Episode 24: Now Entering the Telehealth Boom

Andrew Powell: Hey everybody on this episode we’re bringing you a discussion from our recent webinar series about helping businesses to navigate their digital futures in the wake of the Coronavirus pandemic. Today, we’ll hear from Telehealth expert Joe Brennan and from OST CIO Jim VanderMey. They will be discussing the recent explosion of Telehealth and the way it’s changed over the last few weeks. Take a listen. Enjoy.

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Jim VanderMey: More has happened in Telehealth in the last three weeks than has happened in the three years prior. I’ve seen, obviously, the scale has gone up, the insurance rates are going up, people’s acceptance, physician acceptance. So many things have changed and Joe is the best Telehealth resource I know in the industry and I have really enjoyed our collaboration with him. Joe, want to give your intro to who you are, and then we’ll get into our content?

Joe Brennan: Thank you very much, Jim, appreciate it, and thank you for the opportunity all of you, to have a chance to talk about Telehealth. As Jim said, so much has changed in the last three weeks. It is unrecognizable for some who have been doing this as long as I have. But our time in Telehealth is finally here. And what I hope to do today is give you just a very quick overview of what those changes were. And then also whether you are a hospital or a medical group whether you are a vendor, everyone is trying to understand where their place is, in this changed healthcare environment. Virtual has now become a go-to tool in response to COVID-19. But I think if you talk to almost anyone, they will believe that healthcare is changed permanently. We are not going to go back to the way things were before. This is a change that was forced because of this pandemic, but it’s something that will bring benefit and value moving forward as we live in our new healthcare reality. Next slide please.

The big changes, the very first was that CMS came in and said “We are going to waive the originating site requirements”. Meaning that previously Medicare would pay for Telehealth if the patient was in a rural community and in a designated clinical setting. They waived that, so that Medicare would then pay for any Telehealth service including patients in the home. And so that original waiver changed that primary barrier to Telehealth advancement—which was a reimbursement. It was always the excuse, “We can’t do this because we don’t get paid for it, it’s not something we’re interested in pursuing at this time, but we will in the future.” Well, once that barrier of reimbursement went away, everyone then had the ability to utilize Telehealth. Second is the changes in Medicare Advantage. They were already forward-thinking as it relates to Telehealth, but they expanded it to where everything including remote patient monitoring would be covered. 

The next domino to fall was HHS and the Office of Civil Rights, waived restrictions as it relates to HIPAA. Previously, a video technology that utilized for Telehealth had to be HIPAA–compliant. It had to do with the BAAs and agreements that the vendors had with health systems and whoever is utilizing the technology. But that HIPAA prevented people from using everyday video conferencing technology. And by paving that, it allowed everyone to get started very quickly. Now, everyone you talk to will say that “We don’t want to establish a program that utilizes FaceTime or Zoom or whatever the case may be,” but it allowed everyone to implement Telehealth very quickly.

The next step was the DEA said that we can now prescribe Controlled Substances without a prior relationship. And what that allowed providers to do is you did not have to go through the normal processes, you could treat those patients who needed medications very quickly and fill in gaps.

The biggest sticking point which has caused the most confusion is state licensure. There was a press conference about two and a half weeks ago were Vice President, Mike Pence, said that medical licenses were allowed to go across state borders, but this is a very state-specific regulation. The federal government can’t actually make that change. So, it’s up to the states to change that. About a week ago there were 35 states that would waive licensure requirements so that a physician could practice across state lines without holding a license in that state. As of this morning, we’re now down to 47—or up to 47 states that allow that to happen. Minnesota, Alaska, and Arkansas are still holding out for some reason, but we imagine that that will change in the coming days. And then finally Medicaid where Medicare is federally–mandated and most of the decisions are made at a federal level, Medicaid is very state-specific and so additional states trickle in every day, we’re in the 30s right now as far as states that are waving Tele—previous restrictions on Telehealth as it relates to Medicaid, but we’ll see all 50 states here in the next two to three weeks.

So now that we have had the previous barriers removed and there is this burning demand in order to implement a Telehealth solution, the conversations that I’m having as a Telehealth consultant, conversations that Health Systems and hospitals and vendors are all having is: if we don’t have something established or we have something that was maybe not utilized a great deal, how do we take what we have or how do we start something as quickly as possible but still keep the integrity of a good patient experience and a good provider experience? And so the considerations that people are taking on, we bucketed into five areas.

Very first is the technology. Previously, Telehealth, the conversation was: once we pick a technology we are done. It will take care of itself and what people found was that that was not the case. The technology was a decision to start but it’s the operations and the change management that really made a Telehealth program move forward. So picking the technology, what are the clinical considerations? It is important to know that not everything would be appropriate. But what we’re seeing now is that things that were previously—felt inappropriate for Telehealth are now being seen as something you can definitely use Telehealth for.

Jim: Hey, Joe?

Joe: Yes?

Jim: Just a question to that. What are some examples of things that were viewed as inappropriate that are now being viewed as appropriate? Where are some of those lines being transitioned now?

Joe: Well, you see a lot in the specialty area. Primary care has utilized this for low Acuity Primary Care, cough, cold, sore throat—that type of thing—and so they were very comfortable with it. But specialist had always said, “You know what, I need to lay eyes, I need to lay hands on the patient, I need to have them physically in front of me.” What comes to mind in the last couple weeks specifically is in oncology. We have a lot of oncologists that say, “Telehealth is great, but I need that patient sitting a few feet in front of me, have that conversation and if necessary lay hands.” But now that they are restricted from doing so and they are transitioning face-to-face visits to virtual or finding that they are getting all the information that they need and it’s keeping everyone safe. So it’s really that that physician resistance, initially was: I don’t know what this is, therefore I’m not comfortable with it. And now that we’re forced to do it, they are seeing that there’s tremendous value to it.

Jim: And so the benefit to the patient, especially those with immune-compromised systems in the oncology practices now outweigh the physician–reticence to adopt Telehealth. 

Joe: Absolutely. And if you use oncology as the example, because of the medications and the situation that those patients are in, even when we’re all able to go out to restaurants and do all of that, because their immune system is so compromised, many of them will have to wait until there’s a vaccine. So they are on restriction for months and months and months past when we are. So when you have to think about what their reality is, virtual care is the option. And now that those in the specialty are getting comfortable with it, I think it’s going to benefit everyone.

The training, I can’t emphasize enough to whoever asks the question that the experience needs to be the same every time a patient connects, and every time a provider connects. Those that think this is just about the patient experience and getting them comfortable with it, if you don’t have a good provider experience, they aren’t going to use it consistently. You have to make it easy to use for both the provider and the patient. But once you nail what that is and you create a standard that gets you comfortable, train it so that everybody does it the same way and then you have something that everybody is comfortable using, it’s easy to use and that’s where you get scale and sustainability.

Communication is critical, understanding that you need to get the word out to your patients whether that’s simply somebody from scheduling, making phone calls, whether it’s a blast email whether it’s relying on social media as your communication to your patients, letting them know what’s going on is very, very important. 

And then finally, we need to measure this. We need to measure what we’re doing so that we can prove to those that say, “Hey we need to go back to the way this used to be” and prove it with data to say, “no, we aren’t going back and this is why.” It is also very important to understand where you are having successes and where you are having failures. Having a dashboard that says, “this practice is doing really well. This practice is struggling or this acuity or this service line is really nailing it.” And this is where we need to focus more attention. Data, data, data, that’s what’s going to tell you where you are good and where you aren’t.

An example of that is I have a customer on the East Coast who’s in one of the three state’s hardest-hit and I get a daily update from Tableau that says how many appointments in all of our Medical Group were virtual versus face-to-face and what they have seen in the last two and a half weeks is are hovering around 68% of all the visits in their Medical Group are done virtually. They aren’t canceling appointments. They are flipping them to virtual so that fear of “We do not have elective surgery, we’re going to run out of money, this is having a huge financial impact.” If you implement virtual now, you can maintain some of that revenue by flipping face-to-face to virtual and not just completely shutting down.

It isn’t just video conferencing that people are putting together as quickly as possible. I think when everybody was first hit with this in early March, the talk was how do we put a chatbot in front? How do we put asynchronous Telehealth upfront so that people aren’t just knee-jerk reaction calling the call center? Because you had call centers that were overwhelmed with volume from the worried well, “oh my gosh, I don’t have any symptoms. But what should I do here?” And by putting a chatbot or some type of asynchronous Telehealth upfront, you could screen patients quickly and say based on your responses to these questions, you are okay. Just you know, stay safe. Versus you answered yes to many of these questions and we’re going to direct you to this area. Putting some type of triage tool that was asynchronous upfront really allowed them to control the people they needed to deal with versus the people they did not need to deal with. And so that’s not just somebody sitting at home having a video consultation.

And then what I think we’re going to see in the coming months is that consumer-grade technology. Remote patient monitoring has been around for many years, but it was built in a way that required a lot of resources to stand it up. What I think we’re going to find is that there will be more consumer-grade technologies. There will be the Pulse Ox that you buy from Amazon or items like TytoCare where it’s a 7-in-1 device that will be sent to the home. Then allows the provider who might not necessarily need a video visit but can monitor what the symptoms are so that the patient does not need to leave the home. There are not just video visits. I don’t think that’s all that’s going on. But it’s every type of technology utilized to provide care.

Jim: Well, what about the kind of interactions, Joe, that don’t require the technology of the blood pressure cuff and other things like that? Behavioral Health comes to mind as well as people are dealing with stress. I think that the sub-acute and acute cases are getting so much attention right now, that behavioral health is probably an area that—that’s if not exploding right now, about to. What do you think?

Joe: Well, it already is, based on what’s coming. You look at the big four Telehealth vendors of American Well, Teladoc, Doctor On Demand, and MD Live, those that offer Behavioral Health Services, they are seeing a significant spike because this is a very trying time for those that would normally carry stress and anxiety. When you are stuck at home and you are furloughed from your job and you don’t know what’s coming. They—just the ability to reach out to someone and have a conversation with a trained professional is significant and we’re all in this very strange time and stuck in our own environment. And so Behavioral Health I think is going to be the next major consideration once it’s not necessarily all about, do you have symptoms of COVID-19.

It is always been a very strong use case for Telehealth because there isn’t a physical exam required. It is establishing trust in a relationship and that can be done very well with video conferencing. I had experienced it with my previous employer and I’ve helped three other customers stand up Behavioral Health. Obviously not everything is appropriate. Those significant concerns still require someone to be in a care setting but the stress, anxiety, loneliness, depression, that’s where this plays a significant role.

Jim: Yeah.

Joe: So the question that those that don’t have a program or very early, the question is where do I start? Is it in the asynchronous chatbot? Through our patient portal? Is it just synchronous video visits? Is it remote patient monitoring? The answer is yes.

I think we’re in a new environment where whatever technology is going to produce the best result, that’s what you are going to use. And so doing an evaluation of what do we have currently? What can we use currently to get started? And then we also need to think strategically about what are we going to do long term? Because there’s a world after COVID-19. And we need to start thinking about that now. What are we building now? What are we putting in place now, that’s going to be sustainable, not only the summer but for moving forward as a system?

Jim: What are people using right now Joe?

Joe: It is all across the board. Again, the people that were able to flip the switch already had something established. You do hear some stories about needing if they have Vidyo, V-I-D-Y-O, as the tool baked into their electronic medical record. Having to, if it’s an on-premise solution, they need to triple or quadruple the amount of congruent streams that are necessary. Where they were good with 15? They now need a hundred and fifty, or I have a couple of clients who are in-touch with clients. They had licenses that met the need of where they were and where they were going to be in the next year and then all of a sudden, “nope volumes going to be tenfold. How do we figure out how to do this?”

I have had multiple conversations with smaller independent practices saying, “can I just use FaceTime?” And yes, the law says you can during this crisis, but let’s think about it really quick, is this something that you want to give your personal phone number to a patient? And allow them access to your phone anytime you want? How are you capturing consent if you are doing FaceTime? There is just a lot of considerations that, yes, you need to stand something up quickly. But you also need to do it in a manner that’s not compromising anything else that you are doing.

There is a list from the American Telemedicine Association. They have created a link that provides all of the vendors that are currently giving free solutions during this pandemic.

Jim: You talked about CMS and Medicare and Medicaid, what about the private payer market? How are they responding to this environment?

Joe: Well, in Healthcare previously, they would follow the lead of Medicare. There were a lot of progressive commercial payers that were paying for Telehealth before, but you see the same, “okay, the all hands on deck, this is something that we’re going to deal with. We are going to also make sure that we pay for Telehealth services.” And so they are following in line with what CMS has done. Some are even waving co-pays or any type of obligation from the patient as far as payment goes. But again, it’s company-by-company. And so there are resources out there that talk about, who’s doing what and where?

But the recommendation that we give everybody is: the individual needs to contact their insurance company because every package is a little different, every plan had some nuance to it, but overall, safe to say that commercial payers are also making Telehealth more accessible to everyone.

Jim: Right. And many of them have their own offerings because of their partnerships like Aetna has Teladoc for example.

Joe: Yep. Absolutely. So whether it’s your healthcare system that’s providing it or you are looking for a Telehealth solution that’s offered by your insurance company. I mean prior to this, Telehealth from an insurance perspective, it was a huge cost-saver, where you know, low acuity conditions and follow-up visits were in the hundreds of dollars. Now, this is something at a lower price point. So it made sense for them to encourage it anyway, and now I think you are going to see that continue moving forward. 

Communication is obvious but, critical, if people internally don’t know what you are providing and how it works. There will be resistance. I’ve seen that time and time again that without being communicated to, if someone feels left out or they aren’t a part of the process, they aren’t going to be all in. And so that first bullet point is what we’re telling everyone; if you are going to implement Telehealth and you did not have something previously, make sure that everybody knows what’s going on in that they understand how it works. And why you are doing it. And then recommendations to create consistent scripting so that everybody knows what to say. For many this is brand-new, and this is going to be confusing and just a huge learning curve. But if you create a really good script that everybody can read off of, you will have a much better chance of success.

Jim: But Joe, consistent communication implies a consistent platform. In our previous days of Telehealth, we saw a lot of small-scale POCs or even fragmented implementations within health systems. Are you seeing people consolidating now to create those consistencies?

Joe: Yeah, I think people are just hyper-aware. This is what I’ve seen just in general, not necessarily about the communication of Telehealth, it is all hands on deck. In healthcare, we’re the frontline just like First Responders who are in 9/11. Health Care is the frontline and everyone is open to doing their part. Whatever you need me to do, let’s do it. And if because that’s the mindset now, if we say, okay we’re going to shift and we’re going to put carts in all these intensive care rooms or we’re going to flip all of our ambulatory visits to virtual, where previously there was the luxury of, “well I don’t necessarily agree with that.” Now it’s like, “okay, what do we need to do? Just tell me where and I will do it.” So having that type of mindset I think is what’s making the adoption curve grow so significantly. I think that’s why you see 50% of people utilizing virtual because this is an all-hands-on-deck scenario and people are now hypersensitive to the communication of what’s next. How are we doing this? What is our triage center look like? How are we screening patients? Where are we sending them to? Who needs what? And so getting that communication out to also talk about what your virtual tools are, I think, people are listening. I just want to add to that, I think this has changed permanently. Our healthcare is different moving forward from March of 2020.

Jim: All right. Thank you, everyone.

Lizzie Williams: OST changing how the world connects together. For more information go to the ostusa.com/podcast.