Editor’s note: On March 16th and 17th, 2017, Telehealth and Medicine Today convened a national conference of opinion leaders to discuss and debate “Technologies and Tactics Transforming Long-term Care.” What follows here is a podcast and timecode transcript of the panel discussion telehealth operating within the economic, social and political landscape. Avoiding in-patient hospitalization and new approaches to home telehealth care are also addressed.
“When we talk about Obamacare, all we talk about is coverage, but we don’t talk enough about access and affordability.
Healthcare Reform and Implications for the American Health System
The title is expanding home telehealth within healthcare reform. I’m going to talk about healthcare reform and how to think about telehealth in this emerging context; because what you’re seeing is a lot of activity. But you’re not going to see a lot of progress moving forward.
The essence of healthcare reform in the context that we’re talking about is that when we talk about Obamacare, all we talk about is coverage, but we don’t talk enough about access and affordability. You may have coverage, but that does not imply access to specialists and others.
On the affordability curve, the Commonwealth Fund came out with a publication saying 25% to 30% of Americans can’t afford healthcare today. And so, people are foregoing care. And the net result is a sicker population going forward.1
In the report, I evaluate Obamacare on ten different parameters. You must look at not only coverage, but think about efficiency of care. You must think about the effectiveness of care. What are the related outcomes? What is a cost? We must think about the level of competition. We must think about the experience of care in them.
Later today we’re publishing a piece on Trumpcare: What are the Implications to Medicaid? And it includes an assessment of the American Healthcare Act, which I think is going nowhere. And the bottom line is it’s tough to be poor. It’s always been tough; and it’s going to be tougher. If you’re low income that’s not good either. There’s this transfer of wealth and the plan (American Healthcare Act) is not going to survive the way it’s currently construed. There’s going to be per capita allotment, some block grants. The result is Medicaid funding is going to get cut. There will be people uninsured. And we’re not addressing the root cause of inefficiency and ineffectiveness in our healthcare delivery system.
Distinguishing Telehealth vs. Telemedicine [02:02]
Today’s topic is really about telehealth and what I’d like to do is first begin with Joel. The first question. What is telehealth? How does that differ from telemedicine, and from our perspective how should we think about it?
Dr. Reich [02:18]
I prefer to think of telemedicine as direct provider (of any sort) to patient care. And telehealth is everything else. But if you start to look at CMS (Centers for Medicare & Medicaid Services) definitions, then you look at state website definitions, and they all deviate.
Much of the deviation is about what they don’t want to pay for. They’ll specifically go through all this and say it doesn’t include telephone or fax. You’ll see later in some of the presentations of new ideas and devices that, in fact, the good old telephone may be very effective device as we move into more integrated technology and people systems.
So, what if you’re using virtual or computer intelligence on the other end of the line. Does that make it telemedicine, or does it have to be a live person that’s doing interactions? I think with definitions, you might as well throw them out. But be very careful when you’re dealing with new programs—either funding or contracting with private payers—that you’re specifying that technology and what the people program will be rather than trusting the term telehealth or telemedicine.
Dr. McMenamin [03:26]
I would agree, although I’m a bit more optimistic regarding the probability that we will see better support for telemedicine going forward.
Telehealth Market Acceptance [03:37]
The next question: Has health or telemedicine hit an inflection point in terms of market acceptance? I ask that question because I was around back in the ‘90s and 2000 when telehealth first began. Lots of promise, with big expectations. So, tell me what happened? Why haven’t expectations been met? Are we now hitting the point with the advent of reform and other changes in the marketplace?
Dr. McMenamin [04:04]
Well I think “inflection point” implies a certain binary on-off analysis that I would be hesitant to embrace. Now, TelaDoc® Medical Services, which has been very successful in attracting investment dollars, as well as patients in the form of employees, does, in fact, label this most recent year as an inflection point in the sense that they went from a million visits over something like 14 years to 2 million within another year or 14 months. And that’s certainly a pretty remarkable change. On the other hand, I’m not persuaded that we have an on-off switch so much as we have a continuum. The problems that have impeded progress and growth in the field are still there.
I indicated earlier I’m a little more optimistic with respect to reimbursement because I’m hoping that the American Healthcare Act is not the be-all and end-all of that issue. And pending in Congress are several pieces of legislation intended to encourage growth in telemedicine and to support it more richly than has been the case in the past. For example, legislation pending regarding telestroke. And even with the pro telemedicine views of Secretary Tom Price (Health and Human Services), I think we still have all the legal issues that we’ve always had.
Privacy, I think, is going to be more complicated in the future rather than less because big data is becoming such a big deal. And with the Internet of Things, and robots, and remote patient monitoring, the amount of data being generated is going to grow dramatically, not all of which is subject to HIPPA (Health Insurance Portability and Accountability Act of 1996), which has definite constraints as to its applicability.
I suspect that the FCC (Federal Communications Commission) will play a larger role in the privacy arena than it has to date. I also suspect there will be fights over ownership of data, which will grow more valuable as it grows more abundant.
There’s a lot going on in the states, and I think we’re seeing diminishing geographic restrictions in a lot of the states. We’ve got parity in something like 31 states. There’s been significant emphasis on home telehealth and telemedicine in Colorado Connecticut, Kansas, New York, Washington, and a few others. That’s encouraging, I think. There will be very interesting developments over professional liability, as emergencies are hard to deal with in a home setting. And I suspect people will try to do that even if it’s not appropriate.
There’s going to be claims, I suspect, that will arise from a failure to respond or at least respond timely to signals from remote sensing devices. And there will be some interesting product liability possibilities, because interoperability remains such a big problem, and of course, perpetually, licensure. All those things are there, all of them have been addressed to one extent or another. They still afflict us, but I don’t think they will indefinitely retard us.
Dr. Reich: [07:03]
We’ve seen that technology works. A lot of the studies have had small numbers of patients and conducted maybe not long enough, but they’ve shown it works. You can help people safely stay at home.
The other realm is the direct from provider-to-consumer, which of course I’m sure you are familiar. The major insurers often want the major employers to set up $49 call-in for your teleconsults. That’s raising a lot of issues and a lot of questions. It goes against all the efforts to capture all your clinical data in one place, because now you’re collecting a totally different system. You’re also now interspersing different physicians to take care of primary care.
Last week there was a HealthAffairs publication where they looked at patients who had upper respiratory infections who called the $49 telehealth line. They had an increase in healthcare spending probably because they added discretionary visits and didn’t replace something.2 They didn’t look at preventing people from getting sick or being more expensive, but I think we’re going to see a turn, and it’s beginning to happen. And that is, to take the proven technology platforms but use local primary care physicians within the same network in the same area so the data are captured locally and care is much more integrated into the local system, not going to something totally outside the system.
I believe it must happen if we’re going to be consistent with everything else we are trying to do, which is as much as you can connect the data. I don’t think we’ll get to full interoperability because it goes against a lot of the marketing interests of health systems. But I think that in this area we are going to see much more of: we will help you set up the technology platform for your group of local regional physicians and perhaps use the distant consultation by specialists that are not available in your system. That is still a big plus.
Barriers to Care, Payment Reform, and Telehealth [08:56 Dr. Gruber]
Joe, is the primary challenge the continuity of care or the integration of care? Are we beginning to think about the total cost of care; because for some of these activities of chronic disease management we’re really looking at ambulatory care conditions, which are things such as heart failure where there’s huge opportunity? What are the barriers, and do we need that continuity of care going forward? And comment on the role of payment reform in all this.
Dr. McMenamin [09:24]
Continuity of care has been a problem from the get go and remains one, particularly when we’re talking about home telehealth, if the record generated—assuming there is one—by the encounter does not find its way into the record of the primary care doctor, as too often is the case. And that has significance clinically, of course, because the primary care doc will not know what has happened the night before or the week before.
Of course, it also has legal implications from a liability perspective, because the inability of the primary care person to know what has accrued at the hands of someone else and may have an impact—and perhaps a negative one—upon management decisions. Until we lick that it’s going to be a significant barrier as it has been.
We are looking at total cost. I’ve been encouraged and emphasize, now 30 years removed from clinical medicine, that at least according to the literature I’ve come across in several areas there’s pretty good data now, even though admittedly the studies are small and some have not been well designed, but still pretty good data for not only effectiveness but cost efficacy, particularly in such areas as heart failure3 and management of high blood pressure4 and diabetes—especially type 25 as opposed to type 16—and diabetes education.
When you think about how much of the U.S. healthcare dollars is devoted to just those conditions, the potential for savings is hard to overlook and hard to exaggerate. I think the evidence for a COPD (chronic obstructive pulmonary disease) for example, is a little less robust and well-established;7 but there have been some helpful recent papers that suggest that maybe that’s changing.8
I’ve been impressed too by the value in the home setting of the availability of a service for the benefit of caregivers as opposed to the patients themselves. Especially referring to the “sandwich generation”9 dealing with parents who have had strokes or have suffered from dementia or are requiring palliative care. There are pretty good data suggesting that the caregivers benefit from the availability of telehealth and distance care technologies.10 It’s hard to quantify. It’s hard to put a dollar value on that, but it’s also hard to overlook the importance that such support provides to people who frankly could otherwise be overwhelmed.
Dr. Reich [11:46]
I didn’t invent the term, but it’s perfect here: the “wrong pocket” syndrome. Right now, if you try to do the return on investment (ROI) for many of these programs that Joe is describing, you must look at who is paying for the equipment rental. And it’s often the home health agency, families paying for it, it could be the health system. But where does a return come? And that’s where the ROI gets tricky. The return may come to the state Medicaid program. It may come to CMS or the ACO (Accountable Care Organization) that has a shared savings contract with the feds.
So, the problem is, if say we put 100 high-risk patients out there with heart failure and spend anywhere from $80 to $150 a month. If you look at the device costs or the whole system cost—somewhere less than $2000 a year—you can reduce admissions 30%, 40%, 50% if it’s part of a care management program with proper home care and proper coaching—the live person part of this. But who accrues the 50% savings? The health system says we’ve lost all these admissions now where in trouble. So, why should we support it. And right now, that’s true and creates a huge ethical dilemma. If you lose $100 million dollars in a very successful program, how do you provide care for people that don’t have means in our current system. If you look at it from the perspective that we save money for the system you can easily knock off readmissions. Readmissions for heart failure average somewhere between $13,000 and $15,000, and the patients are often on continuing decline. So, it’s probably more expensive than that.
It’s all about where does our system move from here? How many years do we fight for direct reimbursement for the $80 to $250 per month for the unit and the services versus when do the dollars become part of the same financial system under risk sharing so that we get the money into the same pocket or the right pocket?
Who is the Customer for TeleHealth? [13:39]
It appears, from at least my perspective, there’s lots of good technologies out there. There are lots of good people. There’s lots of data; and the enemy is us in terms of the healthcare system. So, the question I have: “Who is the target customer?” But what’s key here, and one of the big takeaways for everybody in the audience, is that all healthcare is local. Don’t think of a U.S. healthcare system. Every market is different, and you’ve got to find the markets that are ready for this.
So, the question is, these are the choices. Who’s the customer? Is it the patient, is it the caregiver, is it the provider, is the health insurance, or is it the healthcare system, or all the above? And if it is, at what point do we get alignment of interests?
Dr. Reich [14:17]
Right now, it’s the oldest daughter who is usual responsible for caring for the aging parent. But that will shift in the future to either the insurance company or the feds or state that is bearing the largest cost of care. And, depending on how much under our new reform laws, the financial burden will be shifted back to the patients and families.
I think it’s going to be a model that is ultimately sold to the local integrated network that you financially belong to you because of the type of insurance. In a few years, not selling as much to the patient and family, although they must buy in to make it work.
Dr. Gruber [14:58]
Fair enough, and here’s a data point for you: 55% of healthcare costs are not related to what the doctor does.11 It’s behavioral related and psychosocial. And then if you look at that, I think it’s cost effective if you engage the family, because it’s all about self-management. So, I would look in the journals and see how that’s defined, but if a patient is more aware of what’s potentially coming down the pike you could reduce cost significantly.
Dr. McMenamin [15:22]
Joe, your thoughts please. I think I’d have to go with the all of the above answer at least for the present. Everybody you mentioned, David, has a voice in it. Everybody has an interest, but patients themselves, obviously, the caregivers, the providers, the insurers, everybody is involved. And frankly at the risk of seeming too pessimistic, I don’t think the current system is sustainable. And I think that this situation will not remain as it is indefinitely for the simple reason: we can’t afford it. Eventually we will either abandon what we have and go back to something far different from what we have today, and the kind of care that existed when I was a kid before Medicare was even invented, which I think is unlikely. Or then surely, we will move in the direction of some single payer system just because we can’t continue to do what we’re doing. That’s not my preference personally but that’s my prediction.
- Gruber D, Urbanowicz P. Grading Obamacare, While Speculating About Trump: Separating Fact from Fiction. Telehealth and Medicine Today. 2016. URL: http://www.telhealthandmedtoday.com/grading-obamacare-while-speculating-about-trump-separating-fact-from-fiction/. Accessed 4/24/17.
- Jacobs PD, Cohen ML, Keenan P. Risk Adjustment, Reinsurance Improved Financial Outcomes for Individual Market Insurers with The Highest Claims. HealthAffairs. March 2017. URL: http://content.healthaffairs.org/content/early/2017/03/16/hlthaff.2016.1456.abstract. Accessed 4/24/17.
- Lin MH, Yuan WL, Huang TC, Zhang HF, Mai JT, Wang JF. Clinical effectiveness of telemedicine for chronic heart failure: a systematic review and meta-analysis. J Investig Med. 2017 Mar 22. URL: http://jim.bmj.com/content/early/2017/03/22/jim-2016-000199.long. Accessed: 4/14/17.
- Lee CH, Chang BY. Effect of Disease Improvement with Self-Measurement Compliance (Measurement Frequency Level) in SmartCare Hypertension Management Service. Telemed J E Health. 2016 Mar;22(3):238-45. URL: https://www.ncbi.nlm.nih.gov/pubmed/26252620?dopt=Abstract. Accessed 4/24/17.
- Hanley J, Fairbrother P, McCloughan L, et al. Qualitative study of telemonitoring of blood glucose and blood pressure in type 2 diabetes. BMJ Open. 2015 Dec 23;5(12). URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691739/. Accessed 4/24/17.
- Viana LV, Gomes MB, Zajdenverg L, Pavin EJ, Azevedo MJ. Brazilian Type 1 Diabetes Study Group. Interventions to improve patients’ compliance with therapies aimed at lowering glycated hemoglobin (HbA1c) in type 1 diabetes: systematic review and meta-analyses of randomized controlled clinical trials of psychological, telecare, and educational interventions. Trials. 2016 Feb 17;17:94. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758163/. Accessed 4/24/17.
- Kargiannakis M, Fitzsimmons DA, Bentley CL, Mountain GA. Does Telehealth Monitoring Identify Exacerbations of Chronic Obstructive Pulmonary Disease and Reduce Hospitalisations? An Analysis of System Data. JMIR Med Inform. 2017 Mar 22;5(1). URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5382257/, Accessed 4/24/17.
- Cheng Q, Juen J, Bellam S, et al. Predicting Pulmonary Function from Phone Sensors. Telemed J E Health. 2017 Mar 16. URL: https://www.ncbi.nlm.nih.gov/pubmed/28300524?dopt=Abstract. Accessed 4/24/17.
- Taylor P, Parker K, Patten E, Motel S. The Sandwich Generation: Rising Financial Burdens for Middle-aged Americans. Pew Social & Demographic Trends. 2013. URL: http://www.pewsocialtrends.org/files/2013/01/Sandwich_Generation_Report_FINAL_1-29.pdf. Accessed 4/24/17.
- Edelstein H, Schippke J, Sheffe S, Kingsnorth S. Children with medical complexity: a scoping review of interventions to support caregiver stress. Child Care Health Dev. 2017 May;43(3):323-333. URL: https://www.ncbi.nlm.nih.gov/pubmed/27896838?dopt=Abstract. Accessed 4/24/17.Govette J. 30 healthcare statistics that keep hospital executive up at night. Referral MD. 2017. URL: https://getreferralmd.com/2016/08/30-healthcare-statistics-keep-hospital-executives-night/. Accessed 4/25/17.
- Govette J. 30 healthcare statistics that keep hospital executive up at night. Referral MD. 2017. URL: https://getreferralmd.com/2016/08/30-healthcare-statistics-keep-hospital-executives-night/. Accessed 4/25/17.
David Gruber, MD, MBA is a Managing Director and the Director of Research with the Alvarez & Marsal Healthcare Industry Group in New York, specializing in strategy, commercial due diligence, analytics and new ventures. Dr. Gruber brings more than 35 years of diversified healthcare experience as a consultant, corporate executive, Wall Street analyst and physician.
Joel J. Reich, MD, FACEP, is the Chief Medical Officer of Eastern Connecticut Health Network. He is leading the development of the community clinically integrated network, which includes establishing a new shared governance system-physician integrated clinical-business entity, linking the acute care, home health and long-term care providers together via people-to-people and digital exchange. Dr. Reich is an ACPE Certified Physician Executive. He completed his residency at Georgetown University and is board certified in Emergency Medicine.
Joseph P. McMenamin, MD, has been involved in telemedicine since the mid-1990s. With respect to the legal issues pertinent to this form of care, he has advised health care providers, consultancies, private equity firms, telecoms and several organizations facilitating telemedical services. Dr. McMenamin has assisted organizations that train health care professionals in the use of distance technologies and advised a company developing a technology to monitor medication compliance electronically. Joe also assisted in the defense of a provider accused of malpractice for prescribing over the Internet.