Invent Health with Dr. Archana Dubey and Bambi Francisco Roizen; Episode 12Read more...
Telehealth creates the platform upon which preventative care and value-based payments will flourish
Bambi Francisco Roizen interviews Ann Mond Johnson, CEO of the American Telemedicine Association (ATA), and Kyle Zebley (Director, Public Policy) at the ATA to discuss how virtual care is laying the ground work for two important innovations in the healthcare industry: value-based business models and data gathering that can enable more preventative approaches to maintaining health.
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Below is a partially edited transcript.
Ann: I've been at the ATA for three years now. I joined in the beginning of 2018 and I came to the association by way of startups. So I say that because my background is not in running associations. When I joined the organization, again, this was pre-pandemic, it was pretty clear that the adoption engagement and telehealth was pretty low. So we set out to change that. I would say it’s really an amazing change to see change in what's happened in the last 12 months.
Ken: I came to the ACA after about 10 years in government, six years up on Capitol Hill, three-and-a-half years at the Office of Global Affairs at the United States Department of Health and Human Services. And I would say during that 10 years, telehealth actually did come up quite a bit during my my work in the public sector. And it was usually sprinkled in speeches by various policymakers as something that was going to happen in the future but hadn't happened yet. And it was a way to say to folks to signal to those in the audience that they were in the know; that they knew where healthcare was going. And when I was at the department I saw COVID-19 coming very quickly. The speeches and the mentions of telehealth were updated to reflect the fact that telehealth was very much now fully a part of the US healthcare system. And so when I got word of course, with all the excitement that the ATA and the industry was generating, when I got word that there was an opportunity here at the ACA in public policy, I jumped right into it with both feet, understanding really what an extraordinary historic moment This was not only for telehealth as an industry, but for the entire United States healthcare system for the world's health care, because of all the possibilities that are apparent with telehealth.
Ann: Prior to the pandemic, telehealth was the ultimate expression of consumerism and healthcare that people could get care wherever and whenever they needed it. And that when they used it, they knew it was safe, effective and appropriate. So it's been amazing to see today the ATA represents over 400 organizations, delivery systems like Sutter and Aethna and inner mountain payers like Humana and united academic medical centers like UC Health and Denver, and then a range of solution providers, Teladoc, Babylon Health, to Ro and Hims and GoodRX, to organizations that are very focused on remote monitoring, and that would be Vivify and Livongo. And as well as the giants, the enablers, the Philips, the HP’s, Intel’s, Microsoft, Amazon. So it's a really diverse membership. And Kyle and I are just honored to work for such an innovative group of companies and members.
Bambi: I remember when we spoke last year, and I asked you how long you've been working toward this to get telehealth to become more commercialized and you mentioned that the ATA has been around for 25 years. So it's been a long time coming. I know, having worked with a number of startups, how hard it is to just convince people that there's actually a market. 2020 certainly was when we saw this explosive adoption curve, and I can only imagine how many companies are trying to get your attention. What’s happened in 10 days in 2020 is essentially about 10 years of innovation happening. So as you look back at 2020, besides the fact that telehealth became ubiquitous, did it play out the way you'd expect?
Ann: I think that there are a number of things that happened that really accelerated it. And again, I can't emphasize enough the level of innovation and creativity that was engaged by both delivery systems as well solution providers as they work to make sure that the healthcare system didn't implode at the onset of the pandemic. But we also saw some really important regulatory changes that happened that accelerated the growth of this. But I think it's also important to say that there were a lot of trends that were in place prior to the pandemic that were accelerated because of the pandemic. So in the US, we had very uneven access to health care we had. We still have a problem with consistent quality in the United States of health care services so that your geography became your healthcare destiny, and it has still remained that way. So I think the way it has not played out or has unfortunately played out is in exposing the disparities that were so well acknowledged in at least academic circles. And so the disparities in combination with an acknowledgement of the racial inequities and the racism within our system, have really given us a very, very big focus on using telehealth to mitigate those disparities.
Bambi: I want to jump into that more specifically. But first, in 2021, it's finally okay to talk about our mental health. And that's why we're excited to be sponsored by better help. It's time to stop being ashamed of normal human struggles. You deserve to be happy, better help is customized online therapy that offers video phone and even live chat sessions. VatorNews listeners get 10% off their first month at Betterhelp.com/Vator. That's Better H-E-L-P slash Vator for 10% off. So Kyle, bring us up to speed with what's happening at the federal level and also with certain bills in the works to expand or make permanent some of the telehealth services.
Kyle: Absolutely. What happened in 2020 and what continues to be the case in 2021 is that the authority granted by Congress to the administration first the Trump administration, now the Biden administration, through the public health emergency and official act declared by the secretary has enabled telehealth at the federal level to be really fully reimbursed by the Medicare. What essentially seems to have happened at the federal level is that policymakers were reading the statements and policy pronouncements put out by the American Telemedicine Association for years prior to the pandemic. The regulatory barriers that we saw as the biggest hurdles to telehealth really came tumbling down in very quick order, most notably the restrictions that are embedded into law now under Section 1834 of the Social Security Act, which prior to the pandemic meant that those Medicare beneficiaries seeking to have reimbursable telehealth through the Medicare program had to be in a provider's office and in the defined rural location to have access to telehealth. During the pandemic those originating site and geographic barriers were lifted, and millions of Americans, millions of Medicare beneficiaries were able to have access to telehealth for the first time. And so we're obviously trying to do our darndest to make sure that Congress acts and to make sure that there is not what we're calling a telehealth cliff at the end of the public health emergency. And what's really important for your listeners to understand is that if Congress doesn't act, and there's going to be a reversion to form where a very small minute number of Medicare beneficiaries will continue to have access to telehealth that's certainly unacceptable. A recent Medpac beneficiaries survey revealed that 90% of Medicare beneficiaries during the pandemic who have utilized telehealth are satisfied with it. Two-thirds were very satisfied with it. And so we just need to make sure that policymakers understand that if they don't act, there's going to be this cliff. There are a number of bills to do it. Two bills have already been introduced in Congress that are comprehensive in nature. The first by Congressman Mike Thompson of California, is protecting access to post COVID-19 telehealth act that would do away in a permanent way with these originating site and geographic barriers, to make sure that Medicare beneficiaries can keep accessing telehealth. And then another bill very similar that makes permanent those geographic originating site barriers is the Telehealth Modernization Act sponsored by Senator Tim Scott of South Carolina. So we're trying to keep the momentum up and beat the drums so Congress acts before it's too late.
10:46 Bambi: How do they work with the CMS 2021 payment rules?
Kyle: Because of that great latitude of authority granted by Congress during this public health emergency have really allowed for a tremendous new amount of services to be reimbursed, or new telehealth services to be reimbursed. And that's really important. And what's the interaction here? Bottom line is that the authority that CMS has under the public health emergency and offering reimbursable, telehealth services, regardless of your geographic and originating location, again, will go away if Congress doesn't act. And so what we could end up with is a situation where we'll have a great set of of reimbursement codes, we'll have a great infrastructure in place for a very minute number of Medicare beneficiaries to access telehealth. If Congress does act and lifts those restrictions that I mentioned, then we'll be in a great place, obviously, there's always fiddling around the edges. And when we saw that draft, payment, payment advisory come over to us, we have lots of questions, lots of modifications that we'd like to make, but it's still so much better than what the old status quo was. And so that's the interaction as we see it, there's only so much within the law that CMS can do absent congressional action.
12:28 Bambi: Ann, you’re from the startup world. For those trying to innovate in this environment, where we're waiting for the government to kind of act a little bit to extend or make permanent some of these telehealth services, how should a startup think about their roadmap and what to build in this environment?
Bambi: I want to talk about the payments of telehealth and virtual services, because I'm sure that's very much in flux. But you mentioned the geographic restrictions or basically the restrictions that have been relaxed regarding telehealth where a physician can treat someone out of the state that they're licensed in. Can you give us an update in terms of where that stands today?
15:42 Kyle: Right now, during the pandemic, there is what is called payment parity in Medicare and in some Medicaid agencies. There have been mandates at the state level that have in-person payment be in parity with telehealth. In terms of private insurance, as we move forward, we at the ATA are all in on what we call coverage parity, making sure that public programs like Medicare, Medicaid, and private insurance cover telehealth. And in terms of the payment issue, we think moving forward, we should come up with what we call a fair payment model, which understands that there's not the brick-and-mortar facility costs that are associated with telehealth and that telehealth can drive real savings. But also understand that there are significant costs to get these telehealth platforms off the ground and to continue to innovate, innovate them. So definitely one of those tricky issues moving forward and definitely top of mind for policymakers in the industry.
Ann: We want to make sure that there's fair payment; we don't want to get in the business of setting pricing. And so I know that there's been some roll back with commercial payers on this. So I think our point is telehealth is health. It's a modality of care. It's up to the clinician or the patient to select how they want to deliver the service. And we don't want to have special rules associated with telehealth. As long as we maintain the standard of care, then it should be accepted and adequately and fairly compensated.
Bambi: I saw you quoted saying that for decades the Medicare statute has severely limited telehealth services, while other payers increasingly relied on telehealth to provide care to patients. It almost sounds like the private sector was pushing this telehealth service more than the government. Yet in the past year, I was thinking government really was the lever and the reason why telehealth took off. So what were you saying there in that statement?
Value-based models work better than fee-for-service in a telehealth world
Ann: I think that, number one, when we go through all these modalities and talk about the regulations, and so forth, it's important to note that much of what Kyle referenced, in terms of restrictions, for example, geographic restrictions, these were rules that were created before the invention of the iPhone. And so this idea of regulations not keeping up with technology is something that's been a problem for us as an industry. The second point I'd make is that we do have plenty of examples in the federal arena that have been incredibly innovative. The VA as done an amazing job, in part because they don't have many of the same restrictions that we have in many of our delivery systems. So in a fee-for-service world, telehealth probably doesn't do as well as in a value-based model. And plus the VA doesn't have the same licensing restrictions for their decision. So that that's been something that I think we've been very vocal about that the VA has been a model. I think that there are plenty of examples though, where commercial insurers have done an amazing job of innovating. So you have Humana that launched a program in 2018 with Doctor on Demand, and that was for their commercial population. And so you see this in more and more situations. Cigna’s Evernorth acquired MD live.
Bambi: It's an interesting point you brought regarding Cigna buying MD Live. There is a little bit of a debate here about where telehealth lives. And some insurance companies would say telehealth should be part of the insurance offering. And some insurance companies would say no telehealth is more just something that we purchase. It's part of the provider offering. This goes Cigna purchasing MD Live (telehealth platform). The reason why I bring this up is because Anthem has also invested in a telehealth company Amwell. And there’s talk about whether or not Anthem ends up doing what Cigna did, which is buy a telehealth platform. Yet again there is that debate about whether telehealth is more of a provider tool and not something that should be owned by insurance. I know you’re not M&A experts but it’s an interesting debate and wondering if either of you have any thoughts on this.
21:55 Ann: I would just add that it is a modality of care. And the beauty of telehealth and virtual services in general is that it meets people digitally where they are. You will have managed care organizations or entities that take on risk, that are using telehealth to monitor their patient population remotely. They're using it to close gaps of care and even in a fee-for-service environment. Likewise, you see or saw during the pandemic physician practices that just went bananas in terms of their adoption of telehealth in the ability to keep up with their patients. So that was a tool, if you will, a mechanism for staying connected to patients. So I think it sort of plays both ways. And again, the overriding theme in that the use cases were much more professional than anybody had ever expected. The physician adoption, clinician adoption and receptivity to telehealth was much greater than anybody expected. And the consumer population as well as much more accepting and, frankly, very pleased with what they experienced when it came to telehealth.
Bambi: No doubt. I want to get to the pricing model. I know and you mentioned that you're not in the business of directing or dictating any prices. But I'm just curious about the pricing models. In the old model, if providers charged $100 per person visit, each visit was about 15 minutes, the providers would make say $400 an hour. Then the virtual visits I've noticed based on Kaiser, which is my insurance company, the virtual visits are about $30 every 10 minutes, give or take, or about $180 an hour. So basically, there's a shortfall there. How do you think providers are making up for that shortfall?
24:18 Ann: I think that what telehealth did at the onset of the pandemic is that if a provider was operating in a strictly fee-for-service environment, being able to connect with their patients and manage their patient population virtually saved many of these practices. Just picking up the phone even, obviously due to the relaxations of HIPAA compliance, enabled a lot of practices to stay afloat. I think the bigger question for your group is this issue of moving to value-based models because again, if we talk about that, that’s where we're wrong and have been wrong with the healthcare system. We spend more than any other country in the world and the return that we get is just not sufficient for the investment that we make. And I think that's because we're, we're not oriented around a value-based approach.
Bambi: I agree for sure. And, and hopefully with more data, we can move toward that value based system. So, Kyle, here's one for you. I saw a figure that a small number of lifestyle changes can eliminate 80% of chronic disease. So a lot of this behavioral change, sort of better nutrition, just basically behaving in ways that won't get you in trouble down the road. This change is aided by a number of behavioral health services, engaging with consumers via telehealth. Do you have any figures that support that telehealth can reduce chronic conditions?
No one does preventative care better than telehealth
26:07 Kyle: Not offhand. But I know we can certainly provide that for you. And actually, during my time, when I was working at the Department of Health and Human Services, we were involved with work on the World Health Organization's non communicable disease commission, in which we were trying to deal with these issues that are not only here in a developed economy, but also in developing economies. And of course, the great solution to that is preventative care. And nobody does preventative care better than telehealth. And there's no question that if you look at diet, nutrition, exercise, not smoking, not drinking too much, so much of the of the burden of non-communicable disease in which folks can live for for decades with very expensive multiple comorbidities, a lot of that can be avoided with preventative care. And we know that as we think about transitioning towards value-based payment systems, a system that derives value from, from well-being, that telehealth is going to be an invaluable player in that because nobody does preventative care as well as telehealth, including through telemental health, as you mentioned,
Ann: Just listen to your sponsor, BetterHealth, I mean, nothing was more exposed than social isolation, depression, anxiety. And I know, we talked about this before, there was a shortage of mental health services available. And during the pandemic, the ability to interact with your provider virtually meant that more people were able to seek services, it meant lower, no show rates for providers. And it also meant that they had oftentimes more intimate awareness of what was happening with their patients, because their patient, it could either stay in their home, or they could see that their patient was in a situation that they had to take the call the consultation in their car in order to have some modicum of privacy. So I think the mental health issue is just huge, and it does impact our health overall.
Bambi: I think that actually you brought up talking about really focusing on these disparities that were exposed during the pandemic. I saw one study that showed that 69% of black adults with mental illness received no treatment at all and this was pre-COVID. What is the ATA doing to address the disparities?
28:43 Ann: It's something that we're addressing because our members feel very strongly about it. And again, they're focused on this principle that you can't solve for access. You can't solve for inconsistent quality unless you introduce some level of technology and the process is something that we've all embraced. The way we're engaging it is a few things. Number one, there are a number of coalitions that we're participating in, for example, HealthTech 4 Medicaid, which is an incredibly innovative group. Another one is the Telehealth Equity Coalition and the third is a group focused on maternal health, which is a very specific area, poor maternal health as well as higher death rates at mortality rates for mothers and kids in populations of color. So those are three Coalition's that we’re part of and we're supporting. The second is that we have put together a framework for guiding and informing our work writ large, which is we have a number of ways to look at it. If you think about solving for disparities, there's really five components, the first being broadband and connectivity, you know, you have to have that in order to be able to connect [6% of the population in the US still do not have broadband]. The second is affordability of those plans, the affordability of being able to connect. The third is the devices. The fourth is literacy. And by that I mean digital health, technical literacy. And the fifth component is bias. And so our view is that you have to solve for all five if you're going to address the disparities, and if you're going to mitigate them. And so we're really encouraging our members to look at it from that perspective, building the economic case for resolving disparities. So that's the kind of work that we're doing.
Bambi: Has there been any impact?
Ann: We’re seeing a lot of innovation. Again, we're part of a group in New York state, where you see the type of work that's being done to make sure different communities get vaccinated, different communities stay in touch with their providers. I mean, this is certainly something that has been pursued passionately, by these coalitions prior to the pandemic. And now even more so. But I think, Kyle, you have some perspectives on this as well.
31:24 Kyle: I think it's very much part and parcel of our ongoing advocacy in terms of making sure that our public programs, our public insurance programs, be they Medicare or Medicaid are properly covering for telehealth services, because, of course, that level of insurance, public insurance is offered to Americans, regardless of income, and really are helping, particularly for Medicaid programs, those folks and underserved communities. And of course, we're all for broadband expansion, very supportive of the ongoing discussions for the new Biden infrastructure package that will include a big injection of funding for broadband that is designed to go to underserved communities, which we think is tremendously important. And then it also is part of our other areas of advocacy, for instance, our strong support for audio only as an appropriate modality of care. Most importantly, you can deliver a clinically acceptable care that meets the standard of care via audio only. But also, it's really important to have that as a modality. Because for so many Americans for geographic, demographic, socio economic purposes, that's the only way that people can access virtual care for so many. And so we see that as an equity issue. Really, there's no area of public policy that we issue a pronouncement on that we don't keep that equity lens in place. And so we see it as totally one in the same with our public policy goals.
34:25 Bambi: You mentioned the new administration and the infrastructure proposal. What’s in the proposal to expand telehealth besides broadband expansion?
Kyle: It's still in early form and obviously lots of negotiations between the White House and Congress. But as it stands right now, the proposal that has been put forward the right administration for this infrastructure package, the biggest area of overlap for us would be that big expansion and investment in broadband. We applaud lawmakers and both parties in both houses in the White House for pushing. I would note that we are very hopeful to avoid that telehealth cliff I mentioned earlier. And that means that we really are hopeful that we're going to be able to find a place in moving legislation. And so when we talk to members of Congress, when we talked to their staff, when we talked to the White House, whether it be this infrastructure bill or another bill that will be moving sometime soon, we think it would be really vital and absolutely in the nation's interests to make sure that the 1834 issue of the geographic and originating site limitations are addressed in those kinds of bills, in addition to of course, further broadband investment.
Final question at 36:39 - tune in as Ann and Kyle take out their crystal balls and talk about what telehealth and healthcare looks like in 10 years.
This podcast is sponsored by BetterHelp and VatorNews listeners get 10% off their first month at BetterHelp.com/Vator. This podcast is also brought by Octave, your partner for mental health and emotional well-being. Learn more at FindOctave.com. Also thanks to Neuroflow for supporting mental health.
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