As the federal government, via Medicare/Medicaid, and insurance companies strive to keep “heads out of beds” (e.g., patients managed into an outpatient setting [your doctor’s office] vs. inpatient/hospital settings), the need for more clinicians and better access to care grows unabated. In an effort to manage both increased demand (e.g., access) by patients and patients (appropriately) nudged into clinic settings, telehealth and its component pieces provide needed access to healthcare, possible cost savings, and, in many cases, improved continuity of care/care management via patient monitoring and adherence to treatment protocols.
Outpatient care, generally, is less costly to insurance companies and the federal government than hospital-based care. With increased demand in the healthcare system (e.g., more patients seeking care) and with hospitals now being penalized by Medicare for readmissions and extended patient lengths of stay, telehealth and its components furnish the opportunity to offer healthcare services remotely, provide convenience to patients and offer tools to manage doctor supply and patient demand.
While many use the terms telemedicine and telehealth interchangeably, broadly defined, and for the purposes of this article, telehealth consists of various remote care modalities including, but not limited to:
- telemedicine – remote “face-to-face” patient visits via video
- “store and forward” – where a patient visit occurs remotely, the interaction is recorded and the “visit” recording is forwarded to a clinician
- remote patient monitoring (RPM) – in which treatment protocols are deployed and patient adherence is tracked electronically
The benefits of telehealth include reduced “site” visits that enable access in doctors’ offices for “sicker” patients, continuity of care, and, in the case of remote patient monitoring, the management of prescribed care to ensure patient adherence (such as remote testing/reporting of A1C levels). Telehealth can provide triage and keep patients out of doctors’ offices for minor issues that might be handled remotely.
Telehealth can aid hospitals and doctors in better managing patients with chronic care conditions, ensuring that at risk patients are carefully monitored. For instance, the Cleveland Clinic recently deployed “…its first telehealth-equipped neurology step down unit to support constant monitoring of epilepsy and stroke patients' brain activity. [The] unit, which opened in July, provides specialty care for patients who are moved from the intensive care unit.”1 The unit has 17 private rooms and four epilepsy monitoring beds; each room is equipped with epilepsy monitoring units to track patient brain activity 24 hours a day. The unit also has video equipment to record body movements should a seizure occur.
Telemedicine
Narrowly, telemedicine involves a doctor/patient interaction via video (usually a computer or mobile device). These visits provide an electronic “face-to-face” encounter in which the doctor and patient can see each other, discuss issues and even share images (e.g., concurrently reviewing an x-ray or other diagnostic test results). With improved digital clarity and device computing power, these visits may suffice in lieu of an in-person visit for certain ailments. Provided good electronic bi-directional communication between doctor and patient, the visit can be seamless while offering patients the convenience of staying at home vs. fighting traffic, searching for parking and sitting in a crowded waiting room.
The Center for Connected Health Policy succinctly defines telemedicine: “Telemedicine is the use of medical information exchange from one site to another via electronic communications to improve patient’s health status. It is the use of two-way, real time interactive communication equipment to exchange the patient information from one site to another via an electronic communication system. This includes audio and video communications equipment.”2
Protocol/Payment
Telemedicine is managed differently in different states. There exists no one size fits all approach to the delivery of care and/or payment for services. For instance, some states, as part of a treatment protocol, require an initial in-person visit while others empower doctors to provide care remotely without actually physically engaging the patient at an initial in-person visit. There can also be limitations on the conditions and situations that are reviewable via telemedicine. Generally, the care offered via telemedicine depends on the state and their parameters and requirements. Some conditions like rashes, gastrointestinal issues, blood pressure, cough/colds, etc., may be readily addressable via telemedicine.
Relative to reimbursement (payment) for telemedicine services, some services are paid for and some are not. This is more of an insurance company issue than a state issue. In some states, there exists “telemedicine parity,” which means reimbursement from insurance companies for video telehealth services provided, whether live video, remote patient monitoring (RPM), or “store and forward” monitoring, should be reimbursed similarly to in-person visits. That is, if a physician performed a moderately complex telemedicine visit or had the patient in office for a moderately complex in-person visit, each service should be reimbursed at about the same rate, i.e., parity. That said, currently most insurance companies pay something for telemedicine services.
While telemedicine (and telehealth) provide expanded care in rural markets, those areas without broadband coverage can run into challenges implementing telehealth programs. Connectivity can depend on the technology infrastructure and service(s) provided.
Vis-à-vis the financial model’s return on investment, many items require consideration. There are fixed hardware costs, staffing, maybe 24/7 call coverage (depending on the disease state/modality offered), etc. On the revenue side, the question becomes what services are offered and the reimbursement rates for each service. Some telemedicine programs do not generate profit per encounter but instead may realize a financial upside via in-person follow-up care (if necessary) in the hospital’s “brick and mortar” building. Additionally, telemedicine may be an avenue for capturing, and keeping, patients within the health system.
In this ever-evolving care delivery modality, there are hucksters out there trying to defraud the system; an uncontrolled rollout of telehealth could lead to deleterious effects. For example, the CEO of a telehealth company recently defrauded Medicare of nearly $1.2 billion through a series of kickbacks and bribes in exchange for referrals and billing for items that were not medically necessary.3
Program management must be rigid and monitored lest billing compliance issues arise and/or patients fall through the care management cracks. Moreover, the reach of rural connectivity still poses a challenge, requiring health systems to investigate methods to reach underserved patient populations.
Telehealth and its component pieces continue to positively impact the delivery of care. This exciting technology can offer better patient access, better care management and financial returns if developed/deployed properly. With proper communication tools and a “wide pipe” to carry data, telehealth can aid rural communities in managing care and providing access to specialists that might otherwise have been difficult to connect with. As the technology evolves, its uses, processes, and payment methodologies will continue to develop. One hopes acceptance and reimbursement for telehealth services catch up with the technology.
1 Becker’s Hospital Review – Thursday, September 12, 2019
2 Center for Connected Health Policy
3 Telemedicine CEO pleads guilty to role in $424M Medicare fraud scheme, Fierce Healthcare (online), Sept 9, 2019
