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 it also 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 directly billing patients for services that insurance doesn’t uniformly cover. In my practice, for example, the new law guarantees 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 in which we find ourselves 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 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 the one-channel healthcare delivery model, when a patient requests an appointment, the provider’s office simply needs to find a time in his or her schedule for the appointment. 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 should it be guided by clinical criteria? I would argue strongly for the latter (see the use case discussion below). If so, the person scheduling the appointment either needs 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 (even the resolution of HD video is not good enough for dermatologic diagnosis). We currently employ nurses to ensure that 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 when I see patients in the office on Wednesdays. Most provider organizations are now doing 15 to 25 percent 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 percent of care delivery, striking an appropriate balance of in-person and virtual care. Now is the time to make telehealth a legitimate care delivery channel for the long haul by tackling policy, reimbursement, and implementation challenges in the New Year.
This piece was written by Joseph Kvedar, MD, Senior Advisor of Virtual Care for Mass General Brigham. He is also Professor of Dermatology with Harvard Medical School, and has authored two books on digital health.