COVID-19 pushes healthcare delivery closer to an online retail experience

As clinics struggle financially, virtual care technologies are keeping them afloat

(Vator will be hosting its Future of Virtual Care event on July 1. Get your tickets here to see speakers like Carbon Health CEO Eren Bali, MDLIVE CEO Charles Jones, American Telemedicine Association CEO Ann Mond Johnson, El Camino Health Medical Network President Bruce Harrison and more! Thanks to Steve Loeb and Mohammad Gaber, CEO of Wellpay, for contributing to this story)

By now, the idea that COVID-19 collapsed telehealth adoption from years into months is well documented. General medical virtual visits are predicted to reach 200 million this year, more than five times original estimates. Teladoc shares have doubled in three months and Amwell filed to go public. The virus forced everyone’s hand to reinvent themselves on the fly but despite the pain of disorientation and loss of revenue, what is left is a clearer roadmap of how to deliver healthcare, and it looks an awful lot like the modern retail experience, replete with a plethora of transparent options and information, and the conveniences of same-day delivery to your home. 

The COVID experience has awakened everyone to the fact that patients and providers love virtual care and there's no turning back. We won't get back to the old normal, and we certainly won't last in this current normal. But we have a much better idea of what the future normal will be. 

Here’s a look at how a host of clinics reacted to the brutal lockdown; the way they innovated on the fly; and how their ad-hoc experience, however rocky, gave them a glimpse of the future and empowered them with preparedness in case we're hit with another COVID wave in the fall.

Surviving without in-person visits 

While restaurants and retail shops were able to offer curbside pickups during the lockdown, clinics were left vulnerable. For instance, as of the week starting May 10, endocrinology visits were down 23 percent from baseline, ophthalmology was down 39 percent, and pediatric visits were down 45 percent. As bad as those numbers, they’re actually a marked improvement from the month prior. That kind of reduction impacted clinics where it hurt the most: in their pocketbooks. Clinics were already struggling with this before, and when COVID hit, their financial problems were exacerbated. 

At John Muir Health, for example, revenue was wiped out instantly. Chief Strategy Officer George Sauter said, “During that period in March and April we saw reductions in cases not obviously impacted by COVID…conditions like strokes and cardiac surgery. Everything was down quite a bit. People weren't driving around getting in car accidents, which was a good thing, but it also meant we weren’t as busy as usual in our emergency departments and trauma center,” he said. “Financially, we lost $21 million dollars in March, $36 million in April. It's not looking as bad in May and we're on our way back up." 

Bruce Harrison, President of El Camino Health Medical Network, said that the initial drops his clinics saw were even bigger; however, total visits had since come back up, mostly thanks to the implementation of telehealth. “In-person clinic volume dropped by 75 percent in the first couple of weeks, but our total visits in aggregate are now 90 percent of our baseline. Initially, during the peak of Shelter-in-place 60 percent of our visits were accommodated through video and the phone,” he said. “We have since, seen our in-person visits return.  Video visits are currently 10-20 percent of our overall volume. There is tremendous value in the use of video visits that are coordinated between a patient and the doctor, where it’s a complementary tool to help support an established relationship.” 

For other clinics that could switch immediately to telephone and telehealth, their bottom lines were not as impacted, and in fact with telehealth, their visits have gone up.  

“The week of March 16, and the following week, we had 30-percent decline in revenue because of a reduction in visits. After that, it was down 10 percent but, ever since, we've been over 100 percent, and most recently 115 percent of productivity,” noted Jason Cunningham, CEO of West County Health Centers. “Visits coming in have exceeded what we were seeing prior to COVID-19, which I am so thankful for because otherwise we were going to do layoffs and other things because there was no way we could survive. But that only happened because we were able to pivot quickly on to video and telephone.”

One Community Health, meanwhile, managed to keep its reduction in patient visits down to just 15 percent. CEO Michelle Monroe credits that to the fact that the clinics switched over completely to phone visits in just a few days. “In Sacramento, we went to shelter in place before the state did, so we were already in the thought pattern of how to do care and we knew we had to convert to phone visits ASAP. We switched over phone visits in three days, so we didn’t have that much downtime. We got the message out to social media; we were proactively calling patients that were on the schedule, and proactively calling patients that needed chronic care and saying, ‘Hey, we're here for you and we can still see you’,” she said. “During this time, we also continued to accept new patients, where a lot of other clinics did not. Every new patient had a phone consultation with a medical provider.”  

Seeing no-show rates drop; customer satisfaction go up 

There's a benefit to having everyone adopt new habits at the same time. There's fewer risks in making mistakes so when the experience is positive, it's a nice surprise.  

According to One Community Health's Monroe, the switch to phone visits led to no-show rates dropping by half, while patient satisfaction shot up. “Our no shows for in-person visits are down to 10 percent from 20 to 22 percent," she said, adding that for the clinic, the process is far more efficient as well. As for satisfaction rates, they're going up. “Is it going up because it's something we’re doing or because they're grateful to have access to services? Is it because of the phone? We haven't been able to dig into that specifically yet but that's something we'll be looking into."

Even more telling: the clinic hasn’t seen a single complaint for three weeks straight, far from the common five to eight complaints a week. The reason? Transportation. Nearly a third of all patient complaints were about finding parking. 

“Before all of this, when you would look at your no-show rate and ask the clinic staff, ‘Why is our no-show rate so high?’ the very first answer they always give you is, ‘transportation.’ Now, whether that’s the truth or not is another issue but there's always this mindset that transportation is the reason why people don't see us,” Monroe said.

Transportation was also a big hassle factor at West County, said Cunningham, and like One Community, satisfaction rates have gone up since switching to telehealth. 

“The same patient who had to drive literally 40 minutes from Bodega to get to my office to sit in my office for probably 40 minutes, and then see me for 20 to 30 minutes, only to have to drive 40 minutes back, that person can be waiting for me while sitting on their own couch. The reaction from our most vulnerable population, who have transportation insecurity or have real anxiety about going out, has been unbelievable. Our no-show rate has plummeted,” said Cunningham. 

“Obviously there are things that we need to have in-person, so we see patients who need EKGs or lung evaluation or a breathing treatment or immunization, things like that. For the most part, though, most of our work is sufficient for a video. That experience, and the convenience, has been a boon for our patients.”  

Reimbursement and the rise of in-home care 

While it is true that patients weren’t taking full advantage of telehealth until recently, it wasn’t the only thing that stopped clinics from fully embracing the technology: it was also the fact that the clinics weren’t being paid for these visits until COVID forced the government's hand to lift reimbursement obstacles. The CARES Act, signed in March, authorized Federally Qualified Health Centers (FQHCs) to not only set up telehealth services for Medicare patients during the COVID crisis, but also allow them to get paid for those visits.    

“We knew that phone visits, video visits, and remote monitoring would be better for the patients, but we were limited by our reimbursement structure. With the reimbursement structure changed, at least temporarily, we've had the freedom to use technology,” One Community’s Monroe said. 

“Reimbursement will determine whether telemedicine sticks," said El Camino's Harrison.

"We're a business that has historically relied on office visits and fee-for-service billing. In the past, the payers, for the most part, would not reimburse us for telehealth. I anticipate that there will be permanent reimbursement changes forthcoming that recognize video visits can be efficient and effective for consultative visit types” he added. “We're finding most patients are giving us positive feedback about those using the video visit, and the virtual approach. While a virtual visit doesn't replace the physical exam, care plans can be adjusted, some visits can be done virtually and it really can be a very effective tool to help support the way in which doctors and patients interact.” 

The hope for all clinics and patients is that the temporary reimbursement pathways will become permanent post-COVID since telehealth has proven to be popular and effective. 

Not all popular and convenient services, like actual in-home visits, were reimbursed however. “Our doctors were concerned about our patients with complex clinical issues who really needed care but were homebound. We collaborated with Pathways, a home care service, to provide face-to-face nurse visits combined with a virtual visit from the doctor. Our nurses went into homes with PPE (personal protection equipment) and were able to check on patients vitals. Obviously this was very costly for us. It doesn't get reimbursed, but we did it because it was the right thing to do,” said El Camino’s Harrison.   

We need seamless integration

Reimbursement is key to adoption, but seamless integration is the key to a smooth experience. 

The government relaxed the technology requirements for virtual care during this period and that opened up the possibility to use Zoom, Skype or Facetime to interact with patients. “Before COVID-19, providers had to demonstrate that the technology used was 100 percent secure and compliant. Zoom has worked well, but the technology used for these virtual visits in the long term will need to be better integrated, more secure and create a better experience for the users," said Harrison.

Clinics will need to do this if they want to compete with companies like Carbon Health and One Medical, aka the ones that already have those vertically-integrated models and which are currently looking superior because they are able to do those types of all-in-one solutions, said John Muir Health’s Sauter. “The One Medicals and Carbon Healths of the world, they’re digitally native delivery systems where they almost built the technology and then overlaid how the physicians and patients can interact with it. We have had to overlay technology on an existing, decades-old process. Those with an integrated technology stack are incredibly effective,” he said. In other words, those models are the retail-like, Amazon solutions for care.

“You look at companies like Omada or Livongo, the basic architecture of these providers are very similar. They have some sort of digital connection between the patient, the family, the provider, a call center, which is usually staffed with some pretty sophisticated call agents, often either social workers or nurses or clinicians of some sort. And it all works together so that you can basically point the high cost professional interaction to situations where the value is there.”

The integration of technology goes beyond just video visits, though, with the need to be an all-encompassing solution so that the clinic can truly understand who the patient is and what they need. Only then will the physician and the patient truly be able to maintain the same kind of connection they had through in-person visits, even though they are seeing each other virtually. 

“When a consumer accesses John Muir Health, either digitally or by telephone or in-person or video, we need to know who that person is. We need to be able to anticipate their needs. The consumer experience in the phone, via digital, via telehealth needs to be consistent and the handoff needs to be really smooth. And those are the big challenges,” said Sauter.  

Changing clinic real estate 

As care shifts to telehealth and remote patient monitoring, the question is how does the real estate footprint look? Clinics may no longer have waiting rooms given lifestyle behavior changes due to social distancing. 

“The inside of clinics are going to be different, waiting rooms may be a thing of the past. I always look at them as non-revenue generating spaces anyway, so I'm thrilled that we have this opportunity. On the administrative side, we might have the opportunity to downsize our office space and use that space much more rationally by having people work from home,” said John Muir Health’s Sauter.

Clinics may no longer have the same staff requirements. “If a lot of my visits are done by video, I can even rethink my facility. I can even rethink who I hire because I have a hard time recruiting in my most rural areas and some semi-retired providers might be willing to work if half their time was spent working from home,” said West County Health Centers’ Cunningham.   

Conclusion 

The Alliance of Community Health Plans and AMCP found that nearly three-fourths of consumers in the U.S. have “dramatically changed their use of traditional health care services”, ironically thanks to the virus. 

Bringing care closer to the patient, and meeting them where they already are will lead to dramatic, and long-lasting changes to our healthcare system. We’ve already seen that both physicians and patients love the on-demand and same-day, in-your-home convenience as they've become accustomed to an Amazon-like shopping experience.  

Now it’s a matter of executing on improving these new services, not only because they’re effective, but because we might need them in place should an unfortunate second COVID wave hit us this fall. 

(Image source: aluance.digital)
(Collaboratively written and produced by Steve Loeb and Mohammad Gaber, CEO and Founder of Wellpay)