Payers and providers adapted quickly to the need for telehealth services, and most patients responded in kind. Demand will remain strong as long as technology and the industry can meet it.
Before COVID-19 emerged in the U.S., just 1% of The MetroHealth System’s visits were virtual. Fast forward through the first two weeks of the pandemic, when 75% of the Cleveland system’s visits were conducted via telehealth, with a telehealth hotline established to triage COVID-19 patients who had questions or concerns or were in self-quarantine.
The hotline rotated physicians around the clock who would see patients virtually, and healthcare staff then would follow up virtually, whether through phone calls or online telehealth visits. Staff checked on the wellness of patients not only by reviewing their vitals but also by asking each patient about their access to groceries and other daily needs. Through a GoFundMe campaign and other private donations, MetroHealth raised money to send employees out to buy food and cleaning supplies for COVID-19 patients who didn’t have other in-home care.
Just prior to the pandemic, the system had hired its first director for virtual care, placing MetroHealth in the perfect position for telehealth care, even though at the time of the hiring, the need was at 1%.
“At that time, the provider culture was not very supportive of telehealth,” said Nabil Chehade, MD, MSBS, executive vice president and chief clinical transformation officer for MetroHealth. “There wasn’t a burning platform for telehealth, and the reimbursement was very clunky.
“Then the pandemic arrived, and suddenly, we had to rapidly convert scheduled appointments from in-person to telehealth and determine which patients should continue to be seen via telehealth to maintain continuity in care. We also established a 24-hour COVID-19 hotline to triage patients and leveraged telehealth for physician visits with COVID patients, where needed. Some days, we received 800 to 900 calls, and half of those calls resulted in telehealth visits.”
Within a month, MetroHealth trained 265 physicians on telehealth to meet the immediate need for virtual care. Today, MetroHealth has transformed the need for telehealth into a sustainable program that has significantly reduced no-shows and cancellations, including among Medicaid patients.
While Chehade expects demand for telehealth to continue beyond the pandemic, he anticipates overall demand will decrease to about 30% over time, with some departments, such as dermatology, aiming for 40% of follow-up visits to be conducted virtually.
That’s a view held by many healthcare leaders across the nation. Experts say the long-term durability of telehealth programs nationwide will be dictated by payment from commercial insurance and government payers as well as the ability of virtual technology to keep up with care needs.
Virtual care finds its footing
The pandemic accelerated use of virtual care as in-person visits were limited to the sickest patients. A survey of finance leaders sponsored by HFMA and CreditCare found that 83.7% of the organizations represented have increased their use of telehealth during the pandemic, and 71.6% are improving online access for patients.
For consumers, some of the biggest drivers of telehealth use are convenience, speed and safety, according to a J.D. Power survey released in October 2020. Patient experience data underscore telehealth’s staying power: A March 2021 Cigna survey revealed that 78% of patients who used telemedicine for behavioral health were very or extremely satisfied with their telehealth experiences. About three in four patients who used behavioral telehealth are more likely to use telehealth again after the pandemic.
“We expect more employers to continue to invest heavily in virtual benefits for their employees as technology and innovation continue to advance our abilities to address health needs in ways that are simple, predictable and affordable,” said Eric Herbek, vice president of virtual care at Evernorth, Cigna’s health services business.
“I think one of the biggest positives we’ve seen is the expansion of services and access to care providers to patients in many different ways,” said Donna O’Shea, MD, MBA, chief medical officer of population health management for UnitedHealthcare. “When telehealth first came out, people envisioned it as a service for rural residents who don’t have access to various types of doctors. But you know what? It’s not just a rural thing. Urban travel can be difficult, and you have to pay to get there or pay to park and find a babysitter. All of us have access issues — it doesn’t matter where you live. With virtual visits, you may not have to travel, for instance, to see your care specialists, such as a nephrologist: Many care specialists will offer follow-up visits to help with the treatment of chronic conditions, and those follow-up visits are critical to helping avoid complications.”
Cecelia Health, which specializes in diabetes and related chronic diseases, has utilized various forms of telemedicine for the past decade. Since the start of the pandemic, the need to keep patients with diabetes on follow-up schedules has taken on a new importance and given health practitioners a new view into patients’ social determinants of health.
“If you only conduct in-person visits, how do you know the living conditions that a patient is confronted with?” asked Mark Clermont, CEO of Cecelia Health. “Some of our early and continual learnings are that you can ask somebody, ‘Hey on this video call, could you show me what’s in your refrigerator?’ If you’re working with someone who is pre-diabetic or wrestling with obesity, when you’re conducting an in-person physician visit, you don’t have the luxury of seeing what’s there.”
When he started telehealth visits a decade ago, Andrew Hertler, MD, chief medical officer of New Century Health, did so in an office from a remote location, with a nurse practitioner or nurse assistant from his practice taking vital signs. Initially, there was some resistance from patients. Then, the tide shifted.
“I had some patients that started liking my nurse practitioners more than they liked me and really considered them their providers,” Hertler said. “I’ll admit that was a little harder for me because I’d spent 20 years as these patients’ doctor, and I had built these strong relationships. All of a sudden, I felt like a consultant, just flying in and giving advice to someone else who had the relationship. But it was a far more efficient way to do things, and it was far easier for me to hire nurse practitioners than it was to hire additional oncologists. Also, it’s easier to provide care for the patient through telemedicine and telehealth. It saves them a trip, which saves them time.”
Navigating virtual care delivery
While MetroHealth’s infrastructure for telehealth includes phone calls, video visits and remote monitoring, healthcare organizations can leverage technological advances to broaden the definition of telehealth according to their population’s needs.
“There are a number of interactions that would have been in-person or analog before — whether it’s paying a bill, scheduling an appointment or getting a prescription refill — that we’re making easier through digital technology,” said Dan Clarin, managing director at Kaufman Hall.
“All of these services fit within the definition of telehealth, and I think that definition is purposeful, because no provider organization is going to be successful just by doing one piece of it, such as virtual visits alone.
The biggest hurdle to supplanting a telehealth visit with an in-person visit depends on the care the patient needs. Behavioral medicine as well as many therapeutic appointments made an easy transition to telehealth because discussions with physicians and assessments of range of motion are transferable to video conference calls.
But hearing a heartbeat isn’t the same as taking a pulse reading from an Apple Watch.
“Trying to establish a relationship through telehealth can be a challenge,” said New Century’s Hertler. “The saying goes that ‘80% of communication is nonverbal.’ You don’t pick up quite as many nonverbal cues in telehealth. It depends how close the patient is sitting to the screen. In telehealth, when all you see is the patient’s head, it can be difficult to read nonverbal cues; when they’re further away from the screen, it’s easier.”
Hertler does not see a time when all care would be provided through telehealth. “I think something would be lost if that were the case,” he said.
Nonetheless, as an oncologist, Hertler found telehealth offers benefits, allowing him to check in with patients in rural Maine without asking them to drive long distances for in-person visits. Now in a position where he oversees the development of oncology care pathways that guide treatment approaches, he has been waiting for the rest of the healthcare industry to catch up, especially commercial insurance, Medicare and Medicaid, which offered limited payment for telehealth services.
“The willingness and extension of telehealth into the home within the cancer world has been extremely well-received by both physicians and patients,” Hertler said.
The future of telehealth for providers
Now that patients have had a taste of telehealth, whether from an online appointment, a simple diagnosis in a five-minute phone call or a behavioral health visit, it will be hard to shift care back to a largely in-person model after the pandemic.
“What I would say to healthcare providers at large about telehealth is: It’s table stakes,” Kaufman Hall’s Clarin said. “If you don’t have telehealth solutions going forward, it’s going to be perceived as a gap in your services and your network.”
In some geographies, technology will be a stumbling block to more expansive use of telehealth, as broadband access to rural areas must keep up with demand. However, there are also instances where new digital technologies are bridging the gap between in-person and virtual care. For example, apps and wearables are being introduced that help physicians listen with greater clarity to a heartbeat or a patient’s lungs during a video visit.
Moreover, it’s unclear how long payment parity for telehealth will last after the pandemic. Changes to telehealth payment could have a substantial impact on healthcare organization strategy.
“The most urgent needs at the beginning of the pandemic were ensuring access to virtual care services, both in terms of having care available for consumers and onboarding consumers rapidly to a new model of care,” Cigna’s Herbek said.
Cigna took action to address those needs by expanding virtual care threefold and increasing on-demand mental health support partnerships.
“We also moved quickly to ensure that all providers would be reimbursed for virtual care at the same rates as in-person visits, and we’ve continued that commitment with a new virtual care reimbursement policy launched this year,” Herbek said.
In the meantime, organizations continue to explore new ways to derive greater value from telehealth. UW Health in Madison, Wisconsin, has already rolled out virtual rounds, which allow general practitioners a chance to join a hospitalist to visit patients without having to leave their home practice. And in February, MetroHealth partnered with three Cleveland-area EMS services to provide a Virtual Care Enterprise system that helps triage 911 calls to determine which patients require a trip to the emergency department and which ones can have a virtual visit with a physician from the back of an ambulance.
Chehade says part of telehealth’s value has been in expanding access to care for vulnerable populations. Among Medicaid populations, for example, MetroHealth has seen no-shows cut in half.
“There will be some maturation in the industry’s use of telehealth, and things will go back to parity at some point,” Chehade said. “In my mind, the rapid expansion of telehealth during the pandemic was not a natural evolution; it happened as a shock and as a reaction. In the next three years or so, we expect that telehealth will comprise 30% of our visits. We will get to a more natural balance of what the patient wants and needs.”
“There wasn’t a burning platform for telehealth, and the reimbursement was very clunky. Then the pandemic arrived, and suddenly, we had to rapidly convert scheduled appointments from in-person to telehealth and determine which patients should continue to be seen via telehealth to maintain continuity in care.”Nabil Chehade, MD, executive vice president and chief clinical transformation officer at MetroHealth in Cleveland
How healthcare organizations handled initial telehealth stumbling blocks
Although telehealth platforms have existed for some time, telehealth was still new to health plans and physicians when COVID-19 made implementation imperative. When telehealth use jumped 154% in the last week of March 2020, organizations worked quickly to determine which types of visits would be funded — and under what circumstances. They also established protocols for HIPAA compliance and took steps to ensure vulnerable populations could access the technology and know how to use it.
“I think the primary piece in expanding telehealth was the funding equation, with payers establishing payment parity for telehealth visits,” said Mark Clermont, CEO of Cecelia Health. “Prior to the pandemic, a lot of progress in the utilization of telehealth was mainly in the employer space, where self-funded plans would make these services available to employees and their families. Within Medicare, Medicare Advantage and Medicaid programming, however, the reimbursement rates really were not all that conducive for physicians to want to take on those types of visits.”
While physicians were waiting for commercial insurers and government plans to catch up, insurers were testing the waters and finding some care providers weren’t prepared for the revenue cycle shift moving to telehealth would bring. Donna O’Shea, MD, MBA, chief medical officer of population health management with UnitedHealthcare, said her organization tested telehealth services and billing with a few providers in 2017, offering incentives for participation.
When the pandemic began, insurance companies such as UnitedHealthcare held online classes to help providers catch up with the technology for conducting telehealth visits and the tools for billing these services.
“Even in the [medical] groups that knew how to do these things, there were still so many physicians within these groups who didn’t,” O’Shea said. “Then there were all these other provider groups and healthcare professionals who wanted to offer virtual care for the first time, but they weren’t comfortable with the technology, because it was a new way to deliver care.”
Physicians within MetroHealth in Cleveland who had hesitated to accept telehealth before the pandemic ultimately expanded their practices quickly to accommodate it.
“Telehealth became second nature to them; now, there is a strong acceptance,” said MetroHealth’s Nabil Chehade, MD. “Initially, we were all scared to do things differently than we would in a steady state. COVID-19 was a situation where we just had to act quickly. As our use of telehealth matured, we then had to refine it, educating our physicians and clinicians on who is appropriate for telehealth and who is not the best candidate.”