Using Telehealth to Advance Value-Based Care

A man was admitted to the hospital repeatedly with heart failure. After the third or fourth visit, his physician wondered what was going on. The patient connected with his cardiologist through a video appointment, recalled Robert Pearl, M.D., executive director and CEO of The Permanente Medical Group, who heard the story from a colleague. “The physician said, 'Let's walk into your kitchen,' and immediately saw bags of potato chips on the counter. 'That's what's causing your readmissions,'” the cardiologist said.

Video visits like these are helping providers personalize care for patients and are a prime example of how telehealth is expanding access, driving down costs and improving engagement—all tenets of the shift toward value-based care. In fact, meeting the goals of value-based care is one of the top three drivers pushing providers to adopt telemedicine, according to a 2016 Avizia/Modern Healthcare Custom Media survey of healthcare executives.

While telehealth is a broad-ranging term that encompasses email consults, activity-tracking wristbands and mobile apps, clinician-patient video visits stand out in popularity. Sixty-four percent of Americans would be willing to have a video visit with their doctor, according to the 2015 American Well Telemedicine Consumer Survey.

“Video visits give us the opportunity to bring in the best experts, which helps drive quality,” Pearl said.

The primary draw for video visits is increased access to services. Patients typically can sit at home and talk to their doctors through computers, tablets or smartphones. Healthcare providers, in turn, can observe physical ailments, from skin rashes to post-operative wounds, effectively expanding a patient's access to healthcare to anywhere.

“With telehealth, we are extending the access to the physician from any location, and patients don't have to travel,” said Peter Antall, M.D., the chief medical officer of Boston-based American Well, which provides software and other services in support of telehealth programs. “When patients have minor concerns, about 90 percent of them don't need an in-person visit. There are some who believe every patient should have a full exam, but the reality is that's not practical.”

Indeed, telemedicine has some of the highest adoption in some of the nation's most remote areas: The three states with the highest telemedicine adoption rates are Alaska (75%), Arkansas (71%), and South Dakota (70%), according to the Center for Connected Health.

While there's a wide range of how reimbursement for telemedicine is handled, payers will inevitably get more comfortable paying for these types of services as they become a larger part of our healthcare delivery system, said Dan Bensimhon, M.D., the founder and CEO of MLS Telehealth, a staffing company based in Greensboro, N.C. Regardless, telehealth is seen as a tool to bring down costs for both patients and providers.

A lot of health systems will provide telehealth as a service, because it expands their service area, improves the quality of care, and prevents patients from coming to the emergency room for non-emergent issues. Others offer it as a benefit to their employees, because telehealth is often the lower-cost solution.

Payers also embrace telemedicine for specialist visits, said Patrick Tellez, CMO of North County Health Services in San Diego, Calif. “Provider coverage of this service will enable primary care providers and specialists to collaborate to benefit many patients in the primary care setting,” he said. “E-consulting offers a readily available solution to enhance specialty care access, and improved service to members, yet lowers the frequency with which face-to-face specialty care visits are needed.”

With Jeff Connect, the telemedicine program used at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, most video visits are $49, which is sometimes the responsibility of the patient, but can often be billed to insurance. “If part of the telehealth visit is covered under bundled care, it may not be billed and it may be free,” said Judd Hollander, M.D., associate dean for strategic health initiatives, professor and vice chair of finances and healthcare enterprises in the department of emergency medicine.

This predictable cost is appealing to consumers who are skeptical and afraid of the unknown when it comes to medical expenses. Sixty-two percent of Americans believe that online visits with a doctor should cost less than in-person care, according to the American Well survey.

Driving down costs can be equally as important as saving time, as is the case with post-surgery video visits.

For thoracic surgeons at the University of Maryland Medical System, a nurse practitioner and a patient will conduct a telemedicine visit 24 hours after the patient goes home. “The NP will see the wound, and it saves

patients from running back in,” said Marc T. Zubrow, M.D., vice president for telemedicine and medical director of eCare at the system. “You can reassure a patient that it is healing as it should, or you can take care of a problem sooner—a patient might be hemorrhaging and doesn't realize it's a problem.”

Reducing wasted time—taking off from work, traveling to and from a medical office, and waiting to be seen—may be telehealth's strongest benefit.

“The best thing about video is that it's immediate,” said Pearl. “Rather than patients having to schedule a visit for a future date, they can be seen, evaluated, and treated immediately for a range of medical problems.”

The public is fully embracing telemedicine, several experts say, and many patients prefer to simply interact with their physicians digitally.

“I think the younger generation has embraced social media and technology as a form of communication, and they don't miss the interpersonal element of in-person medicine,” Zubrow said. “As the younger generation of physicians continues to grow and mature, any resistance to telehealth will eventually go away.”

Meeting patient and consumer demand for healthcare services is, in fact, the primary reason that providers are adopting telehealth technologies, with 72% of healthcare executives pointing to this as a driver of their adoption, according to the 2016 Avizia/Modern Healthcare Custom Media survey. Additional key drivers include improving clinical outcomes (66%) and increasing patient engagement (49%).

“I think the person willing to get on the phone and work through a Skype program is probably more apt to want to be more involved in their own health,” said Ronald A. Navarro, M.D., the regional coordinating chief of orthopedic surgery at Southern California Permanente Medical Group based in Harbor City, Calif. He has used used the RespondWell Zimmer telerehabilitation technology to remotely help patients with physical therapy exercise post hip- and knee-replacement surgery.

Of course, different health problems require different approaches, but for many, telehealth is preferred. “Persistent

fevers, chest pain, unrelenting belly pain, and low blood pressure—we would never handle those with telehealth,” Bensimhon said. “But with a sore throat, rash, sinusitis, we can easily handle through telehealth.”