They’ve tried the technology and tested the workloads. Now that telehealth is here to stay, providers are looking closely at what telehealth strategies do and not work for them.
September 14, 2020 – With the onset of the coronavirus pandemic in March, healthcare providers across the country launched or expanded telehealth platforms with the goal of moving as much care as possible into the virtual realm.
Half a year later, the pendulum is swinging back in the other direction, with access to in-person care on the rise and telehealth visits declining. But while some critics suggest the shift marks a death knell for virtual care, others feel the healthcare industry is just looking for firm footing in an uncertain landscape. Providers are sifting through changing patient demands and a still-uncertain payer landscape to find out what can – and should – be done via telehealth and what still needs to be done in person.
The variable in the equation is reimbursement. With the COVID-19 crisis creating a public health emergency, federal and state regulators issued a string of directives aimed at expanding telehealth coverage. They opened the door to new types of care providers and services, and added coverage for new modalities, such as the audio-only phone, but only for as long as the nation is in a public health emergency.
Since then, CMS has come out with its proposed 2021 Physician Fee Schedule, a document that includes new and expanded coverage for connected health programs and the potential for further expansion if public comments prove persuasive. HHS is also on the hook, with an executive order from President Donald Trump that calls on the department to push new telehealth services to address rural access issues.
And then there’s Congress, which is faced with dozens of telehealth bills and an unwritten mandate to legislate long-term telehealth expansion.
Some states, like Colorado and New Hampshire, have already taken steps to make their temporary rules permanent, while others are moving toward extending coverage for a limited amount of time or waiting for the feds to take action.
Amid this uncertainty, health systems, hospitals, clinics and small practices are taking stock of what they’ve been able to do with telehealth and planning for the future.
Here are just a few examples of telehealth strategies moving beyond the COVID-19 pandemic.
The Oklahoma-based, two-campus hospital complex had one telemedicine platform for clinic visits and post-operative services prior to the pandemic, says Bryce Ell, who took over as manager of the network’s telehealth services just as the public health emergency hit. Realizing they had to shift as many of their services onto a virtual care platform, they trained and on-boarded close to 200 providers in just 72 hours.
“Everyone wanted access to telemedicine at once,” says Ell. “They knew what was happening and they wanted to be able to handle (that shift in care).”
Ell sees this shift as being as much mental as physical. Many providers were hesitant to embrace telehealth at first – until they were, in essence, forced to try it out. Now that they’ve had a chance to use the platform for a while, they’re comfortable with the process.
“It’s gotten to the point that, any opportunity we have to grow the service line, we’re taking the opportunity,” says Ell, noting the health system is now launching virtual platforms for breastfeeding and treatment of sleep disorders. “People are starting to realize that telemedicine is an effective means of improving access to care.”
Along with many other health systems, Norman Regional is now setting its sights on remote patient monitoring.
“It’s gotten to the point that, any opportunity we have to grow the service line, we’re taking the opportunity.”
Ell says the health system developed a platform to monitor “high-risk, high utilizing patients where they live, work and play,” to reduce their chances of becoming infected with COVID-19. The service has also proven useful in isolating those with the virus who are able to receive care at home, and in continuing care management for people who’ve been discharged from the hospital.
“Everyone has been looking at remote patient monitoring in light of COVID-19,” he says. “It’s something that is new to healthcare, and I think that we’ll find more advantages to using it as we explore ways to deliver population-based care.”
As with the initial rush to go online, Ell says the health system’s care providers have to adjust to a new way of delivering care, and find a comfort level. This includes understanding what can and can’t be done on a telehealth platform and what needs to be done in person.
“Where does the provider feel comfortable making the best clinical decisions for the patient?” he asks. “For some, it’s a completely different way to view healthcare, and it takes time to adjust. Our patients have to adjust to this as well, so we aren’t rushing anything.”
A 49-bed acute care hospital in southeastern Minnesota, Winona Health has been building up its virtual care capabilities for several years. Roughly a year ago the hospital integrated the Bright.md platform for asynchronous direct-to-consumer telehealth services.
When the COVID-19 crisis hit, the hospital added a screening module to its direct-to-consumer (DTC) platform, then looped in a video visit platform to improve care for its high-risk patients.
Those additions were certainly helpful, but CEO Rachelle Schultz says they have to be careful not to rely too much on telehealth.
“This technology is certainly something that needs to be integrated into an entire care system, but it’s not going to replace face-to-face care,” she says. When the initial crisis passed and the hospital was able to schedule in-person visits again, many patients “were quick to drop that and say ‘I want to come in for an appointment.’”
Schultz says the pandemic put the pressure on federal and state regulators and payers to accept that telehealth has value, and to reduce some of the barriers that have kept hospitals and health systems – particularly small and rural ones – from adopting virtual care.
“They kind of dropped those barriers when COVID hit,” she says, and everyone jumped on board.
Now providers are struggling to find out what they can keep in place when the emergency ends, and how they can integrate connected health with in-person care.
The pandemic “gave us a broad opening and acceptance that we need to find ways to connect with patients” outside the hospital, Schultz says. “I think this is just the beginning of things … but we have to be careful to understand what the community needs.”
Therein lies the challenge, and the reason telehealth visits are dropping. Providers who went all in to deal with the pandemic often did so without having any plan for long-term growth or sustainability. Now they’re finding that some of these services can’t be maintained, while others might not even be improving care outcomes or reducing provider workloads.
Schultz says Winona Health is taking things slowly, introducing new telehealth services in tiers, with an eye toward access and affordability. DTC and video-based telehealth services are in place now, and the health system is looking at remote patient monitoring and specialist consults. But just because it worked during the pandemic doesn’t mean it’s good to go for the long run.
“We keep practicing to teach ourselves,” she says. “And we’re learning as we go on.”
Based in Trenton, NJ, the four-site federally qualified health center weathered one of the earlier COVID-19 waves, and went all-virtual (except for one emergency care site) in two weeks.
“We were very aggressive in making sure we were problem-solving as we went along,” says Lee Ruszczyk, the practice’s senior director of behavioral health. “We didn’t really have a whole lot of expectations because it came up so suddenly. It was a safety issue for everyone involved, so there was no room for negotiation.”
Ruszczyk says telehealth “was something that we always wanted to do,” and the health center had added virtual care programs in dribs and drabs as time and resources permitted. But COVID-19 changed that routine.
“We didn’t have the processes in place, but we learned quickly,” he says. “You don’t know what you don’t know until you start to do it.”
Now they’re facing a new crisis: a surge of people needing behavioral health services because of the pandemic, and struggling to connect with care providers in a virtual setting instead of the clinic or doctor’s office.
“I’m very concerned with the trauma aspect,” Ruszczyk says. “This will escalate just due to the things that were open but that no longer exist.”
“You don’t know what you don’t know until you start to do it.”
“People need stability to process what’s going on, and they’re not getting that right now,” he adds. “I think we’ve only seen the tip of the iceberg so far.”
With a telehealth platform in place, the health center is focusing on quick contact to assess each patient’s needs and develop a care management plan. That attention pulls in many patients who are typically ambivalent about healthcare, and the center has seen its no-show rate drop from about 50 percent to 20 percent.
Once patients are engaged, Ruszczyk says, they’re more likely to take an interest in their care. Telehealth gives the center an opportunity to create and enhance that engagement with frequent touches, pushing information that patients need and can react to when and where they feel like doing so.
Ruszczyk expects that the health center will develop a hybrid telehealth platform in time, balancing telehealth with in-person visits. He wants to expand the platform to feature virtual group therapy, and would like to see standards and reimbursement for phone calls. Any channel that enables patients and providers to connect on care should be explored.
But like the patients they serve, the health center is also struggling.
“Part of what we do (in the future) will be driven by reimbursement,” he says, noting they’re the only FQHC in the city. “We need to be able to create access (for patients) without barriers. We can’t make it any harder than it already is.”
In Maine’s Lewiston-Auburn region, the three-hospital Central Maine Healthcare system had developed a limited but steadily growing telehealth platform on the Innovaccer platform, serving a rural population “in very focused ways,” says CMIO Stephen Martel. The key uses had been for telestroke services, emergency department and NICU consults, and interpreter services.
COVID-19 opened the doors for the health system to expand its triage services. While Maine hadn’t seen a surge in cases like other states to the south, the fear level was high.
“There was a lot of uncertainty around in-person care, so we started by curtailing elective visits,” Martel says. “Our first steps were to get phone visits up and running, followed shortly by video visits. We needed (a platform) that was reliable and very easy to use.”
Martel says emergency measures by state and federal governments to reduce barriers and boost coverage for telehealth “really is the key driver for organizations moving quickly into the space.” In many cases, they set up their services quickly and do what needs to be done, and save the long-term planning for later.
“We did what we needed to do, and I’ve been surprised by how much our patients and staff have enjoyed” telehealth, he says.
Like any rural state, the set-up had its issues. Martel says the health system had to quickly create a questionnaire that would enable them to determine whether a patient had the internet connectivity to handle video visits – and the digital health know-how to set things up. Neither was a given, and in many cases staff had to help patients make that connection.
How Central Maine Healthcare expands its telehealth platform in the future will, like so many others, depend on how telehealth laws are amended to improve coverage after the pandemic.
“This has been a very effective introduction of an alternative to in-person visits,” Martel says. “But a large part of where we go with this is going to depend upon what the government decides to do,” he says. “The economics just don’t make sense to use it in a widespread way.”
For now, the health system is using its platform to facilitate primary and specialty care, and they’re collaborating with other health systems in the state to improve community and population health efforts and facilitate hand-offs.
“We’ve now seen that there will always be a place for telehealth,” Martel says. “The question is ‘What is that place?’”
Cancer care management is a grueling process. Aside from the surgeries and chemotherapy, there’s a lot of back-and-forth between patients and care teams over daily health and wellness routines, medication management and care coordination.
“You’re having conversations all the time about treatment and prognosis,” says Michael Choti, MD, MBA, FACS, chief of surgical oncology at the Gilbert, Arizona-based center, a collaboration between the multi-state Banner Health network and Houston-based University of Texas at MD Anderson Cancer Center.
Choti says the coronavirus pandemic was a catalyst for the center’s move to a virtual platform, giving them the nudge to do something they’d been considering for a while.
For the center, telehealth serves two distinct purposes. First, it helps to reduce chances of infection for a patient population that has already been through enough, and which is at heightened risk. Second, it gives providers the opportunity to push specialist consults, care management and family conversations and pre- and post-operative check-ups online, reducing time and travel and giving patients a chance to spend more time at home.
“The value proposition of these technologies goes far beyond COVID,” says Choti. “The physical (effort) of coming to and going from a hospital or a clinic is extremely expensive and also very uncomfortable for the patient.”
“The care is better in many respects just by reducing the frequency of visits,” he adds. “I can see someone every day or every week if I need to (rather than waiting for that patient to come into the office). When I see them more often, I get a better idea of (their care) and I can identify any problems earlier.”
“The value proposition of these technologies goes far beyond COVID.”
Prior to the pandemic, “there was never enough value proposition to develop the infrastructure” for telehealth, so most of the contact between doctor and patient was done in-person. With the pandemic came emergency measures that reduced those barriers, giving the clinic more opportunities to set up and try out different telemedicine services.
“We’ve learned a lot over the past few months,” Choti says. “We know that the telephone is … a significantly better interaction for certain things, but it’s not the only tool. The technology … now gives us a chance to have a really robust encounter.”
Choti has questions about how they’ll use telehealth once the emergency is over. He doesn’t know how the different types of encounters can be defined for billing, and roughly one out of every four patients doesn’t have the internet connectivity, technology or knowledge of how to use it to handle a telehealth encounter at home.
And while a virtual visit can replicate certain tasks and visits, in others it’s better to have patient and provider together in the same place, particularly when dealing with difficult conversations and sensitive issues.
“There is a time and a place” for virtual care, he says. “Now that we’ve had a chance to use it, we have to figure that out.”