Virtual visits outside of the hospital fueled telehealth growth

When a Mount Sinai Health System patient had to go to the emergency department for what turned out to be a stomach virus, Dr. Bruce Darrow followed up with him by video to ensure that it wasn't a heart issue.

The patient, who had a history of heart problems, felt and looked great two days after he was discharged, the cardiologist and chief medical information officer at New York City-based Mount Sinai said.

"He did not have to take a half day off of work and could do that from the comfort of his own desk," said Darrow, adding that he was able to verify the patient's medication adherence and check any lingering or new symptoms. "For him, you could argue he had a better visit with a doctor by not going to a doctor."

These types of virtual visits are becoming much more frequent, new data show. Discharge-related telehealth consultations saw the second-most growth among all commercial insurance claims for telehealth, according to Fair Health, which analyzed its database of 28 billion claims, the largest repository in the country.

Non-hospital-based telehealth fueled the surge in the burgeoning technology's growth, rising 1,393% from 2014 to 2018, according to Fair Health's new white paper. These types of virtual consultations or remote monitoring that occurs between providers and patients outside of the hospital made up 84% of all telehealth claim lines, compared to 52% in 2014. Most of those encounters were in urban areas.

Advocates argue that telehealth is poised to bend the cost curve by improving treatment adherence particularly for those with chronic conditions, boosting access and reducing utilization of more expensive care settings.

"Telehealth can reduce utilization of the ER, which is high cost," said Fair Health President Robin Gelburd. It also may comfort people, knowing they have a more convenient and affordable option, she added.

But notably, telehealth outside of the hospital is still only being used on average 1 out of every 1,000 visits, or 0.104% of all medical claims, looking at Fair Health's raw data. Use is rapidly expanding but it started from an extremely low baseline of 0.007% in 2014.

Telehealth overall grew 624% from 0.0192% of all commercial insurance claims in 2014 to 0.1394% in 2018. The most common recipients of telehealth services were individuals ages 31 to 40 and nearly two-thirds were female.

"What that age cohort is showing is that telehealth is really becoming part of the front lines of primary care," Gelburd said. "And telehealth is providing a means of access to care that may be challenging for someone who may be working full time."

The top three reasons individuals sought treatment from a provider via non-hospital-based telehealth were acute upper respiratory infections, mood disorders, and anxiety and other nonpsychotic mental disorders.

"It is sometimes challenging to get behavioral health services to as many patients as would benefit from them," Darrow said. "Being able to bring down barriers to access associated with transportation becomes really valuable."

Drilling down into telehealth that's used after patients were discharged to monitor treatment adherence, for instance, shows most claims were for individuals age 51 and older.

The most common condition associated with patients who visited a provider in-person within 15 days of a telehealth session was heart failure.

For initial valuations, Darrow said he prefers to examine someone in person so he can feel a pulse, listen to the heart and form a connection. But for follow-ups, if the cardiologist needs to check in to potentially adjust medication for high cholesterol or blood pressure and ensure they are using an at-home blood pressure machine correctly, a virtual consultation is often a viable and more convenient option, he said.

"That would be a use case where the value of a patient spending 45 minutes on a subway and 20 minutes in the waiting room so they can spend six minutes in the office talking to me is somewhat limited," Darrow said.

For primary-care physicians, Darrow said, it may be entirely suitable to connect via video to check out a rash and determine whether an in-person visit is necessary. Likewise for a surgeon, a follow-up shortly after a patient is discharged might be appropriate to do by video if someone is having an uncomplicated recovery, he said.

Mount Sinai also digitally consults with other providers, Darrow added, although that practice is not widely utilized across the country, according to Fair Health data.

Meanwhile, both federal and state governments continue to loosen telehealth reimbursement restrictions.

"Medicare is starting to recognize the importance of telehealth as are health plans that are including telehealth providers in their network," Gelburd said. "In addition to the technical means to allow these exchanges, the challenges are how do you ensure telehealth encounters are integrated into the total healthcare model to optimize efficiency and reduce redundancies."

Forty states and Washington, D.C., have adopted substantive policies to expand telehealth coverage and reimbursement since 2017, a related study from the American Telemedicine Association found. Meanwhile, 36 states and D.C. have parity policies that require commercial insurers to cover telehealth and 21 states and D.C. have coverage parity policies for Medicaid. But only 16 states mandate that insurers' payments match in-person visits compared with 28 states for Medicaid.

Parity laws are an important step in the right direction, but not the full answer, Darrow said. Parity laws say that the insurer has to pay for a telehealth visit, but it doesn't say it has to pay all providers that offer one, he said.

"Insurers can decide how narrow they want their coverage networks," Darrow said. "The more agreement there is between what services are covered and who covers them between Medicare and Medicaid and commercial insurance, the simpler it will be for doctors to provide this service and for patients to get this service."