THE TELEHEALTH MARKET REVIEW 2019 & BEYOND

TECHNOLOGY BARRIERS TO ADOPTION FOR BOTH PROVIDER AND PATIENT

BOTH REAL AND PERCEIVED

Executive Summary

Telehealth technology is growing at double-digit rates according to recent reports. However, that growth still minimal when compared to the total delivery of care in the U.S.  Additionally, consumer studies recently report show use of telehealth by patients looking to telehealth is mounting. Healthcare providers with telehealth capabilities today can offer their patients even for routine issues will be laying the foundation for the sizable growth of telehealth adoption.

OVERVIEW OF TELEHEALTH MARKET GROWTH

The recently well-publicized executive order known as “Medicare-for-all” enacted in October 2019 by President Trump, coupled with a slew of States passing telehealth parity laws, reflect the market is gaining momentum.

The telehealth technology, sometimes called telemedicine, has seen substantial growth across the Nation over the past few years.  It is a healthcare market segment that is on the move and not just in a few States but over the entire Nation.

A news release by the American Medical Association, based on a report released by Fair Health (FAIR HEALTH, Inc., 2019), Reported that “a national study of insurance claims filed for alternative settings of care telehealth rocketed up 53% from 2016 to 2017. The growth outpaced other places studied (not using telehealth) – 14% at urgent care centers, 7% at retail clinics, and 6% at ambulatory surgical centers. In a telling sign of the shift in the delivery of care, emergency room departments were the one setting reported on that experienced a decline—it was 2% (FAIR HEALTH, Inc., 2019).” (American Medical Association, 2019) Article here.

The AMA news article is just an example of the dozens of mainstream news outlets that printed similar reports based on the Fair Health report. Since its release in May 2019, there has been a secondary report released by Fair Health since that went into more dept on the telehealth and further validated their first report.

Figure 1 – below gives the reader a reference to what kind of sizable jump in utilization the Fair Health report concluded.  In one year, to see a 53% increase in an industry as non-cyclical as healthcare is an excellent reason to take pause.

Figure 1 – Percent of claim lines with telehealth usage by rural, urban and national settings, 2012- 2017 (FAIR HEALTH, Inc., 2019)

All of this reporting of how the Telehealth industry has seen double-digit growth since 2014 –2018 is a catchy title for a news article. Closer examination reveals an essential short-term truth when compared to the universe of all utilization in the study telehealth technology still ranked below .02% and grew to a nominal .16% of the total care studied.  The reality the time is now for telehealth technology the key is to ensure it is done in with a thoughtful approach with realistic expectations.

“…compared to the universe of all utilization in the study, telehealth still ranked below .02% and grew to a nominal .16% of the total care studied.”

The reality is that for providers, the studies show tremendous opportunities that are working on implementing telehealth technology into their practices now.  Substantial adoption barriers, both real and perceived, are slowing providers and their administrative teams into assimilating telehealth into the treatment regime for patients.

The layperson, even those in the healthcare industry, it would be reasonable to get the impression for the graph that the proverbial “horse has already left the barn” when it comes to telehealth technology.

For those you that feel they have missed out on this opportunity, you can relax you have not.

WHERE IS ALL OF THIS DOUBLE-DIGIT GROWTH FOR TELEHEALTH?

Fair Health followed up their “Health Indicators and Medical Price” report with a more robust deep dive into the telehealth. In October 2019, they released a White Paper titled “A Multilayered Analysis of Telehealth – How this Emerging Value of Care is Affecting the Healthcare.” Fair Health report here   This report looked at the time of 2014-2018 specific to the four years and the growth showed (Fair Health, Inc., 2019)

Telehealth Technology can be broken into four broad types of categories

Provider-to-Provider Telemedicine

provider-to-provider telehealth involves consultation between healthcare professionals

Provider-to-patient out of the inpatient setting

The provider and the patient communicate via telehealth without relation to a hospital. For example, a patient located at home without a recent hospitalization has a video chat with a provider to show his or her wound health.

Provider-to-patient-discharge from the inpatient setting

The telehealth visit is a follow-up after the patient is discharged from an inpatient stay in the hospital.

All Telehealth

This portion of the graph reflects the total growth of all telehealth services

Emergency Services

In rural areas, telehealth is being provided to a patient with the provider in the Emergency Room

Telehealth Market Growth

Figure 2.Claim lines with telehealth usage by type as a percentage of all medical claim lines, 2014-2018. Fair Health, A Multiplayer Analysis of telehealth

PATIENTS/CONSUMER SURVEY SHOWS SIMILAR RESULTS BUT FOR DIFFERENT REASON

J.D. Power found that only one out of 10 patients have used telemedicine in the past year. Urgent care was the primary driver along with and other low acuity types of care, were the predominant reason for these patients to turn to telehealth for their concern was for relatively minor conditions.

Telehealth Market Growth

One of the most revealing results of the study was that 51% of those consumers/patients rate telehealth a more personal visit with their doctor than a traditional office visit (Greg Truex, Managing Director, Health Intelligence, 2019).

This data is starting to confirm that patients are beginning to migrate away from their PCPs and into delivery models that offer “walk-in” access.  Telehealth is redefining “walk-in” to be that of not going to the local urgent care of retail clinics, and they are simply turning to their computer or smartphone and connecting with a provider at a time and location convenient to them.

PROVIDER AND BARRIERS TO ADOPTION

Providers should recognize the following top 3 challenges that all health organizations today are facing.

  • Lack of training and understanding of telehealth technology is and what is available to them
  • Interoperability challenges around an office practice management system, electronic health record (EHR), and scheduling processes are considerable.
  • Ability to navigate the reimbursement rules for telemedicine for Medicare, Commercial and Medicaid

Telehealth Technology has a much longer history than you might think

The World Health Organization found that telemedicine – meaning “healing from a distance” — can be traced back to the mid-1800s, was first featured in published accounts early on in the 20th Century, and adopted its modern form in the late 1960s and early 1970s, primarily through the military and space industries. Not until the international World Health Organization took on the effort to define telemedicine technology in 2008 did, we have a definition that countries could adopt and make it universal for healthcare. This work culminated in an internally recognized first of its kind by WHO titled “Telemedicine: opportunities and developments in the Member States”: report on the second global survey.” Access here

With the question answered of how the term “telemedicine” evolved, we can move to more concrete terms.

Clinical Telehealth Technology

  • Live, interactive video consultation uses videoconferencing technology to facilitate a patient visit with both physician and patient present at the same time.
  • Store-and-forward consultation captures information at the patient site to be analyzed and evaluated by a physician at another location.
  • Hybrid consultation: uses components of live, interactive video consultation, and store-and-forward consultations.

Providers are encouraged to take any of their respective and available Continuing Medical Education (CME) or Continuing Education Unit (CEU).  In some states such as Kentucky, providers have requirements on the amount of CMEs/CEUs they must have to follow State regulations if your State has no such requirements,  worth most providers’ time to take advantage of the resources available that are approved by other States.

Providers should seek out organizations in your specialty field such as the American Medical Association or smaller State and Regional trade associations as a reference point or “source of truth” on questions they are not sure about.

An excellent starting place for all providers to begin to learn about telehealth is the National Consortium of Telehealth Centers (NRTC). This national-level organization is comprised of a network of 10 regional centers broken out by geography.  Their charter, to assist with provider adoption of telemedicine technology. Figure 3 below shows how each local center covers just a handful of states and has focused on being the subject matter expert for their regions.

Best Training Tool is the Hands-on Kind

Probably the most critical thing provider can do once they found a telehealth technology platform they are comfortable with, order it, and start to use it.  Nothing is better than hands-on training. As with most things, academic knowledge is a good start, but without actual hands-on practice and doing some trial and error, you and your practice will be dead in the water.

A Telehealth technology company that provides live training to you and your staff during on-boarding is ideal (not just a demo).

Additionally, they will have an active customer support program on-going with such things as:

  • Online Knowledge Compendium that is updated regularly
  • Training and FAQ Manuals
  • Email, Text and Live support for questions
  • Updates on reimbursement guidelines and regulations

Unfortunately, most do not offer much, if any, live customer service for their lower-priced products.  It is worth spending a little bit more if you find a system you like that offers this kind of provider support.

Telemedicine Technology Interoperability Challenges

Interoperability is a sizable and expensive barrier to telehealth.  And those still with nightmares of implemented Electronic Medical Records (EMR) a few years ago will not want to endure the pains associated with trying to interface an extensive system, not your current EMR and business systems.

Medicare is quite forward-thinking when it comes to the technology, defining reimbursable telemedicine technology  as “interactions between a healthcare professional and a patient via real-time audio-video technology” (CFR Title 42, Part 410.78, “Telehealth Services.”). This definition is in line with the model policy of the Federation of State Medical Boards (FSMB), which represents the multitude of state medical and osteopathic regulatory boards. Because the FSMB is considered the ultimate arbiter of quality in medical practice and regulation, its recommendation carries considerable weight, setting the standard for the industry.

The telemedicine technology challenge of system compatibility or limitations in conjunction with market “buzz” that is drawing customers to want to purchase and take advantage of the latest and greatest is not a new phenomenon.  This trend occurs in all technology-based service industries.

Some companies address this problem by offering a full suite of systems all integrated into several processes like EMR, billing, collection, and telehealth.  The problem is that you must buy the entire suite of products, not just the telehealth technology option.

And others will customize the telemedicine technology products you purchase for an additional cost interface with your scheduling and EHR systems but at a price.  For many providers, the demand and expected utilization they would need to justify this cost does not make sense now in the present.

There are a lot of efforts by the Telehealth technology IT companies working to address these issues.  Unfortunately, with one solution to integrate with a provider system is a lot of times, just that-one solution.  A Telehealth technology company will have to almost start from scratch when building integration with the same platform but a different provider system.

Interoperability between two IT systems is not unique with healthcare and something that every industry deals with as technology improves and gets better.  There have been studies done on industries around just this issue and have correlated with demand with technology interoperability and have shown a measurable and repeatable adoption trend around this area.

Navigating the reimbursement rules for telemedicine technology

Telemedicine is a hot topic in healthcare, with consumers more willing than ever to see a doctor remotely. While no single factor accounts for the overall lag of the adoption of telehealth, arguably, none has had as significant an impact as the confusion surrounding provider reimbursement for these visits. Lack of understanding about how each of the three major payer types—Medicare, Medicaid, and commercial payers—reimburse for telemedicine visits has understandably prevented many providers and delivery systems from making informed decisions about adopting this technology.

Below will explain how each significant payer type makes decisions around reimbursement and clarify when telemedicine visits are covered. Beyond providing this essential knowledge foundation, it will also reveal trends toward increased levels of payment—especially in the commercial sector. Physicians today can feel positive about bringing this powerful tool into their practices as telemedicine continues to receive increased levels of compensation.

Medicare & Medicaid Telehealth Reimbursement

With so many Americans enrolled in either Medicare or Medicaid, providers need to understand how this program makes determinations about telemedicine reimbursement. Fee-for-service Medicare reimbursement is dictated by four key areas: the patient setting, the type of technology, geography, and provider type.  Medicare is beginning to open up the rules for each of the four key areas, so providers need to keep up to date with the evolution of CMS in what is reimbursable for telehealth.  Medicare-General-Information/Telehealth

Forty-eight state Medicaid programs and the District of Columbia have some telemedicine coverage. However, Medicaid differs from Medicare in that its policies vary from State to State; each State has the flexibility to determine how it will reimburse for telehealth, and many have gone well beyond the scope of Medicare.  Each year, additional states expand their range of reimbursement, and new proposals are filed regularly.

Here are some vital high-level insights, although it’s essential for medical professionals and administrators managing the systems, they work in to review state-specific resources. The American Telemedicine Association’s (ATA) report, State Telemedicine Gaps Analysis, is one particularly comprehensive and accurate resource.

The following overview of Medicaid policies is broken down by the determining factors of patient setting, technology, and provider type.

Telemedicine and the Patient Setting

According to the ATA’s report, 24 states and the District of Columbia do not specify a patient setting as a condition for reimbursement, and 25 states recognize the home as an originating site. This means that many Medicaid patients do not have to travel to a traditional healthcare setting, allowing them to take advantage of the convenience afforded by telemedicine.

Telemedicine Technology

Similar to the patient setting, no one policy dictates reimbursable technology across all state Medicaid programs. A broad span of modalities—from telephone to video to remote monitoring and store-and-forward technologies—is in play. According to the ATA, states are slowly but surely embracing a variety of new technologies for the delivery of telemedicine.

Commercial Payers

Commercial payers—that is, private insurers—have been most aggressive in reimbursing for telehealth visits. Many national plans embrace this healthcare innovation and have been steadily broadening coverage through partnerships with telemedicine services companies. American Well, for example, now covers 50 million commercial lives for telehealth visits through 30 separate major health plans. This is happy news for doctors and the systems in which they work. Their patient populations are steadily gaining telemedicine benefits, and companies like American Well offer real-time eligibility and claims processing, letting the provider know before starting a telemedicine visit if the patient’s plan will reimburse them for their services.

Regulation affects the commercial payer realm, as well. Today, 29 states and the District of Columbia have parity laws that mandate commercial payers to provide comparable coverage and reimbursement for telemedicine services as in-person services. This is excellent news for providers, as it suggests that over time telemedicine will gain parity footing with in-person consultations across the board

Despite all this, reimbursement through private insurance companies is the least confusing and the most promising. With national health plans such as United Health Care and Anthem advertising their telemedicine visits and coverage on television and the web, it’s clear that some dominant players stand behind telemedicine and are dedicated to making it work as an integrated part of the healthcare system, not just for patients, but also for providers.

Exciting Future for Telehealth

Telemedicine has vast potential to improve access to quality care and decrease costs and to make healthcare encounters more convenient and satisfying for providers and patients. Understanding how and when providers are reimbursed for delivering healthcare through telemedicine can be challenging, but not impossible. Breaking it down by each type of payer makes it easier for providers to gain clarity and make informed decisions about telemedicine.

And there’s more good news—there are positive indicators for reimbursement across all three major payer types, and restrictions on compensation continue to be lifted as industry advocates work with federal and State government and commercial payers to integrate telemedicine into our healthcare system. Not too long ago, there were several states where it was illegal to practice telemedicine. Today, 47 states are “green” for telemedicine. Industry advocates are working just as hard on the issue of reimbursement. Doctors who want to adopt telemedicine have support—both for understanding reimbursement today and changing compensation tomorrow.

Conclusion

The telehealth market is exceptionally complex and comprised of a myriad of market forces that boggles the mind.  The providers that focus today on how to provide telehealth to requesting patients current will have a significant competitive edge that will pay in dividends today and going forward.

Those providers that embrace this change now and begin to assimilate telehealth into their practices, if that means scheduling it once a month for their patients, will find their endeavor will pay dividends in the long run.  The national healthcare delivery system is poised to undergo a paradigm shift delivery of care due to advances in telehealth technology and regulatory opening the door for telehealth that is sweeping the country.

Multiple studies on providers and patients around the adoption of telehealth have reveled one constant for both a desire to utilize this technology in the provision of healthcare.

There is no longer a cost barrier, and a provider can access a secure platform to conduct live or real-time video/audio for their patients over the internet with a computer, iPad, or smartphone. Sounds easy enough, right? It’s not, but it will get better in all areas.

Providers that start now and take a thoughtful approach to telehealth will be rewarded in the long run.  Blocking an afternoon of the week that is devoted to providing care to their patients via telemedicine will help the practice as a whole to adjust to the adjustments of managing things like a virtual waiting room.  It also allows for that time to be set-aside for virtual “walk-in” hours that can be advertised and attract new patients.

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References

American Medical Association. (2019, May 29). American Medical Association. Retrieved from Digital: https://www.ama-assn.org/practice-management/digital/telehealth-53-growing-faster-any-other-place-care

Fair Health, Inc. (2019). A Multilayered Analysis of Telehealth, How this Emerging Venue of Care Is Affecting Healthcare. New York: Fair Health, Inc.

FAIR HEALTH, Inc. (2019). FH Healthcare Indicators and FH Medical Practice Price Index 2019. New York: FAIR HEALTH.

Greg Truex, Managing Director, Health Intelligence. (2019, October 28). As Telehealth Technology and Methodologies Mature, Consumer Adoption Emerges As Key Challenges for Providers. Costa Mesa, California, United States of America.

The Office of the National Coordinator for Health Information Technology (ONC). (2019, April). Health IT.gov. Retrieved from Health It.gov/Topics: https://www.healthit.gov/faq/what-types-telehealth-services-can-i-offer

Thomas, L., & Capistrant, G. (2017). 50 State Telemedicine Gap Analysis – Physician Practice Standards and Licensure. American Telemedicine Association.

Eric Haden is the President of DRrexly Health Solutions, LLC

He can be reached at ehaden@drexly.com

866-210-2298