While thinking about my keynote address at the 2021 American Telemedicine Association (ATA) annual conference, I kept coming back to Daniel Kahneman’s Nobel-prize-winning theory (his book is called Thinking Fast and Slow). This theory formed the basis for the field we now know as behavioral economics. What Kahneman describes as heuristics (pattern recognition or System I thinking) drives most of our day-to-day behaviors. System II thinking, by contrast, kicks in when we must learn something new or think carefully about any action we will take.
A year ago, when we met at ATA2020, the healthcare world was engulfed in System II thinking as we responded to the pandemic, and a big part of that was the rapid expansion of telehealth. Each sector of our industry had its challenges. Providers lost enormous sums due to decreased volume of in-hospital procedures. Payers maintained cash flow but grappled with how to control the emerging channel of provider-initiated telehealth. Suppliers worked to manage rapid escalation and scale.
A View from the mountain top
Last year at this time, telehealth was on the top of a mountain. From March to June of 2020, 30% of all outpatient activity was conducted via telehealth, in contrast to 0.8% in 2019. The virtual visit became a universally understood concept, and by all accounts, patients loved it. Here are a few snippets from a COVID-19 Healthcare Coalition survey (ATA is a member): 83% of patients reported overall high-quality visits, 78% said their virtual care visits were with their regular provider (I will come back to that theme), and over 75% said they would continue using telehealth for chronic disease management.
What happened between June of 2020 and where we find ourselves today? In short, we learned what a hybrid environment looks like.
Two-channel healthcare delivery
There has been a leveling off of telehealth nationally – to 50% or less of what it was at the height of the initial lockdown. According to the Commonwealth Fund, in April 2020, 14% of outpatient visits were telehealth, and that leveled off to 7% in August and has remained stable since. And, the Fair Health Telehealth Tracker found a dip in claims from 7% in January 2021 to 5.9% in February. Does ‘hybrid’ mean that telehealth is losing steam?
Here, I come back to Kahneman’s concept of System I thinking. Those of us in healthcare delivery are trained around several concepts that will create a magnetic pull back to in-person care as usual if we don’t actively plan otherwise. For example, as a dermatologist, if I care for an acne patient via telehealth, I’m inclined to offer them another telehealth visit for their follow-up care. Interestingly, if I see someone in the office who has acne, I am inclined to provide them with follow-up in the office. This is due to heuristics burned into my brain over 30+ years of in-office care.
When I talk to other provider organizations, I hear common themes dragging them back into an in-person-dominant care model. Themes such as filling beds and charging facility fees come up repeatedly, not to mention the threat of lower reimbursement for telehealth visits compared to in-person.
But before we conclude that telehealth is dead or that it was just a pandemic solution, let me share some other data.
I recently talked to a friend who works at one of the largest national payer organizations, which led to an important insight. From January through October of 2020, local providers (i.e., ‘your doctor’) generated 96% of their telehealth claims, and only 4% came from national providers (i.e., Teledoc Health, Amwell). Compare that to 2019, when 54% of claims were from national providers – and the trend is moving back in that direction.
What this says to me is that there is indeed a market for telehealth. However, the choices we make in the next few months will determine the landscape for telehealth in the U.S. for at least a decade.
Telehealth is here to stay but who will deliver the services?
Providers must resist that strong magnetic force that draws us back into an in-person, brick-and-mortar world and find the right balance of in-person and virtual care. Healthcare systems must embrace value-based care rather than a fee-for-service model that brings people into facilities. This is difficult after experiencing a period of significant financial loss.
We also can’t forget that the challenges our healthcare system faced before COVID are still looming and will continue to escalate, including the onslaught of chronic illness and the limited supply of providers, as well as the threat of a future pandemic.
Some wild cards could influence this strong pull back to face-to-face care.
- If we don’t get the originating site rule (1834m) repealed before the lifting of the public health emergency, that will put providers into a telehealth ice age. One of our biggest priorities must be to ensure passage of federal policies and state laws that support the permanent, widespread adoption of telehealth. And, I’m very pleased and proud to say that the ATA has been leading that charge.
- If we witness an expansion of value-based reimbursement, that will pull us toward more telehealth adoption.
- When I talk to forward-thinking providers, their biggest near-term fear is the entry of large consumer tech companies into the care delivery market. If they can turn that fear into a pivot away from reliance on brick-and-mortar, that could accelerate telehealth adoption.
We need to come up with logical, financially sound reasons for providers to pivot long term. Simply saying that telehealth is the right thing to do or that patients demand it won’t be good enough. Even taking a most objective view, a future where providers are not engaged in telehealth is not a pretty picture.
Payers have choices to make too. Historically, they have been much more comfortable controlling telehealth utilization through partnerships with big national providers. Depending on coverage policy going forward, we could go back to that model. This will test the hypothesis that consumers value convenience and access as much as they value the familiarity with the doctor on the other end of the conversation.
A call to action for consumers and suppliers
This brings me to patients and consumers. Now more than ever, you have a voice! Urge your elected representatives to pave a regulatory path that enables telehealth. You can also influence your employers and health plans, so let them know you want more access to telehealth and if you prefer it be from your doctor, make that clear.
For suppliers and innovators, I have a special plea: keep innovating on efficiency. In 2019, my soapbox theme was that the demand for healthcare services had far outstripped the supply of providers. As I alluded to earlier, that is still a long-term worry, and as we emerge from the pandemic, that problem will come back into focus. We need to catch up to where other services are: integrated digital-first, chatbots, symptom checkers, patient engagement, social robots, and the like will be more critical than ever in the next few years.
And we all need to collaborate to make sure that telehealth is part of the solution to health disparities and inequities. This is complicated, but we have prioritized these activities at the ATA, including support for universal broadband and reimbursement for audio-only visits.
We’ve lived through a historical time. I’ve heard it said over and over that telehealth advanced ten years in the first two months of the pandemic. Yet, our work is far from done. As providers, we need to confront our place-based past or risk being marginalized as the brick-and-mortar resource. Payers need to develop payment policies that allow appropriate telehealth to flourish without encouraging overutilization. Suppliers need to innovate beyond virtual visits. And patients must advocate for healthcare delivery that is high quality, convenient and accessible.
All of this will require System II thinking and thus work. But there is too much at stake to do otherwise.