By Kelsey Brykman, Center for Health Care Strategies
Telehealth use has increased dramatically as a result of the COVID-19 pandemic. “Telehealth” refers to a broad range of technologies that support remote care, such as providing care to patients by video and phone, mobile health applications, and remote patient monitoring that supports collection and evaluation of patient data. Telehealth implementation both prior to and during the pandemic suggest that telehealth holds the promise of increasing access to and improving efficiency of care, including for populations with complex needs.
As stakeholders consider how to sustain telehealth services, they will need to align telehealth strategies with broader payment and care delivery reform efforts to provide high-value care. Providers and payers, including those implementing value-based payment (VBP) approaches, may consider how to best support and implement telehealth services to encourage high-quality and cost-efficient care.
The Playbook recently spoke with Ateev Mehrotra, MD, MPH, a professor of health care policy at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center, to explore the intersections between telehealth and value-based payment and how telehealth can support high-value care for populations with complex needs. Dr. Mehrotra’s research focuses on delivery innovations, including telehealth, and their impact on quality, costs, and access to health care.
Q. What opportunities are there for telehealth to support improved quality of care for people with complex health and social needs specifically?
A. The argument is that quality of care and access to care for patients with complex health and social needs is often inadequate. The hope is that making it easier for people with complex needs to access care more frequently, we can provide better care. For example, individuals with complex health and social needs often face transportation barriers that telehealth can address. Increased telehealth access may also provide opportunities for better chronic illness management and lead to fewer complications down the line.
While we have strong evidence showing telemedicine can provide equivalent quality of care as compared to in-person visits for many populations, we do not necessarily have evidence demonstrating that adding telemedicine actually leads to better outcomes. That is a different bar to meet. Additionally, while there is a lot of research on telehealth, many of the fundamental questions about who benefits most from telehealth, costs of telehealth, and how telehealth impacts access remain to be answered. That said, there are a lot of reasonable assumptions for why telehealth can be helpful for patients with complex needs – the health system is not meeting people’s need right now and we need to strive to do better.
Given where the gaps in the evidence are, I would start with focusing on access to telehealth services for populations that have the highest barriers to care. One example is patients with mental illness who often struggle to access care. Telehealth is particularly helpful in behavioral health, and many states as well as Congress have accordingly moved in the direction to authorize telehealth for this population. Similarly, there may be opportunities to better use telehealth to support people in nursing homes who generally face transportation barriers getting to their primary and specialty care appointments.
Q. To what extent can VBP support adequate payment for telehealth services? How may this differ from a fee-for-service framework?
A. It's useful to go back to the question: why don’t we just cover all telehealth services? The problem is that in a fee-for-service environment, the use of broad reimbursement for telehealth could lead to substantial increases in spending that are not commensurate with improvements in care at the population level. The worry is that while certain people may have improved care from telehealth, we would also see a lot of low-value care. However, this is all based on a fee-for-service system. If we paid people through capitation, bundled payment, or other types of VBP, we can solve this problem. VBP gives providers a substantial amount of flexibility for their patients. If the interventions are ineffective, however, provider organizations would be accountable for the costs, so organizations would not have an incentive to provide low-value services.
Remote patient monitoring is a concrete example. Remote patient monitoring allows patients with chronic conditions to send physiologic data, such as blood pressure, to providers on a regular basis. Instead of checking in every three months, patients can send daily measurements to their provider. Theoretically, this should lead to better outcomes because it’s easier for the patient and allows real-time adjustments in care. Use of remote patient monitoring has gone up, but focusing on the right populations is important. This is useful for patients with chronic illness, but we’re also seeing a lot of patients without chronic conditions or with well-controlled conditions who are also on remote patient monitoring. The result is payers are now paying for a lot of patients who were doing just fine without remote monitoring. This is why tying VBP to telehealth might be helpful.
Q. For stakeholders aiming to support telehealth uptake through VBP, what are some design elements that are important to consider?
A. The devil is in the details in terms of VBP implementation. Inclusion of telehealth in VBP models brings up new complexities in terms of making sure payment is adequate and determining which providers are appropriate to provide services. For example, for almost any clinical condition you can now find start-up telehealth-only companies. How does payment and coverage of these services interact with VBP models, such as primary care capitation? Should a primary care doctor who is paid capitation be responsible if their patient goes to a telehealth company for an urgent care problem? In other words, when should payment for specialized telehealth services be paid outside of the capitation? If they are included, should we give primary care doctors the ability to limit the use of these telehealth options? Should we require a primary care referral?
Another consideration is risk adjustment. Risk adjustment is already challenging, and telehealth makes it more complicated because it adds the need to capture new variables that could impact the payment. There are many factors that impact how much telehealth is used such as internet savviness, availability of broadband internet, etc. these are not variables that are easy to effectively measure. All this means telehealth may make risk adjustment more challenging, for say, a capitated payment model.
Q. Have there been any lessons from the rapid expansion of telehealth during COVID-19 related to how telehealth can support high-value care?
A. In terms of sustainability, a lot of issues are currently outside the hands of provider organizations, such as payment and licensure policies. Once the policy landscape is clearer, providers will be better able to react appropriately. In the meantime, providers have mostly worked out infrastructure issues, such as what telehealth platform to use. One issue that is still challenging, especially for populations with complex needs, is how to support patients in accessing telehealth, such as leveraging positions known as “telehealth facilitators.’’ This was not a job two years ago, but now there is a sudden need for people to sit down with patients and help with video visits and tech support. Providers are still figuring out which staffing models work best. This will be key for sustainability.
Q. Are there other considerations you would like to highlight for stakeholders considering how to sustain and maximize the value of telehealth services?
A. Medicare and Medicaid payers and policymakers should consider the tensions between immediate and longer-term telehealth payment policy. The immediate issue is determining payment policies to sustain video and phone visits following the pandemic. However, there is also a need to consider the long term: what forms of telehealth are going to have the greatest impact on people with complex health needs five to 15 years down the line? I believe we will be considering many other options outside of video or phone visits. As one example, for people with substance use disorders, having an app that allows not only phone visits but also features like text messaging, educational resources, and other ways to get personalized feedback can provide many different touchpoints over the course of a week. When developing policies, there is a need to think about the big picture, including how to pay for and regulate these types of innovations that encompass much more than a video visit.