Hospital executives are planning for how they can sustain telehealth momentum from the COVID-19 pandemic and build the practice into their future care delivery strategies.
Patient visits conducted via video or phone could account for between 10% to 30% of total visits after the COVID-19 pandemic subsides, according to healthcare executives and analysts. But to achieve that, hospitals will need to fine-tune the patient experience, improve training and trouble-shooting resources for clinicians, and figure out payment challenges.
"The technology part of this is sophisticated, but the really hard part is the human factors," said Dr. Arthur Southam, executive vice president of health plan operations and chief growth officer at Oakland, Calif.-based Kaiser Permanente. "How do you make the telehealth experience—the waiting room, and the start, and the finish—a really good consumer and clinician experience?"
Even before the pandemic, Kaiser had a relatively large telehealth presence, with about 15% of scheduled outpatient visits conducted virtually.
That figure shot up to 80% in the early spring; it has since settled at around 50%. Kaiser obtains much of its revenue from its prepaid membership model, Southam said, which helped weather the pandemic as the organization doesn't rely on fee-for-service payments and procedure volumes as heavily as other health systems do.
"We're very bullish on the potential for digital and telehealth services to complement what we do in person-to-person services," Southam said.
In the future, he expects 40% to 50% of Kaiser's outpatient visits to be completed via telehealth.
Nationwide, telehealth visits accounted for nearly 20% of physician visits in early December—down from 50% in April, but still significantly higher than the less than 1% adoption seen before the pandemic, according to an analysis the Chartis Group and Kythera Labs published based on claims data from commercial payers and Medicare Advantage health plans.
The 20% figure is also trending up from early fall 2020—when telehealth utilization had seemingly plateaued at around 15% of total visits.
On a weekly basis, MedStar Health in Columbia, Md., has been conducting between 10,000 to 12,000 of its scheduled visits directly to patients at home via telehealth, a stark increase from the fewer than 100 visits delivered that way cumulatively in the first few weeks of 2020, before the onset of COVID-19 in March.
"Where (telehealth utilization) settles out is still an open question," said Dr. Ethan Booker, medical director of the MedStar Telehealth Innovation Center and MedStar eVisit. "I don't think it's going to go back to the pre-pandemic levels … patients have come to expect the convenience and accessibility of it."
Forty-one percent of U.S. patients indicated they would prefer to use telehealth to meet with at least one of their providers after the pandemic, according to a report from the Healthcare Information and Management Systems Society. Seventy-seven percent said they would be willing to use telehealth.
And roughly one-third of patients who received remote care during the COVID-19 pandemic said they expect to seek care digitally again in the future, according to report from market research firm Forrester.
In the report, Forrester predicted that virtual care will surpass 440 million visits in 2021, down from 2020, which is on track to hit 481 million visits.
"At this point, virtual care is table stakes—it's no longer a way of offering competitive advantage," said Arielle Trzcinski, a senior analyst at Forrester who co-authored the report.
Not just a tech project
Health systems trying to differentiate their telehealth offerings will have to work on improving the patient experience during a telehealth visit, rather than just the basics of setting up a virtual care service, Trzcinski said.
That could include working to reduce the time patients have to spend navigating a patient portal, downloading a separate app, or staring at a blank screen in a virtual waiting room before their visit, as well as consolidating telehealth programs across service lines so patients know what to expect organization-wide.
There's an "opportunity to reimagine that (patient) experience," Trzcinski said. "What could this experience look like? What should it look like?"
Patient experience is an area St. Louis-based Ascension is working to streamline, according to Dr. Joe Cacchione, the system's executive vice president of clinical and network services.
There are a few ways patients can access video visits today, such as through Ascension's mobile app, but Cacchione said Ascension is working to roll out a program that would send patients a message with a hyperlink before an appointment, which they would press for one-click access to their virtual visit.
"We've got to make it simple for the patients," Cacchione said. "Too many clicks, log-ins, passwords—those things aren't going to work long-term."
About 10% to 20% of all patient visits at Ascension are being conducted through telehealth today, depending on the market.
In the six months before March 2020, Ascension had conducted roughly 5,000 to 6,000 telehealth visits in total—a "fraction of a percent" of the system's overall visits, Cacchione said.
In the short term, Cacchione expects the proportion of visits conducted via telehealth at the system to "settle out" at around 10%. But he envisions that figure could grow over time, particularly for follow-up visits for specialty and primary care, as patients continue to become more familiar with the technology and as "we make it more efficient to have a virtual visit."
And patients aren't the only end-users on a telehealth visit. Health system executives need to ensure clinicians have a user-friendly experience during the encounter, too.
Before the pandemic, Renton, Wash.-based Providence had already established a team of coding, engineering and nursing staff to help train and field questions from clinicians interested in adding telehealth services. That internal consulting service became crucial in the wake of COVID-19 as a place for clinicians to reach out with questions about billing, technology and workflow.
Telehealth is "way more complicated than just, 'Hey, we'll FaceTime and do a video visit,' " said Dr. Todd Czartoski, chief medical technology officer at Providence.
The health system completed 70,000 video visits in 2019, most of which were connecting to people at other healthcare facilities for specialty care. In mid-April of 2020, that jumped to roughly 70,000 video visits per week, many of which involved clinics connecting directly to a patient at their home amid stay-at-home orders.
About 20% of clinic visits at Providence are still being completed through telehealth.
Czartoski said he's not sure what proportion of visits will remain virtual after the pandemic. "It's going to depend on regulatory and payment structures," he said. "If CMS stops allowing home visits with the lifting of the public health emergency, the visit numbers will drop."
Getting paid
Health systems in fee-for-service payment models are largely reliant on decisions from private and public payers for whether—and how much—they will be reimbursed for care delivered via telehealth.
Medicare, for the most part, doesn't reimburse for telehealth services that patients receive at home.
While some insurers waived fees and restrictions on telehealth because of COVID-19, they haven't committed to doing so after the pandemic subsides.
Many health system executives hope that will change. At the same time, they note that the industry's movement toward value-based care and at-risk contracts could also support telehealth reimbursement.
"We'll continue to make investments in the infrastructure for being successful delivering telehealth," such as working to more closely integrate telehealth with the electronic health record system, said MedStar's Booker. "We fully expect the reimbursement environment will continue to shift."
Some patients expect telehealth to cost less than in-person care, too. Forty-nine percent of patients said they would expect out-of-pocket expenses for a video visit with their established provider to cost less than an in-person visit, while 37% said they expected it to cost the same, according to the report from HIMSS.
A virtual visit tends to generate between two-thirds to three-quarters of the revenue of the comparative in-person visit, according to Ascension's Cacchione. It's not that they get paid less for the same tasks, he explained, but "oftentimes, we'll do an (electrocardiogram) in the office, we'll do a blood draw—there will be some other code that's billed for."
To account for that, hospitals will have to retool processes to ensure they capture patients following up on-site after a virtual visit, as well as ensure that information is sent back to the ordering physician.
"It's just going to be part of the normal workflow going forward as we see more and more people virtually," Cacchione said.
Even if telehealth accounts for less revenue than in-person visits, it's going to be necessary for most health systems to have virtual care in place and build it into their business model. As more patients expect to see telehealth as an option, they may start seeking out virtual care at other organizations in lieu of in-person care with their current provider and may even choose to leave health systems that don't regularly offer video visits.
Health system executives working to build out sustainable telehealth programs need to ensure there's "clear, quantifiable return on investment," considering money spent alongside money saved, improved patient outcomes and possible new patients drawn in by the virtual care offering, said Tom Kiesau, leader of the digital transformation unit at the Chartis Group.
Providers "see consumers wanting (telehealth)," Kiesau added. "If they don't provide it, someone else will."
