How COVID-19 is accelerating telehealth adoption and how government is a big driver

Interview with American Telemedicine Association's CEO Ann Mond Johnson

Bambi Francisco Roizen (Vator Founder & CEO) speaks with Ann Mond Johnson, CEO of the American Telemedicine Association (ATA). 

As social distancing is the major policy to fight COVID-19, demand for telehealth and remote care has skyrocketed. Telehealth healthcare providers can screen diagnose and treat patients without having to compromise themselves or have facilities flooded with patients. Joining Bambi to talk about the adoption of telehealth and virtual care services is Anne Mond Johnson, CEO of the ATA, which is an organization working to advance remote care and help integrate this modality into economic models such as value-based care.  

BF: This pandemic, however, disrupted, has validated your assumptions about remote care and your mission to expand telehealth services. I’d imagine your organization really came to exist to meet the obstacles in place that inhibited the adoption of telehealth. So, what were some of the headwinds, you're facing pre-COVID-19? And how has the virus now turn those headwinds into tailwinds?

AMJ: Great question. The American Telemedicine Association, the ATA now, was started over 25 years ago by the pioneers and academicians and researchers who began this field in telehealth. And for the last 25 years, they spent the majority of their time first establishing telehealth as a legitimate mode of medicine. And then, secondly, really fighting the headwinds, if you will, reimbursement, licensure, and broadband lack of sufficient broadband in the US. And those are the three major categories. I came to the association two years ago and took those areas and really put it in terms that were a little bit broader, more encompassing for others, and said that while the technology has been around for 25 years, adaption engagement was really poor by both patients and providers. And so what we needed to do was to create a new vision of the organization in the industry, which is to ensure that people get care where and when they need it. That when they do, they know it's safe, effective, and appropriate while ensuring that clinicians are able to provide more services to more people. So with that as a focus, it's saying, licensure and broadband and reimbursement were still headwinds, but we had to put it in language that was more engaging for a broader audience so we could get more people under our big tent. And now with the pandemic, what's clear is that in many instances, regulations have now finally caught up with technology. So you've seen a lot of relaxation with the waivers in terms of what CMS and HHS have done as well as a number of states. And so the issues of reimbursement have not totally gone away. But many of the issues associated with it have gone away as well as licensure. Although it's a little bit more complicated than just waving licensure, you know, there are nuances between the federal and the state level.

BF: Let's talk about reimbursement. I do want to talk about the CARES Act and telehealth funding provisions in that, but let's talk about the reimbursement where we were pre-COVID and where we are now, and whether some of those new implementations will be the new normal post-COVID-19 or at least post the lockdown?

AMJ: I think the way to think about it is that a lot of these laws were put in place before anyone really anticipated what this technology could do, right? And so there were restrictions in terms of where people could practice care, or what kind of care could be provided. With the CARES Act, Congress gave really broad authority to CMS and HHS to waive those restrictions. And that has really been what we're seeing now in terms of the ability to practice medicine and have an originating site, those restrictions removed the idea of the qualified provider, which was with the first wave of the CARES Act, limited to people who had interaction with a patient within the previous three years that's gone away. We have federally qualified health centers, which are now able to serve as what we call distance site providers for the provision of telehealth. We've also seen restrictions lifted as it relates to home dialysis with hospice care and even high deductible health plans that held health savings accounts. Previously, you could not use that HSA to pay for a telehealth visit prior to reaching the deductible and now those are able to be used and tapped into as well.

BF: Wow, that's quite a bit. That's a long list of restrictions that have been lifted.

AMJ: And they're even more.

BF: Are there any restrictions you think should have been lifted? It seems now with life on the line, they probably would be more generous lifting pretty much anything. Were there any restrictions not lifted?

AMJ: I think what's very clear is that there have been a number of champions of telehealth. Luckily, it is a bipartisan issue. People really can’t get behind it. And so they've shown a lot of leadership. CMS has HHS and so I think the idea of really making it easier for people to access care, we've started to see people embrace very passionately and deliberately. So a lot of the restrictions have been lifted. I think it's pretty clear that there's an opportunity to see many of those maintained going forward. And that's part of the conversation that we're engaging at. And on behalf of our members and with our members as well.

BF: I had a conversation with some VCs and CEOs of mental health and behavioral health companies. We talked about some of those restrictions that were waived or lifted, specifically the 1135 waiver,  which prohibits certain medical providers to service someone out of state unless they were licensed. There was a debate about whether this would be permanent given the state board revenues.

AMJ: Let me first address the whole issue of tele-mental health, behavioral health services being offered virtually. The ATA has, and its members participate in what we call special interest groups. These are typically clinical in their orientation. Two years ago, they published practice guidelines that were then endorsed by the American Psychiatric Association. And those guidelines basically said the headline was that virtual was as good as if not better than face to face when it came to mental health services. So that was really important for a couple of reasons. And if you go back to the power of telehealth, it's really the notion that there are insufficient clinical resources in the case of mental health services. 75% of counties don't have access to mental health services and therapists. And so yet, one out of five Americans pre-pandemic had a mental health crisis who were likely to have a mental health crisis. Who knows what those figures are now probably significantly higher. And so the idea of using technology to provide access to people where and when they need it was, you know, the mental health services, it was a perfect use case. So as it relates to licensure at the state level, we've seen, of course, a lot of variation that's occurred. And we've been very active in identifying and providing guidance to Governor's suggestions on what they should be doing to address this. I think that what the conversation is going to evolve to in short order is, what can we as a country do differently, including licensure during a pandemic because we know there will be another one What can we do differently based on what we know what worked today or didn't work and change that anticipate that Going forward.

BF: I think that those are all well-intended. But just to be a devil's advocate here, from what I've been researching, I guess it's $350 million in lost revenue if states don't get paid for licensing doctors. And so there is one side of the debate that, yes, that enabling sort of these cross-state servicing abilities without regulation is a good thing. But at the same time, there's a lot of lost revenue at stake as well. And so there's going to be some pushback from these medical boards. Do you see that? Or do you see them more open to forgoing that 350 million in lost revenue and finding it elsewhere?

AMJ: I think that you know what I found In the two short years I've been with the ATA Is there a lot of things that were done a certain way because that was the history that was the way it was done. And a lot of what we talked about within the telehealth world is allowing clinicians to practice at the top of their license. Why encumber them with services that really don't add value that they don't need their training, their clinical training, and their expertise to execute. So I think we're going to see these kinds of conversations evolve across the board. And as it relates to the lost revenues, again, seeing how these conversations will be addressed. I think we all want to be is to acknowledge that there are insufficient clinical resources to deal with our aging population with the conditions they have. And so the more that we can deploy resources directly to that in the highest value-added possible way that's going to be better for all of us.

BF: That's great. I think I'm on. I'm behind you there. And I think I agree with you there. Let's switch gears and talk about payment parity. How important is payment parity in the discussion of expanding telehealth?

AMJ: Well, it's been an issue. I mean, obviously, there's a lot associated with that. And what we've said is that we want to support the growth or the investment in telehealth services. And but yet, By the same token, we don't want to dictate market prices, right? So there's a fine balance. We're not going to tell someone what they have to pay. We think it should be commensurate with the services provided regardless of the modality. There has been a lot of progress even within the last several months, the use of a lot more CPT codes that came out of dem pag, which was a group put together by the AMA. And our president-elect Joe Kavita was one of the members of that along with one of our former presidents, Karen Rubin, both physicians, Joe is at partners in Boston, Karen's at UVA in Virginia. And what happened was this acknowledgment that remote monitoring really did have some value. And so we've seen an immersion of codes there. What's been really interesting now with the waivers and how this is all accelerated, is you see incredible use of remote monitoring ways that perhaps we never expected or anticipated. I heard a great example yesterday from one of our clients who talked about the first responders fire department that is being monitored, and they're being monitored to make sure that they're not developing symptoms of COVID-19. Despite all their work on the front line, and this is being done with technology, it's being done asynchronously or requires someone monitoring the signals as opposed to having a face to face visit having the first responder. So I think that is the kind of power and that is the kind of benefit we see with changes in reimbursement and acknowledging that these new technologies exist and provide enormous value.

BF: So you're touching on some of the benefits. I think some of the benefits you've seen with telehealth would be caring for people in rural areas. We can monitor people who are on the front lines of this pandemic, putting their lives at risk? What other benefits are you seeing with telehealth?

AMJ: It's pretty significant. So, a couple of cases one is even pre-pandemic. There are a lot of medical deserts in urban markets like San Francisco or DC or Chicago, where it's very difficult for people to seek care. And so technology telehealth virtual health services can be used to basically support them in their home and allow them to be monitored at home or have somebody come to their home and do a virtual link with their provider in the clinic. Another example is client a member of ours who provides services they have a backpack that they fashioned to provide services to people on the streets homeless population in Denver. That's really impressive. That's all digital. That's all virtual. That's what this remarkable industry does. The other is enabling people to age in place or stay at home. My stepmother in her 90s has one of these things around her neck that she's supposed to press the button when she falls, right, the little necklace with the thing I can't get up. And like many women her age, she doesn't press it. She's embarrassed when she does fall. So what you're seeing is a whole growth of tools that are able to remote, remote monitor people remotely, and do it in a way that enables them to be very passive about it. So the lesson we learned from Amazon early on, when you ordered your Kindle and it showed up at your house and you turned it on, it worked and it had your name and profile loaded. So the lesson from Amazon is that if you want someone do something, don't make it do it. Don't make them do it. Right. So that's what we're seeing as well with all the services and remote monitoring. And you're seeing really interesting big players coming into the business like Best Buy.

BF: What is it that Best Buy is doing?

AMJ: Best Buy acquired a company Great Call, which was really one of the leaders in this service. And so if you think about how we used to use Geek Squad to come in our home and set up our home office, for example, so that we could work from home. Likewise, you'll see the same sort of approach in terms of outfitting homes so that people can stay in place.

BF: That is, great work. I'm going to have to look into that. I live with my elderly parents, so I'm very cognizant of monitor them somehow. So, fortunately, they visit me every day since we're sort of in the same compound.  

AMJ: That's great. That's really great. I think the other thing that we're seeing is that and again, this was pre-pandemic, but there were services that, you know, really, you could use avatars that would engage with people who would otherwise be isolated and alone. And I think these are really, again, remarkable applications. And we're just seeing and you're very close to the startup world. There's a lot of creativity and innovation coming out of that.

BF: A couple more questions. What about false positives? You could imagine being inundated or the healthcare system being inundated with a number of false positives. What are your thoughts there?

AMJ: Misdiagnosis is interesting because we have a bias towards a physical intervention in healthcare, right. That's how we've been raised. And so the idea of not being able to lay hands perhaps conjures some perception in your mind that it's going to be more, it's going to be less correct then if you can't do that. I think that it's the wrong mindset. We have to think of telehealth as a modality of care. So what that means is that if it's used correctly, then it's going to have every likelihood of being as correct if not more than face-to-face. And we're seeing that proof proven in a couple of areas. For example, one is the use of telehealth with dermatology, for example, the resolution of cameras and being able to quickly go through and see skin lesions and determine whether or not they're likely to be benign or not. We're also seeing this with ocular health and how much more accurate it is as it relates to diabetic retinopathy virtually than you are face-to-face or using a person to do that. So I think it goes both ways. And, again, I think that what we're seeing is that with the advent and use of AI, and machine learning in the industry, that we're not replacing clinicians, we're augmenting them, we're helping them function and diagnose faster and more accurately. So I actually have huge aspirations and hopes of where this is going to go and how clinic clinicians will feel increasingly supported by this and not threatened.

BF: I think you're right about the imaging. I think they say that AI is much better, much better at analyzing images and with regards to diabetic retinopathy. I know a company called IDX.

AMJ: Yes. I know Michael Abrahamoff. So I think there are a couple of examples that you can point to. Another is interactive assessments. One company in the month of March did over 190,000 assessments COVID-19 assessments of people interactively using a chat feature. Before people were actually triage onto other clinicians, I mean, that's remarkable. And the ability to do that volume cost-effectively is pretty significant. So I think we're, we're seeing those sort of, you know, examples of this being used. The other is the idea that, you know, we talk about pre-COVID, we talk about time in the car to go from point A to point B, and the ability to really save time for both patients and clinicians. In terms of servicing, you have companies like title care that offer devices that can be easily used by consumers to check and see whether or not they have ear infections or, you know, something, you know, some other instances, acute instances that need to be diagnosed or followed up with. So again, I think that you're seeing more and more the idea that things will get more broad sped more widespread and the manufacturing cost of those should go down as well.

BF: In the interest of time, I don't want to keep you on much longer. Last question, what brought you there? And why are you so passionate about this?

AMJ: My background is in starting companies in healthcare, they've all used data, and the last three focused on consumers and helping them navigate the healthcare system using decision support, and digital mobile apps and so forth. And so, when I moved from Chicago to Washington and start exploring possibilities, I was really struck by the fact that telehealth was at an inflection point, and it was now or never, and I also saw it as the ultimate expression of consumerism and healthcare, the idea that you get what you need when you need it, where you need it. And so that's me really made me excited about it. What I am passionate about now is that we have an opportunity and an obligation as an industry to just go all in. And that has been really inspirational of what I see from our members, the delivery systems, the payers, the solution providers, that they're all in and flattening the curve and really taking the promise of the technology and making it stick and hoping that we work very cohesively to ensure that the benefits that people clinicians and consumers have enjoyed in the last couple of weeks from this technology are available going forward.

BF: OK quickly about your organization. How many people and what is it that you're doing for these members? Are you lobbying for them? Are you creating research? Can you just give us a little color there?

AMJ: So the ATA our members are largely organizations across the industry. And we provide a couple of services. One is in the area of policy and advocacy and we’ve been incredibly effective. And that would not be me, that would be one of my colleagues on the policy side, who's been incredibly effective at informing and guiding decisions and changes that need to be offered in short order, in large part, doing it by working with our members, and getting their input and advice in the process. The second is in tools and resources and ensuring that people have what they need to accelerate the adoption and engagement and telehealth and that was pre-pandemic and even more so now. So a whole host of webinars and things like that. And then in the area of research, we're just getting started because again, the proof points that you asked for in terms of have we done things cost-effectively? Or have we done things that are, you know, value add. We know in a value-based environment, telehealth is a no brainer and a fee for service environment. It's a little tougher to prove. But we also think that there are many, many instances where perhaps the research question wasn't framed correctly. So we're tackling that head-on. And then finally, we do a lot of events and conferences.   

[Editor's note: Future of Behavioral and Mental Health with BetterHelp, Headspace, Ginger.io, Providence Hospitals, UnitedHealthcare Optum, Khosla Ventures, Oak HC/FT and more has become 4 virtual conferences! REGISTER. We also have our Future of Virtual Care event on July 1, which includes separate sessions throughout June. You can register for that HERE.]