How do providers strike the right balance between in-person care and telehealth?
While telehealth usage exploded early in the pandemic, in-person care is resuming to normal levels. For many healthcare decision-makers and providers, questions loom about how best to balance these care modalities moving forward, so as not to lose the benefits of telehealth while understanding its limitations.
Healthcare IT News interviewed Sean Cavanaugh, who serves as the chief policy officer and chief commercial officer at Aledade, whose technology offerings include population health and telemedicine. Cavanaugh previously has served as the deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services and as deputy director for programs and policy in the Center for Medicare & Medicaid Innovation.
Cavanaugh discusses where healthcare is today with telemedicine, how providers can find the right mix of in-person care and telehealth, and what role value-based care can play in the future of virtual care.
Q: While telehealth usage has exploded during the COVID-19 pandemic, in-person care has started to come back. What is happening in healthcare at this unique moment?
A: It's pretty incredible to think about the fact that, as recently as 2016, only a quarter of 1% of all Medicare beneficiaries used a single telehealth service in a year. But, between mid-March and mid-June of 2020, telehealth use in Medicare skyrocketed to more than 20% of beneficiaries, with more than nine million Medicare beneficiaries using a telehealth service in that time.
Primary care practices were using telehealth for as much as 50% of all visits during the height of the pandemic. It's incredibly clear that the necessity to keep people safe, cared for and at home paired with the Center for Medicare & Medicaid Services' quick action to loosen many of the existing restrictions around telehealth led to an explosion of virtual services like we've never seen before.
Now, as vaccine distribution continues to ramp up, and more appointments are available for in-person care, we've seen the pendulum shifting back toward more in-person care delivery. This makes sense, particularly in cases where patients delayed necessary care because of the pandemic. At the same time, we should not take this as a sign to go "back to normal" when it comes to telehealth.
"It's clear that we can't go back to a system in which virtually no one could use or access telehealth services."
Sean Cavanaugh, Aledade
It's clear that we can't go back to a system in which virtually no one could use or access telehealth services. But at the same time, we'll need to be thoughtful about the best way to create a hybrid model moving forward, so that we can reap all the true benefits telehealth can offer without creating a new piston in the fee-for-service utilization engine or overwhelming our providers.
Q: Providers proved they can optimize workflows and deliver quality care via telehealth. And, prior to the pandemic, providers had optimized their ability to provide in-person care. But many are struggling to find and implement the optimal mix of telehealth and in-person care. How do workflows fit in here, and what do providers need to do?
A: Even before the pandemic, providers were reporting historic levels of burnout, and the added stress caused by COVID has only exacerbated this crisis. COVID caused them to change nearly everything about their workflows – adding PPE requirements, shifting intake procedures and pivoting to providing care via telehealth.
As we move into a future hybrid model, we need to make sure that we're right-sizing the telehealth component so that we are not just layering an additional burden on top of already overwhelmed providers and their staffs. This is particularly important for small and independent practices who lack the administrative support and in-office capacity to simply double the amount of patient care they're providing every day.
For one, we need to help providers identify situations in which telehealth can actually fill a particular care gap, or in which a virtual visit can help improve outcomes. One great example is checking on patients transitioning home after a hospitalization to make sure they understand their post-op instructions and aren't having any complications that might otherwise result in a readmission.
Figuring out the best use cases will take good data and analysis. But it will also take shifting how we think about care delivery to focus more on the overall value, as opposed to focusing on individual services, like telehealth, as separate widgets.
Q: Is it possible value-based care offers better incentives for striking the right balance between in-person and telehealth care? What role should value-based care play?
A: I think value-based models offer the most promise for achieving a better balance of telehealth and in-person care as we look to the future beyond the height of COVID. These payment systems take into account the total cost of care for a patient, reward providers for keeping patients healthy and reducing wasteful spending, and are already designed to prevent overutilization.
In these systems, providers are incentivized to use telehealth as a complement to in-person care. Telehealth then becomes a powerful tool in the provider's toolbox for improving their overall patient outcomes. If used correctly, telehealth can actually extend providers' capabilities and can be hugely beneficial for reaching patients unable to come into the office.
Particularly as CMS grapples with whether to extend many of the telehealth restrictions that have been lifted during the state of emergency caused by the pandemic, it seems like a no-brainer that, at the very least, they should extend them in the context of value-based payment models designed to support the right-sizing of telehealth services.
Q: Telehealth has proven very popular with many patients. It does not seem like it will be going away. What do providers need to do with what appears to be the new normal of telemedicine?
A: There's no question that we'll continue to see demand for telehealth services now that patients have gotten more familiar with the technology, more comfortable interacting with their providers virtually, and have seen the convenience of being able to receive care in this way. This includes many older Americans and Americans with disabilities, for whom an in-person office visit requires a lot of effort and physical demand.
There's an opportunity here for policymakers. If consumers continue to demand telehealth services, and we embed greater telehealth flexibility exclusively in value-based models, we can help drive greater participation in these value-based models as providers seek to offer the services valued by their patients.
Providers who abandon telehealth and return to purely delivering care in-person are being short-sighted, and are going to face intense competition from many new actors in the market whose entire focus is delivering convenient, virtual care.
From an overall quality of care perspective, this worries me because those services can't be as coordinated with a patient's entire health journey as a longstanding primary care provider. Episodic convenience care will certainly continue to play a role, and can be hugely beneficial in certain circumstances, but I wouldn't want to see a model where primary care providers are only doing in-person care and these select virtual providers take over all telehealth.
Providers will need to communicate clearly with their patients about what services they are able to offer, but that will require clarity from CMS about payment rates and other policy changes that could impact whether doctors can afford to keep delivering telehealth.
We have a huge opportunity in this moment to create a better system that supports a balanced approach to telehealth, and we need to capitalize on it by designing a new future for telehealth that works for patients and providers.