Telehealth's future: What's coming for payment and patient care?

Telehealth is hot right now among physicians and patients, but what’s its long term outlook? What impact will telehealth have on patient outcomes and physician reimbursement?

To learn more about the future of telehealth, Medical Economics Managing Editor Todd Shryock sat down with Jeremy Gabrysh, MD, a physician and CEO of Remedy, for a wide ranging discussion on the future of telehealth.

The following transcript was edited for length and clarity.

Medical Economics: Because of the COVID crisis, telehealth has made huge inroads into medicine. Is this good for both providers and patients?

Jeremy Gabrysch, MD: The explosion of telehealth that we have seen during this pandemic is such a boon for patients. It really helps ensure a continuity of care at a time when you know patients are scared. They're seeing what's happening on the news. They're hearing stories. They are afraid of going and sitting in a waiting room where they might be sitting next to someone else who's sick. So, you know, this puts a pressure on the doctor-patient relationship. But telehealth relieves that pressure; it allows a way for patients to stay connected to their doctors. We're told that 25-30% of care that we have traditionally given in a clinic could potentially be given virtually, and I would say our experience with Remedy is we have a virtual-first approach.

And so what we've seen is that we're able to resolve about seven out of 10 cases virtually and it really kind of opens your mind to the prospect that there's probably a huge opportunity for telehealth here, much bigger than what we even realized. The other thing that you're seeing right now is that people are delaying care because of fears around the pandemic. And so, you know, a Kaiser Family Foundation study, it found that half of the public reported that either themselves or their loved one had delayed care. And I think we'd all agree, that's not good. One out of 10 of those said there was actually a deterioration because of a delay in care. And, and so, when you bring telehealth in as an option, now you restore that connection to the doctor, they're able to get a consult, they're able to either allay their fears about the condition or find out if they truly need to go get in-person care. These kinds of things have proved vital during the pandemic.

Medical Economics: Do you think the level of telehealth will continue after the crisis passes? Or do you expect it to decline?

Gabrysch: I think that is a great question. I mean, it is certainly at an incredible level right now in terms of the adoption that we're seeing. For telehealth, when you look at last year, for example, McKinsey did a study in which they asked people what was their interest level and engaging their doctor by telehealth was and only 11% said that they were interested in that venue versus in-person. Now, you look at that same question today, are you interested in using telehealth to connect with your doctor, 76% of people say that they're interested. That's a huge jump. And that is definitely being affected by what we're seeing with the pandemic. So, you know, you also look at the numbers of cases. For example, we're a very virtual-focused company, and do a lot of telehealth. And even with that in mind, our numbers were up—we're seeing 1,000% increase in the number of telehealth video visits that we're doing relative to this time last year, so the spike right now is huge. And so then when you say, well what's going to happen when this crisis subsides or passes, it's definitely going to decline some from where it is right now.

There is going to be a tendency to sort of go back to the “old way” of doing things. Providers are going to be maybe more eager to see patients back in the clinic, patients might even gravitate towards that a little bit. But I don't think that we're going to go back to where we were. And I would say that we really should resist going back at all because this is a huge opportunity that this has presented. We have moved virtual care forward. And we know that we can provide a more connected experience, better outcomes and just a more virtual-first approach to medicine. Think about the way you bank, for example. You probably engage with your bank, mostly through your smartphone, or your computer, and occasionally you go into the branch.

We're not saying that all in-person care is going to go to virtual. But, you know, if you look at the banking analogy, a lot of what you can do can be done remotely, and then occasionally with those, those visits to the brick and mortar branch. And what I would submit is that this is an opportunity for us to move medicine more into that paradigm, where we're doing a lot of the care virtually, and occasionally bringing patients in for in-person visits, when that makes sense.

Medical Economics: From your experience, what are some best practices to apply during a virtual visit with a patient?

Grabysch: Well, you definitely want to make sure that the patient has a phenomenal experience, right? So you want to sort of use that as your starting point. Certainly, telehealth is convenient, but you want to make sure that connectivity issues are resolved, and that there's a very seamless experience for the patient of getting into the video with the doctor and that they aren't just staring at a wall or something, but they're talking to a real person as quickly as possible. And then, standard things like, look into the camera and be engaged with the patient. I also recommend that providers use a second screen. Oftentimes, we're needing to interact with the patient's medical record. So we're needing to look at their medications or their previous visit.

And so I'll have a screen over to the side where I can have that medical record open on the screen, and then you want to tell the patient what you're doing and what you're looking at. If you're referring to some papers down below you, or you're looking at a screen to your right, you just say, “Mrs. Smith, I've got your electronic health record pulled up here on the screen to my right, so you'll see me looking over there.” You want to keep patients sort of apprised of what you're doing.

The other thing that can be really helpful is using photos, because sometimes the quality of video can vary. And so what I recommend is for certain things like skin conditions, or even sore throats, you know patients have a smartphone, and they've got a real high quality camera. Have the patient takes some photos before the visit and send those in, or sometimes they can be uploaded during the visit. But those provide a really nice complement to the video interaction and give you, as a provider, more information.

Medical Economics: In the past, telehealth wasn't widely embraced because many payers wouldn't reimburse it at the same level as an office visit, if at all. Do you think the success of telehealth during COVID has permanently changed the reimbursement outlook for the better?

Gabrysch: I certainly hope so. You know, this is a question that I get a lot. And before COVID hit, I think there was a question about whether or not payers were going to pay for virtual care, and I think that question has largely been answered. We're seeing that payers are saying that they're going to pay for it. And so, it's not so much a question of if they will pay for it. But then the next question is this idea of parity, you know, will payments be equal to what payments for in-office care will be and I think that's an open question. I do think in order for these gains in virtual care to sustain and for us to really capitalize on this, we've got to solve this issue.

And, you know, value-based contracting is one way in which to solve it. If you're paying for sort of the total package of care that's being delivered, then the providers are definitely incentivized to provide more care virtually, to provide these sort of virtual touchpoints with patients that will probably improve outcomes. Within a value-based construct, they actually have a way to get reimbursed for it. In a fee-for-service structure, we definitely have to think about how can we incentivize this behavior? And how can we reimburse providers so that they actually are incentivized to drive this type of care as we move forward, and not just go backwards and lose all the momentum that we've gotten here.

Medical Economics: Do you think the attitudes of doctors toward telehealth has changed for the better during COVID?

Gabrysch: I think it definitely has for some, but not all. I think that definitely the younger generation of doctors, many of them grew up with smartphones; they're very comfortable with technology and interacting with patients virtually. I think that varies as you get into some of the different generations of providers. I will say that I have often, just in my practice, and with family and friends, interacted with patients over FaceTime or texted with them and typically it's a friend or family member reaching out.

But these are ways that I've stayed connected with folks and been able to help them over the years and are comfortable with it. I do talk to doctors who are rather reluctantly embracing it right now during the pandemic. They realize that this is something they have to do in order to stay connected to their patients or maintain a revenue stream, given these circumstances, but they're eager to get back to sort of the old way of doing things. They're eager to get back into the clinic and more of the in-person care. I would say that we should be careful about swinging too far back to the old status quo, because there are these younger patient groups who are wanting this kind of virtual care. And actually, in fact, people across all generations have found that this is very convenient, and that they still feel very connected to their doctor even when they connect with them by video. So again, we don't want to lose this opportunity.

Medical Economics: Smaller rural practices often struggle with technology because of cost and complexity. What can be done to make sure they aren't left behind with telehealth and some of these other advances?

Gabrysch: Well, one of the big issues here in rural areas is internet connectivity. And so fortunately, state and larger organizations are working to improve broadband access and cell phone coverage in many of these areas, because that really is imperative if you're going to be able to deliver care in this way. But I will tell you in the states that we serve with Remedy, we see lots of patients in the rural areas, patients who might be a decent drive from a brick-and-mortar facility, but they're able to get connected to care using virtual care. As we look at rural practices, where their patients may be fairly spread out, it may be more difficult for them to get in. Maybe they have transportation issues, so this is a huge opportunity to really transform care for those areas as well. And again, some of it comes back to the reimbursement issue, as well. These are smaller practices in these rural areas who are relying on fee-for-service income, a lot of times from these office visits. We can improve connectivity, we can talk about more connected care and all these things. But at the end of the day, we have to figure out a way to reimburse these providers for that type of care in order to incentivize it and make sure that it does indeed, take off.

Medical Economics: How will the standards of care change in medicine post COVID? What do you think will look different? What's going to change once this crisis has passed?

Grabysch: Well, I think there needs to be an openness in the medical community to what a new standard of care that is heavily focused on virtual, and leveraging virtual—what that new standard of care could look like. I'll give you a couple of examples. So the other day, I had a friend who was experiencing some heart palpitations. And she, through using her Apple Watch, was able to obtain a digital EKG, which was then submitted to cardiologists, virtually, who took a look at it, chatted with her, and then ordered some additional tests to be done. All of that typically would have taken place in an emergency room or urgent care clinic or the cardiologist’s office. But because of technology, because of this wearable device and access to virtual care, we're able to envision a new standard of care about what that looks like.

Another example, and this is another specialty care example, but I talked to a patient who had a foot injury, and using high quality photos of their foot and video and a consultation with an orthopedic surgeon over virtual care, an X-ray was ordered, a small non-displaced fracture was found in the foot, and the specialist recommended a walking boot for several weeks. Again, all of that care took place virtually. And typically we would say, well the standard of care there should require in-person visit. And I would challenge that. I would say, we should really rethink in light of our access to technology what the standard of care looks like with these new connected devices with virtual meetings. Patients have a lot of monitors, on their body and in their homes that are providing us a lot of information and we can actually deliver a very high quality of medicine virtually, whereas we might not have been able to do that before. And our medical system is heavily invested in the brick-and-mortar model that got us to where we are today. We have to be careful not to be too saddled by that, because if we do, we're going to be very reluctant to embrace these changes, and we're going to be more inclined to go back to the way we used to do things. We're too narrowly focused on that brick-and-mortar model and that old way of doing things, and virtual care can solve so many of the things that people typically have come into the office for.

There is an opportunity for us to really change the way we deliver care, and the way that that we pay for care and actually the cost of care. We waste a ton of money in this country, providing in-person office visits and care that doesn't actually make us healthier, and doesn't make us live longer. Of the $3.5 trillion that we spend, there's a huge chunk of it. That's just waste. And if we really are open to adopting this more virtual approach, we will save so much money and we will provide a better experience and will get better outcomes for patients.