case involves managing value-based reimbursement and its associated patient accountability. Reimbursement policies haven’t caught up yet: Medicare, Medicaid and private insurers still set limits on where telemedicine can be practiced and by whom, says Gary Capistrant, chief policy officer of American Telemedicine Association.
“All that micromanaging that may be appropriate under fee for service isn’t when a provider is bearing the risk,” Capistrant says. To mitigate the risk of value-based payment, payers should remove the restrictions from telemedicine and allow accountable care organizations latitude to create the value for which they are responsible, he asserts.
Risk-shifting to providers through the Affordable Care Act is remaking Medicare, and private payers are following that shift. But ironically, when it comes to using telemedicine as a risk-mitigation tool, “The laggard in this whole thing is Medicare,” says Capistrant.
On the positive side, the Centers for Medicare and Medicaid Services has increased the types of billable services, including tele-visits for primary care and behavioral healthcare, says Madhavi Kasinadhuni, senior consultant at the Advisory Board, adding that the list expands each year.
But CMS continues to exclude telehealth services for the 80 percent of Medicare beneficiaries who live in metropolitan areas, notes Capistrant. And eligible patients in rural areas are still required to go someplace dedicated to a telemedicine encounter instead of using their own computers or smartphones. Medicare also doesn’t cover remote patient monitoring of chronic conditions.
The lack of authorization for telemedicine affects reform-minded progress. For example, even though CMS established billing codes for chronic care management, there has been little uptake, partly because of barriers to managing that care, says Capistrant. “Diabetics have to keep track of their blood glucose, and you can do that writing it down on a piece of paper, but you can’t do it digitally,” he says. “Medicare doesn’t pay for that.”
In areas with a large but ineligible Medicare population, it’s difficult to amass enough volume to make telemedicine pay for itself. Medicare accounts for not only a high number of patients but a significant number of those who regularly receive healthcare services, he points out. “If you don’t have those patients to work with, it’s hard to create a viable telehealth network.”
Medicare policy is beginning to soften, as evidenced by the recent removal of some barriers to telemedicine for Advantage programs. But the more promising possibilities are elsewhere. “There is a lot of advocacy at the state level to improve the environment for practicing telemedicine,” says Kasinadhuni.
By the ATA’s count, 49 states now cover at least some aspects of telemedicine in their Medicaid programs, and 31 states have rules on parity in healthcare services—payers have to offer coverage of telemedicine-provided services that are comparable to that of in-person services.
Payers, too, are recognizing that telemedicine can help people stay out of more expensive care settings and prevent readmissions while meeting consumers’ desire for more immediate access to care, says Marcin.
Increasing care access and reducing avoidable expense are high on the agenda of the expansive UPMC tele-network, which already represents a significant portion of the organization’s overall care and treatment. The telestroke service, using videoconferencing to link EDs with the Stroke Institute, handled 447 cases in fiscal 2015.
In terms of all telemedicine cases handled by UPMC, it recorded 9,690 cases in fiscal 2013, nearly 50 percent more than the previous year. Then, the telemedicine caseload nearly doubled to 18,614 by the end of fiscal 2015. The program projects a 2016 caseload of more than 28,000.
Congestive heart failure is a ripe target. An existing remote-monitoring program has recorded a 12.9 percent incidence of 30-day readmission, compared with 20 percent for patients who went unmonitored. A broader program involving more hospitals and care providers was launched June 1, combining home-based monitoring and portals for direct contact between patients and providers into an advanced “early warning” system, says Watson. Objectives include fewer readmissions, shorter lengths of stay and less use of the ED. “We have built prospective models showing that will be the case.”
“It’s about as far upstream as you can go in healthcare,” he says. “From a population health standpoint, it’s fabulous, because you’re saving money—and yes, you are improving quality, because it’s better symptom management, it’s earlier detection of problems. The patient gets the ability to say, ‘Help, I need a call.’ The challenge that you have in this model is that in a fee-for-service environment, the hospitals and doctors are losing money. But we all know that healthcare is moving out of that environment.”
“Once healthcare moves to risk, telehealth is going to be a tool,” Watson says. “As a surgeon, it’s like having a retractor …it’s a tool that enables us to take care of patients.” Healthcare will go back to the days when doctors followed patients into their homes, he says.
UPMC also is tackling what’s dubbed “advanced illness,” the end stage of life recognized as a time for palliative care in the final months, but which often begins two years earlier. Payers are recognizing that healthcare can be intense during that entire period, and expenses pile up because of complications, says Watson. UPMC, as a payer itself, is considering how telemedicine can ease pain for hospital and patient.
CHF, cancer and chronic obstructive pulmonary disease are major causes of advanced illness. “These are terminal conditions, but you’re catching them further upstream to help patients in a humane fashion,” Watson explains. More frequent contact is key. Instead of a social worker visiting a home once a month, for example, patients can be surveyed two to three times a week in live video chats on things such as taking their medications, their breathing status and other influences on their condition.
Although it’s too early for outcome statistics, “we are already seeing a significant impact on patients saying they’re getting better care because we’re offering symptom management and an early warning system at the home. It’s very exciting.”
UC Davis has published evidence on the clinical benefit and efficiency of using telemedicine to connect its pediatric intensive-care specialists to 35 hospitals throughout northern California.
“We use it to see sick kids that present to emergency departments, or kids that are getting sicker on the pediatric ward in a community hospital where a doc may not be in the hospital 24/7,” says Marcin. Other pediatric specialists connect with neonatal nurseries for virtual bedside expertise. “Lives have been saved,” he says. “We’ve shown higher quality of care delivered to these kids.”
Part of the value is in safer care through fewer medication errors and fewer transfers from rural facilities to the tertiary facility because of a lack of expertise in the countryside. One study found that tele-consults resulted in 31 percent fewer patient transfers, compared with telephone consultations and a return of $1.96 for every $1 invested in telemedicine.
Even with the beneficial results, “it’s still not fully incentivized,” says Marcin. But data in hand for five to 10 years is now taking on the importance needed for telemedicine to be more fully embraced, now that some types of readmissions are financially penalized and other incentives for early intervention are building, he says.
Some smaller community hospitals are solving expertise issues on their own—they believe that significant upgrades in medical care can be planned wholly around telemedicine capability. For example, a four-hospital group in eastern Florida, part of the Adventist Health System, turned around a middling response to strokes presenting in their EDs under the direction of a “tele-neurologist” 200 miles away, says Maryann Fields, who directs the group’s neuroscience program.
At facilities in Daytona Beach, DeLand, Palm Coast and Orange City, a remote specialist can be on the two-way video screen at the bedside within five minutes, to “see” and size up the situation—an improvement over trying to get the local neurologist on call to phone in and have the situation described to the best of the emergency physician’s ability. The tele-neurologist can view stat lab results and diagnostic images as soon as they’re available, and the resulting diagnosis sends the hospital stroke team’s response into overdrive—for example, a dash to start the blood thinner tPA intravenously.
Since the tele-neurologist group came aboard, the “door-to-needle” time has been shortened by 30 to 60 percent, depending on the hospital. Two of the hospitals have it down to 38 minutes, and all facilities are averaging less than an hour, the standard for best practices in stroke response, says Fields.
Spending on information technology for population health management predictably has been concentrated on the 20 percent or so that are the sickest and use the most healthcare resources. But what about that remaining 80 percent? Problems around convenient access to care can turn into significant use of costly services if it affects a large segment of a covered population, says Kasinadhuni.
After Stanford Health Care launched an ACO and associated health plan in 2014, plan data showed that people 18 to 45 years old weren’t selecting primary-care physicians; instead, they were going to EDs and urgent care when they needed to see a care provider.
In focus groups, plan members in this age group said they would love to have a primary-care doctor, but many practices either weren’t accepting new patients or they weren’t available at their patients’ convenience, says Sumbul Desai, MD, associate chief medical officer of Stanford Hospital and Clinic.
That problem prompted an initiative to offer virtual primary-care visits. It wasn’t a solution by itself, because patients wanted to see a doctor in person at their option, as well as have the convenience of using other options, such as a phone call or video visit, says Desai. Stanford devised a “bricks and clicks” approach, a telemedicine operation at a practice that also saw patients in person.
About 2,000 patients have taken the offer to use the virtual option, called Clickwell Care, as their principal primary care provider. For the 5,500 visits they logged—more than half scheduled the same day they were requested—25 percent were by video, 32 percent by phone and 43 percent in person. Sometimes a physician will request a video visit, in situations where it can yield information that a phone call can’t, says Desai. Other times, the patient will opt for video because he or she wants to better develop a doctor-patient relationship.
Although the program has increased primary-care visits and practice revenue, the purpose of telemedicine was not to increase utilization but rather to engage a population that was not currently getting care, to induce interactions that will prevent downstream costs by catching rising health risks early, Desai explains.
Telemedicine initiatives typically are hatched to make existing healthcare activities more accessible and spread specialty coverage, but the rising importance of certain types of care only now becoming essential to an overall continuum of care—from behavioral health and home care to post-acute care—create opportunity for video over distance to make an impact.
More is expected, for example, from a relatively thin clinical staff at skilled nursing facilities as they serve both long-stay, frail residents and short-term residents recovering from a hospital stay. Hospitals are incentivized to intervene in nursing home incidents that lead to readmissions, to avoid CMS penalties as well as be accountable for attributed panels of individuals. Health systems have moved into the SNF environment to improve responses to medical episodes and clinical decisionmaking.
Other telemedicine moves into post-acute care can be thorny. In the CMS payment bundle for joint replacement, rehabilitation therapy is pivotal, but Medicare is “loathe to cover it,” says Capistrant. It enables a surgeon to follow up on a patient by video, but it doesn’t cover the physical therapist, who can keep a close eye on recovery milestones while directing post-op exercises by video and monitoring via home-based devices, he says. “There are huge opportunities for Medicare that they are letting pass by.”
Telemedicine is also the answer for bringing mental health and substance abuse treatment to more of those who need it. Psychiatrists are hard to come by, even for top academic medical centers, says Capistrant, and it’s much worse in the average health community. “If you need a psychiatrist that specializes in adolescent substance abuse and uses sign language—good luck. But technology provides a way to make that much more available.”