Value-based telemedicine

By Blake McKinney, MD

When a family member was a new mom, she called me concerned about her 7-day-old baby’s breathing. I almost sent them to the ER. Then she asked me if we could FaceTime. What I saw was a warm, pink, dry baby looking around, looking quite well to me. I was able to tell that she had no labored breathing, no retractions, or nasal flaring. She just had a little stuffy nose. I had been answering questions, treating minor ailments, and triaging the acutely ill for several years via text, but it was in that moment that I knew the iPhone and other smartphone devices would fundamentally and forever change the way physicians can deliver our services.

Fast forward to next year. An eMarketer report estimates 2 billion people will have smartphones across the world in 2016. Industries are being transformed radically by the widespread uptake of these devices. Health care will be no different and will continue to move toward more virtual care enabled by smartphones. As the example above demonstrates, it makes sense for both care and economics. Virtual care and telemedicine worldwide is expected to be a $34 billion market by 2020 according to a Morder Intelligence report, with the U.S. accounting for 40 percent of that, nearing $15 billion in the next five years. Several early stage telemedicine companies have raised many millions of dollars in the last several months.

Payment reforms are driving the market toward value-based care and will only accelerate the use of telemedicine via smartphone. Many new forms of payment for medical services are emerging that are not tied to the legacy fee-for-service reimbursement model. Patients are paying more out of pocket and therefore have increasingly aligned interests with payers to reduce costs while achieving better overall health. These changes are, in turn, driving the empowered health care consumers’ demand for a better experience and convenience.

Estimates are consistent that more than half of all clinic, urgent care, and ER visits “could be handled safely and effectively over the phone or video,” according to the American Medical Association and the Wellness Council of America. A recent JAMA study found no difference in quality between in-person and telemedicine visits for minor conditions. Physicians and payers are both looking for ways to adapt to these new realities.

In this new context, the old ways of treating many ailments in an expensive facility across town or even across the neighborhood no longer fit with modern consumer expectations. If a patient can visit with a physician by phone, video, or secure text in the middle of the night or during working hours at little or no cost for the individual, in-person visits in many circumstances may become unnecessary. In-person care can be a drain on resources and productivity, with substantial opportunity costs associated with missed work or school.

To get to high quality telemedicine, it will take more than just a doctor on a phone. To help align patients, providers, and payers toward achieving telemedicine that works for each, the following are necessary for getting value-based telemedicine right.

1. Close the loop, continue the story.

It’s often been said, recently by The Commonwealth Fund, all health care is local. Ironically, the same is true for telehealth.

Providers in value-based systems want to ensure their patients get the care they need in a way that takes care of urgent issues but also ensures that physicians can communicate with primary care and hospital services when needed. It isn’t as simple as an isolated video chat, text message, or phone call: it requires working remote physician access into an entire continuum of traditional care; supplementing and integrating virtual with in-person visits and closing the loop.

Telemedicine shouldn’t create yet another silo of data and care. Each patient is a story, but treating a patient out of network turns a chapter in a story into an isolated event, in a separate book, kept in another library. It can become very difficult to enable true patient engagement and behavior change when episodes of care all too easily disappear from a longitudinal record.

“In this new context, the old ways of treating many ailments in an expensive facility across town or even across the neighborhood no longer fit with modern consumer expectations. If a patient can visit with a physician by phone, video, or secure text in the middle of the night or during working hours at little or no cost for the individual, in-person visits in many circumstances may become unnecessary.”

2. Don’t add a co-pay to telemedicine services.

Adding a co-pay or other fee-for-service component creates a cost barrier for the patient to use the service and therefore doesn’t meet the litmus test of the triple aim. Co-pays disincentivize individuals from using the service (and possibly receiving needed care) and create perverse incentives for providers to try to accumulate more individual calls rather than providing treatment in the most effective and efficient way possible. Payers and risk-bearing providers are learning that it makes more sense to provide a free service to their members. When more than half of in-person visits to the ER and urgent care are unnecessary and virtual care provides equal results, the value-based approach is the more sensible one.

3. Make it convenient, available anywhere via text and video.

Direct access to a physician can be valuable anywhere, anytime and in an unpredictable fashion. The telemedicine of yesterday was built on closed-circuit TVs, video teleconferencing technology, and hub-and-spoke network architecture. However, today’s telemedicine is based upon technology that most Americans carry in their pockets. We spend a lot of time on our phones and on our computers, asking questions and holding conversations. As many doctors currently text, call, and video chat with their own friends and family when a medical issue arises, often conferring great value, so should doctors be able to care for large populations, supported by the right technology and business models.

4. Help doctors work the way they want to work, the “quadruple aim.”

Physician dissatisfaction is rampant. What many doctors acknowledge as a workforce-wide collective depression results in large part from how physicians today spend the majority of their time: entering documentation into bulky electronic health record systems designed primarily to maximize fee-for-service billing rather than clinical utility or doctor-patient engagement. According to Dr. Bob Wachter, a UCSF physician and the author of “The Digital Doctor,” a large part of physician dissatisfaction stems from the time they spend interfacing with EHRs and their billing apparatus, often called “administrative overhead.” What this really means is that physicians have to spend more time figuring out how they are going to get paid and entering data to justify why they should be paid than actually listening and interacting with patients. Physicians hate it, and patients feel irrelevant. By making the interaction with technology a byproduct of a conversation that is self-documenting within the technology platform, physicians can get back to working the way they want to work. If we then structure physician compensation around value-based payments and measure success against outcomes, we can reward physicians for delivering the type of high-quality, customer-centric care that most doctors got into medicine to provide in the first place.

Because physician burnout endangers the triple aim, the Annals of Family Medicine suggests it be expanded to the quadruple aim by including physician satisfaction. Data capture around a clinical encounter doesn’t have to be a chore. Value-based care with the right technology allows for the capture of real interactions the way they happen in nature, so to speak, without the need for artificial billing codes. It enables us to return to one of the oldest and most intimate forms of human interaction – the doctor-patient encounter.

Moving to a new health care model based on value requires more than just repackaging old technology systems. It requires enabling the ways people are already communicating, and the right telehealth solution reinforces new business models that create the right financial incentives and physician/patient workflows to align the interests of all participants.

Blake McKinney, MD, is chief medical officer and co-founder of CirrusMD.
This story first appeared on The Health Care Blog.