On New Year’s Day, Massachusetts Governor Charlie Baker signed into law a healthcare reform bill that is a metaphor for the state of telehealth as we put 2020 in the rearview mirror. Telehealth advocates have plenty to be pleased with in the final legislation (see the American Telemedicine Association’s press statement here). The law requires that payers doing business in the state, including Medicaid, reimburse for behavioral telehealth visits the same way they cover in-person care and mandates rate parity for two years for primary and chronic illness management.
It seems like good news for the telehealth industry, right? It is, mostly, but sets up some potential administrative challenges. Providers make care decisions independent of insurance status. Ideally, that leads to more egalitarian care. But we also have concerns about direct billing patients for services that insurance doesn’t uniformly cover. Take my practice as an example. I think the new law will guarantee I can bill insurance for caring for an acne patient but not a patient with a new changing mole. We are not set up to parse patients in this way.
This is just one example of the betwixt and between state we find ourselves in concerning telehealth as we (finally!) kick off 2021. There is no doubt we are leaps and bounds ahead of where we were at the beginning of last year, but there is much critical work to be done in this next phase. Much of this revolves around the change in our healthcare delivery apparatus from a one channel (everything in the office) system to a two-channel or hybrid environment where telehealth co-exists with in-person care.
Here are some priorities to consider:
We need to create new roles. In one-channel healthcare delivery, when a patient requests an appointment with a provider, the provider’s office simply needs to find a time in his or her schedule for the patient to come to the office. The options offered by a hybrid system require different decision making. Is the patient appropriate for telehealth? Should the choice be one of convenience for the patient or guided by clinical criteria? I would argue strongly for the latter (see the use case discussion below). If so, the person scheduling the appointment needs either some clinical training and sound judgment skills or a very well thought out flow diagram to aid in decision making.
A second example is in my field of dermatology, where we ask patients to electronically submit images of their skin for review before our telehealth visits (the resolution of even HD video is not good enough for dermatologic diagnosis). We currently employ nurses to ensure that the images are of diagnostic quality. I would argue that a trained, non-clinical person could do this.
We need to define clinical use cases for telehealth. I see three broad categories – examples where telehealth is ideal (e.g., behavioral health); examples where in-person care is required (e.g., procedural work) and examples that could fit in either category depending on other variables (e.g., if the patient lives very far away, telehealth becomes more attractive). Which scenarios fit into these categories will vary by clinical specialty, possibly by practice, and maybe even at the individual practitioner level. I had hoped that each of the specialty societies would intuitively begin to work on this, but I have seen only spotty evidence of any effort.
We need to rethink how we use our brick-and-mortar facilities. I do my telehealth sessions every Tuesday afternoon from the comfort of my home office. In doing so, I consume much less institutional overhead than I do when I go to the office to see patients on Wednesdays. Most provider organizations are now doing 15% to 25% of their ambulatory activity via telehealth. The legislation noted above is an example of a trend that will likely sustain this mix. We need to rethink how we use our physical clinical space and how we plan for new facilities.
We need to tackle the disparities issue. Beyond advocating for universal broadband and continued reimbursement for audio-only telehealth (the latter appears to be in peril), we need an industry-wide approach to this glaring problem.
While the initial lockdown in early March was the stimulus that catapulted telehealth into both providers’ and patients’ everyday lexicon, it gave people a sense that we could render all care that way. That simplistic view has become a disadvantage as we get into the groove of two-channel delivery. Our best estimate is that telehealth usage will calibrate to around 15% to 20% of care delivery, striking an appropriate balance of in-person and virtual care. Now it is time to make telehealth a legitimate care delivery channel for the long haul by tackling policy, reimbursement, and implementation challenges in the new year.