Telehealth has the capability of transforming healthcare, bringing better care to rural areas, reducing costs, and improving patient outcomes. However, barriers ranging from insurance payments to legislative issues have made it far more of an evolution than revolution. As 2018 draws to a close, we look at how three major areas have developed recently.
“Telehealth possesses a significant potential to revolutionize healthcare delivery processes by challenging some of the long-held assumptions about healthcare delivery and by creating innovative alternative models. Those assumptions relate to the location-linked nature of healthcare and its episodic nature.”
Those words were published in November 2008. The technological innovations made in the decade that has passed since then are nothing short of remarkable, as start-ups and established giants alike have made a claim for their stake of what is now a billion-dollar industry.
The oft-touted benefits of telehealth include better outcomes for patients, improved efficiency for healthcare professionals, and limiting the damage caused by the lurking threat of a significant physician shortage. All while saving a whole lot of money.
Despite the tech getting smarter and major players getting involved, however, the healthcare industry often feels as though it operates under a shell, the layers of which – health insurance, legislation, and an often-out-dated IT infrastructure – make it almost impervious to widespread changes, however beneficial they appear to be for everyone involved.
The much-anticipated revolution has thus far been a slow-burning one, to put it generously.
In the past few years, however, the aforementioned layers have been gradually chipped away and telehealth has finally been fulfilling some of the potential it has promised for so long. With 2018’s conclusion drawing near, here is how three important areas have developed this year.
Shifting Towards Value-Based Models & Telehealth-Friendly Legislation
“Telehealth has been stymied, it’s has been held back,” Terry Hill, of the National Rural Health Resource Center, told me.
Given that improved access to healthcare in rural areas is perhaps the most cited benefit of telehealth, Mr. Hill’s role means he has taken a keen interest in its progress over the years.
“The biggest barrier by far has been the payment system,” said Mr. Hill, whose 30+ years of experience has seen him work with hospital leaders across the country.
“The central government, for example, which leads the other payers has been slow to approve payment for telehealth and telemedicine services.”
In particular, Mr. Hill highlights the shift from fee-for-service payment models to value-based ones. Under the former, doctors are paid based on the treatment they provide to each patient. Value-based models, of which there are several variations, focus on outcomes.
The Affordable Care Act (2010) and the Medicare Access and CHIP Reauthorization Act (MACRA - 2015) pointed Medicare and Medicaid firmly in the direction of value-based models such as capitation. Under capitation agreements, providers are paid a set amount per patient, which is determined on factors such as age and medical history.
“Everything in this country resolves around money, so once the money aligned with it, then the hospitals will get on board and the physicians will get on board as well”
– Terry Hill, National Rural Health Resource Center
Falling between fee-for-service and capitation are several hybrid models that employ elements of each.
The pros and cons of fee-for-service and capitation models can be, and is, endlessly debated. Indeed, the reputation of the word capitation is still recovering from the damage is received following the financial failure of the model in the ’80s and ’90s. However, in today’s world there is renewed belief that it may help reduce costs and improve outcomes, at least in certain sectors of healthcare.
And, as Mr. Hill alluded to, many private insurers follow the Medicare’s lead. As such, the industry as a whole has been shifting towards value-based models at an ever-increasing rate.
While value-based models encourage the use of telehealth by holding providers to greater accountability for the cost of caring for their patients, Medicare’s reimbursement policies have long countered that by restricting what is actually covered.
The CHRONIC Care Act 2018, passed at the start of the year, expanded what can be offered to those covered by Medicare Advantage (19 million people) and Medicare beneficiaries who receive healthcare from Accountable Care Organizations (ACOs – 10 million people).
- Remove geographical restrictions for telehealth consultations for stroke patients, beginning in 2019
- Expand telehealth coverage under Medicare Advantage Plan B, beginning in 2020
- Reduce telehealth restrictions for ACOs
- Expand the number of originating sites from which the beneficiary can have a telehealth assessment with the nephrologist to include freestanding dialysis facilities and the patient’s home; and enables these telehealth visits to be conducted from the expanded list of sites without geographic restriction, beginning in 2019
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While these benefits don’t come into effect immediately, the fact they have been passed into law this year is a huge boost to the telehealth industry.
If telehealth challenges the notion that location is particularly relevant to healthcare, there is another issue that arises.
Telehealth Across State Lines
Mr. Hill lives just outside of Duluth, Minnesota, where waiting times are often long.
“I absolutely don’t want to have to drive half an hour to get to Duluth to sit in an urgent care center for an hour or two hours,” he told me.
“It’s much better in other cities. If I have that visual contact with a physician in Seattle, for instance, and he or she can send in a prescription for me, then you can see where the industry is going. It’s pretty clear for me, it’s about mobile health.”
The concept of physicians being able to treat patients, regardless of location, is one of the reasons telehealth is so attractive to rural populations.
Mississippi and Idaho have 186 and 192 physicians per 100,000 people respectively, well below the national average of 271. The shortage of physicians across the country could reach over 120,000 by the end of the next decade, according to the Association of American Medical Colleges (AAMC).
The problem with Mr. Hill receiving telehealth care from a Seattle-based doctor from his home in Minnesota is that physicians require a license from each state they practice in.
The possibility of the physician and patient being in different states – or even different countries – has created something of a grey area. Archaic regulations are, naturally, ill-equipped to deal with telehealth and are, unsurprisingly, slow to be updated.
Physicians understandably tend to err on the side of caution, given the severe consequences of being found guilty of practicing without a licence.
Teletherapy is an area of telehealth that holds huge potential but is being currently restricted. If a mental health professional in Washington is proving teletherapy to a client in Minnesota, for example, under which state’s jurisdiction do they fall? Logically, if the practitioner is in Washington, they must act under that state’s law. However, there is a lack of clarity and many providers simply steer clear of interstate care.
This is obviously bad for clients, who may not find their ideal therapist locally. Or, perhaps they have built a relationship with a therapist but choose to move to another state. Should they really be forced to cease that relationship?
“The number one sector, from a needs standpoint and from a financial standpoint, is mental health”
– Terry Hill, National Rural Health Resource Center
Similarly, consider rare conditions that only few physicians are qualified to diagnose and treat. Teleconsultations could be cost-effective and hugely valuable but are restricted by licensing laws. If one is too unwell to travel, or restricted financially, the situation arises that they are being denied care because of regulations, despite the technology making it possible being readily available.
Of course, there are issues such as quality control and malpractice laws that need to be taken into consideration regarding remote care, but the benefits of overcoming such obstacles are surely worth the effort of doing so.
Perhaps the most promising development in the past year has been the growth of the Interstate Medical Licensure Compact (IMLC), which is designed to make it easier for physicians to obtain licenses from multiple states.
Seventeen states are now able to act as a State of Principal Licensure (SPL), meaning they are responsible for conducting the process of verification of the doctor’s qualifications. A further two states are members of the IMLC and able to issue licenses from SPLs but are not SPLs themselves.
Legislation has been passed but not implemented in two more states and another seven states, plus District of Columbia and Guam, have started the process.
The remaining 21 states, however, are not currently involved at all.
Aside from the IMLC, the Department for Veterans Affairs (VA) announced a federal rule “that will allow VA doctors, nurses and other health-care providers to administer care to Veterans using telehealth, or virtual technology, regardless of where in the United States the provider or Veteran is located, including when care will occur across state lines or outside a VA facility.”
These are steps in the right direction and hopefully signs that regulations and legislation is beginning to catch up with technological advancements.
However, it is an area that needs far greater focus. Countless people could benefit from telehealth that is free from the burden of state restrictions, and healthcare professionals must be able to administer it – when appropriate – without the threat of civil or criminal charges looming over their heads.
Growth of the Tech Companies Driving Telehealth
Putting issues such as legislation and insurance coverage to one side, the actual technology that drives telehealth continues to advance apace.
There is a huge number of both budding start-ups and established giant shaping the industry, and significant moves have been made in 2018.
Teladoc promises to connect patients to a physician via web, phone, or mobile app in less than 10 minutes.
In 2017, the company reported revenue of $233.3 million. It’s third quarter revenue alone in 2018 was $111 million, with a projection of over $410 million for the year. Of course, these figures are a drop in the healthcare ocean but, in terms of percentages, it is growth that many companies would envy.
It also followed up its 2017 acquisition of Best Doctors by purchasing virtual care provider, Advanced Medical, in September of this year, and has announced collaborations with academic institutions such as Jefferson Health.
The company is planning to take its service worldwide when it launches Teledoc Global Care next week.
One of its rivals, American Well, announced a partnership with tech giants, Samsung, and health insurance company, Anthem, to provide telehealth services to the latter’s 74 million members. The company also boasts Philips as a major backer, as tech companies vie for their slice of the telehealth cake.
Indeed, American Well has experience with the largest tech company of them all: Apple. Their service was used to support the Apple Heart Study just over one year ago.
Throughout the study, participants were alerted when their Apple Watch – a smartwatch with a built-in heartrate sensor – detected signs of an irregular heartbeat. They could then use American Well technology to video chat with a doctor to discuss the best course of action.
The study was the foundation for the next big step this year – receiving FDA approval for two apps designed to detect atrial fibrillation.
Apple will also be cropping up more and more in the telehealth market, given how healthcare appears to be a vital component of its strategy. It is one of the few companies that may be able to successfully tackle one of the biggest issues that has plagued healthcare IT in recent years: interoperability of electronic health records (EHRs).
In January Apple announced the Health App would be able to connect seamlessly with 12 healthcare institutions, allowing iPhone users to download their EHR. That was followed in June by the announcement that external app developers would be able to utilize the information.
The number of institutions enrolled in the service has grown to over 130.
Apple’s approach is blurring the line between mHealth – the concept of users capturing their own health data, such as heart rate – and telehealth. If implemented well, doing so has the potential to improve the usability and usefulness of both.
Apple is joined by the likes of Amazon and Google in having a keen interest in healthcare. Having such powerful companies having a vested interest in telehealth will surely be significant in driving the industry forward in the coming years.
Healthcare revolution may make for enticing headlines, but the truth is that bringing wholesale changes to the industry is a painstakingly slow process. The developments made in 2018, however, suggest that the barriers standing in the way of its widespread adoption are gradually being eroded.
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