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Challenges and Opportunities in Virtual Care — Are You In?

In our recent Benchmark Survey Report, we examined some of the trends that are shaping how healthcare organizations are deploying virtual care solutions. We examined the opportunities that exist for new players to get into the game, as well as how those that are already playing can expand their offerings. We also dove into some of the challenges that are being felt throughout the industry – whether in the day-to-day management of currently deployed virtual care platforms or the challenges that are expected by those that have yet to launch any telemedicine services. One thing was clear from our survey however, as virtual care continues to advance, the opportunities that exist in the industry greatly outweigh the challenges.

We’ve Come a Long Way

The truth is virtual care is nowhere near where it was 10 years ago, or even just last year for that matter. For example, our Benchmark Survey indicates that while the industry still leans heavily on video – one of the more traditional modes of careModality Type Deployment, video alone isn’t sufficient to meet the changing needs of today’s patients and providers. Because of this, many are turning to multi-modal care, with 61% of health systems reporting they offer more than one mode of care today. Which of these is gaining the most momentum? Believe it or not, it’s chat, with 44% of health systems saying they expect to include chat in their virtual care launch.

As technology changes, the clinical impact that these platforms provide also improves. Our study shows that virtual care solutions have the power to impact both clinical quality and efficiency. Quality reporting has always been difficult for healthcare providers, but 33% of survey respondents say their technology provider offers a reporting and analytics solution and 30% say their technology provider offers scheduled or ad hoc reporting. At the same time, virtual care is enabling providers to shorten patient visits by as much as 15 minutes – from the current patient visit average which is approximately 16 minutes to between one and five minutes, as reported in our survey. I don’t know about you but the ability to make five or ten times the health impact is an amazing opportunity I would not want to miss out on!

Miles to Go Before We Sleep

As much as virtual care has evolved, there are still hurdles that we need to get over before we can realize the adoption rates that we seek. What’s fascinating however is that the actual challenges providers face in their day-to-day operations are different from those that respondents anticipate they’ll encounter, which include integration, patient utilization, and claim management. Diving into each of these a bit deeper:

  • Program ChallengesIntegration – EMR integration specifically, has long been a pain point for providers and our research shows that this is only growing as an important focus area as virtual care adoption moves into the mainstream. About 21% of survey respondents who have virtual care identify lack of EMR integration as a challenge, even though 42% say their service doesn’t integrate with the EMR at all. That’s in comparison to the fact that nearly 54% of our survey respondents expect EMR integration to be a major challenge.
  • Patient Utilization – There’s still a bit of a “Field of Dreams” assumption to virtual care, despite research from multiple sources, including a 2018 Deloitte study, showing slow adoption. If you don’t believe me, just look at the disparity in the number of respondents in our survey who identified patient utilization as a challenge. Only 31% of those without a virtual care solution, compared to 64% of those with a virtual care service already deployed.
  • Managing Claims – We also saw an under-realization of the challenges associated with managing claims and reimbursement. In fact, only 15% of respondents without a virtual care solution thought that this would be a top challenge, versus the 39% of those with virtual care services who acknowledged this obstacle. The truth is, the healthcare revenue cycle has many parts, making it difficult to manage. Increased integration of virtual care solutions with EMRs and other legacy systems are important and can help make your life a lot easier.

What Lies Ahead

As patients, providers and as those with a stake in the virtual care industry, we should feel encouraged by the opportunities we have at our fingertips. Our survey shows that nearly 100% of health systems expect utilization to increase in the next 12 months – and that’s great news for everyone! So where should we focus our efforts and what can we expect? Undoubtedly, there are many applications for virtual care, but there’s a growing desire for it to be used for more complex conditions, with a big focus on behavioral health. However, to realize this in an effective way, we need increased collaboration between the technology companies that are creating the virtual care solutions and the health systems that are deploying them.

Regardless, the fact that we’re seeing such confidence from health systems when it comes to expanding their virtual care offerings in the coming year, signals to us that the industry is ripe for incredible growth. And it’s about time! Virtual care has long suffered from slow adoption rates, brought on by patients who were hesitant about leaving their trusted physicians and providers who were weary of expected financial and technological barriers. But virtual care doesn’t have to be scary and as our survey shows, many organizations have skewed ideas about the challenges that actually exist in the industry. To overcome this perception, we must educate patients and providers about the opportunities associated with virtual care, while continuing to focus on improving the patient experience. Though technology vendors may provide the platform, I believe, it’s with health systems, who are in a unique position to confidently vouch for the integrity of virtual care, and effectively market the service to truly increase adoption expand access to quality health care.

Interested in learning more about the On-Demand Virtual Care Benchmark Report?

We called out our key business, technology, and clinical findings, discussed what they mean for virtual care in 2019, and hosted an open discussion about the research in our latest webinar: Top Virtual Care Trends for 2019.

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HIMSS19: A Sunny Outlook for Virtual Care

Sunny Outlook for Virtual Care

Last week, myself and some of our Zipnosis team had the privilege of attending HIMSS19 in Orlando, Florida – a global conference bringing together over 45,000 health information and technology professionals, clinicians, executives and market suppliers. Due to the rapid changes in today’s current healthcare climate, this year’s event had a strong focus on innovative ways to improve the patient experience, monitor the patient journey and drive synergy across the industry. In the face of change, the brightest minds convened on ways to generate new efficiencies while improving levels of convenience, safety and accessibility across the healthcare continuum.

As innovation builds, policy changes and trends surface. Sometimes this can make the healthcare industry look cloudy at best. Below are three major takeaways from HIMMS19, giving way to a much sunnier forecast, especially when it comes to the evolution of virtual care:

Utilizing Data in a Turbulent Atmosphere

Often times, salient trends are a direct result of major legislation. Day 1 at HIMSS19, the Trump administration released its proposed interoperability and data blocking rules. It’s no coincidence that a major theme at the conference this year revolved around the idea of data-sharing and new technologies to support the free flow of data between patients and physicians. As data is integrated and utilized, it’s vital that it also be safe guarded.

Cybersecurity and the idea of securing actionable data was a prominent theme at HIMSS19. When it comes to virtual care, both the exchange and safety of patient data is key. We need to assure patients that their health data will be used responsibly, while also finding new ways to free data previously locked in silos to do our part to advance population health and provide more personalized care.

Making it a Breeze to Personalize the Patient Experience

Another major theme prevalent at HIMSS19 was the overarching idea of empowering patients to make more informed decisions about their health. What patients want today, is interactions that are as specific and personalized as possible, but also innately human. Ironically, humans alone often struggle to create the type of personalized experiences that patients today crave. As such, wearables and other devices were once again prevalent at this year at HIMSS, with many innovators demonstrating how these technologies are empowering patients to take control of health experiences.

Leaning on AI and innovation to continue to address complexities across the healthcare continuum is something we will continue to see more of as personalization becomes increasingly important. For virtual care, adaptive interviews are a game-changer: asking patients only the most relevant questions determined by demographic information and previous responses. Aside from the convenience of virtual care, patients also receive personalized and clinically impactful interactions that are synonymous with the typical doctor’s visit to keep that human touch alive and well.

Spotting the Reimbursement Rainbow

As strategies to engage patient populations change, it’s important to consider the impact of these programs on reimbursement models, which are shifting to accommodate the rise of virtual care. At HIMSS19, while various sessions focused on the power of technology to improve patient care outcomes, many also focused on helping providers execute on a future-forward vision. Improving payment accuracy and developing a reimbursement strategy that is supportive of new technologies is essential to changing the public perception of newer methodologies. Capturing reimbursements that prop up provider budgets as justified by the utilization of virtual care will be essential moving forward.

HIMSS19 made it quite apparent that the healthcare industry is changing rapidly to make patient/provider interactions more personable, streamlined, cost-effective and more efficient than ever before. In today’s digital age, it’s important to consider how our strategies and processes can be enhanced with innovation. While a storm of change is inevitable amidst intense innovation and policy modifications, like with every storm, once it’s over the sky and our future will become clear once again.

The Virtual Care Reimbursement Parity Puzzle: What Everyone Should Know

In a 2015 survey of family physicians conducted by the AAFP’s Graham Center, family physicians cited education and reimbursement as the two leading barriers to telemedicine adoption by family physicians. Since that survey, not much has changed – particularly in the area of reimbursement parity.  

Telemedicine reimbursement regulations remain complicated, complex and fragmented. And the notion of parity has been variably defined and interpreted within and across states. Today, reimbursement is often a key issue in pending telemedicine bills across the country.

One concerning trend is language included in telemedicine legislation that explicitly prohibits the state from requiring reimbursement parity. If this sort of “carve out” language becomes commonplace, we risk diminishing the ability to use virtual care to address the quadruple aim—improve cost, quality and access, and reduce physician burden.

The Current State of Reimbursement

Currently, 29 states offer coverage parity, which requires insurers to cover telemedicine/virtual care services the way they do in-person care, some with exceptions or restrictions. Only 3 states have legislation mandating both patient coverage parity and provider reimbursement parity, though several states offer provider reimbursement for specific specialties or circumstances. To date, 18 states either do not have legislative language or explicitly exclude parity for coverage and/or reimbursement.

The Trouble with the Current State

The current state of reimbursement parity is largely payer-centric. What I mean by that, is that individual payers determine reimbursement for virtual care and telemedicine services based on their contracts with healthcare organizations and telemedicine service companies. In my experience, this model isn’t in the best interests of patients and providers. Often, primary care providers get cut out of the care delivery process, limiting their ability to use virtual care and other innovative technologies to care for patients at the lowest cost, most appropriate point of care.

What Payer-Centric Reimbursement Looks Like

Payer-centric model; no reimbursement parity

    1. Employer / health plan contract with telemedicine service company for online care delivery.
    1. Member is routed to telemedicine service company provider for care.
    1. Telemedicine service company receives any co-pay and is paid contract rates by employer/health plan.
    1. The visit record remains with the telemedicine service provider.
  1. The primary care provider is left out, and the patient record is often incomplete.

How Reimbursement Parity Should Work

In an ideal world, reimbursement will be fair and equal across all providers, giving primary care physicians and healthcare organizations the ability to effectively compensate providers who care for their patients online.

What Patient and Provider-Centric Reimbursement Looks Like

Patient/Provider Centric Virtual Care; Reimbursement Parity

    1. Patient connects with provider’s virtual care service.
    1. Provider makes diagnosis & treatment.
    1. Provider submits for and receives reimbursement beyond co-pay.
  1. Information is retained in patient’s EHR.

Tower of Babel? Virtual Care Legislative Challenges Go Far Beyond Language

Last week, Mobihealthnews published a piece providing one perspective on the legislative barriers for telemedicine. We were interested to see where the discussion would go, particularly considering Zipnosis’ significant role in supporting – and even drafting – inclusive legislation targeted at making online care delivery more accessible to health systems, providers, and patients. Our interest was rewarded with a piece that offered few solutions and much blame. That said, this piece did get some things right – albeit obliquely.

The Boogeymen of Telemedicine Legislation?

The Tower of Babel concept is a long-standing challenge in online care delivery. The language we use (telemedicine, telehealth, mhealth, virtual care – the list goes on) isn’t unified, and yet, somehow we manage to have valuable, informed conversations about the technology, direction of the industry, and value to providers and patients. More concerning than our lack of unified language, is the defining of “telemedicine” in legislation – an outcome more of general misunderstanding than lack of specific language.

The Congressional Budget Office (CBO) was also targeted as “having a hard time coming up with a number that says what’s going to happen when we allow technology to help healthcare delivery.” While strictly speaking accurate, this statement is more than a little misleading. The CBO’s purpose is to provide Congress with objective, impartial information about budgetary and economic issues. Its role includes supporting the finance, budget, and ways and means committees, as well as producing  formal cost estimate for nearly every bill approved in committee. You’ll note that none of that includes forecasting a hypothetical economic impact for “[allowing] technology to help healthcare delivery.”

In fact, when called into action to score the CHRONIC Act, the CBO noted that the legislation, including the telemedicine provisions, would “reduce direct spending for the Medicare and Medicaid programs by $217 million over 2018-2022.” With the CONNECT Act, another piece of federal legislation that expands the reach of telemedicine, in the Finance Committee, we can likely look forward to further CBO scores related to online care delivery in the not-too-distant future.

Real Regulatory Challenges & Real Solutions

Just because we don’t see the items cited as the major challenges facing telemedicine legislation doesn’t mean there aren’t legislative barriers. For the past ten (or so) years, we’ve been diligently working with state boards of medicine, state legislatures, members of the U.S. House and Senate, and – really – anyone with clout to overcome the challenges in the regulatory landscape.

Regulatory Fragmentation

Zipnosis has  been talking about regulatory fragmentation for years, and it will remain a challenge in the regulatory landscape for the foreseeable future. Between state and federal legislatures, boards of medicine, health departments and other governing bodies, there are just too many cooks in the kitchen for anything short of complexity. Rules and regulations differ from state to state, and even sometimes within different agencies in the same state.

That said, strong legislation at the federal level or improved rules and policies from the Centers for Medicare and Medicaid could help provide guidance for states, catalyzing some uniformity to regulation of online care. Barring this, it’s vital for virtual care and telemedicine companies, health systems, and even individual providers, to speak with regulators at all levels to educate them on the benefits of online care and help craft a unified strategy for regulating and reimbursing telemedicine.

Telemedicine Definition

Here is really where the “Tower of Babel” makes itself felt. Often, the legal definition of “telemedicine” ends up focusing on technology and modalities, rather than the standard of care. This creates challenges for health systems, providers, and regulators, as the rapidly changing nature of technology means legislation is often out-of-date as soon as the ink is dry.

Rather than focus on the mode of care delivery, regulations that address telemedicine and virtual care need to focus on upholding the standard of care. This not only creates opportunities for innovation, but future-proofs regulations, helping them remain relevant regardless of where technology takes care delivery.

Reimbursement

We aren’t going to go heavily in-depth here because Zipnosis just published an in-depth piece about how regulation and reimbursement are impacting the adoption of virtual care. That said, there is a distinct tendency in regulation to focus heavily on patient reimbursement, leaving providers struggling to get paid for care delivered online.

Reimbursement also falls prey to the modality trap, with state Medicaid and Medicare policies focusing less on the standard of care and more on the technology by which care is delivered. According to the Center for Connected Health Policy, 48 states provide some form of Medicaid reimbursement for video-based telemedicine, while only 21 reimburse for remote patient monitoring and 15 for store-and-forward.

Here, too, movement has occurred at the federal level, through legislation like the CHRONIC and CONNECT Acts, both of which contain language expanding online care access and reimbursement for Medicare and Medicaid.

Continuity of Care

The final area where regulation has an opportunity to make appreciable, positive impact is through policy that supports continuity of care. Telemedicine is often looked at as a culprit in the fragmentation of care delivery, but it doesn’t have to be that way. In the current landscape, direct-to-consumer telemedicine service providers – companies who provide clinical services via telemedicine, not to be confused with technology companies who facilitate care delivery – are adding to fragmentation challenges by shifting care away from local caregivers. This is compounded by insurers and employers contracting directly with these companies, which  adds to an already fragmented healthcare landscape, pushing employees and/or plan members to use clinicians with no relationship to or connection with their local healthcare resources – all in the name of cutting costs.

In some states, this has led to increased resistance to telemedicine as a whole, but that’s not the answer. Instead, we should craft telemedicine policy to  encourage continuity of care and pursue regulatory policy that defines telemedicine as a tool that many, if not most, clinicians will eventually come to use, rather than a “service” or a specialty. By doing so, we can eliminate barriers to telemedicine and other technology-facilitated health care and provide patients and their clinicians new ways to connect, that support rather than circumvent the patient-clinician relationship.

Reason for Optimism

This response isn’t intended to be a smack-down. Rather, we truly want to open the dialogue in the telemedicine and virtual care space around what will help drive positive movement on the regulatory front. And we think there’s reason for an optimistic outlook for telemedicine regulation in 2018.

First, as we’ve mentioned before, there is great work being done at the federal level by Sen. Brian Schatz and others on the CONNECT Act. 2017 also saw a lot of movement toward more inclusive, forward-looking telemedicine legislation at the state level, exemplified by the well-publicized example of the new telemedicine regulations in Texas. We anticipate that this trend will continue into 2018, as boards of medicine and state legislatures, fuelled by greater knowledge and understanding of the benefits virtual care can bring to their states, work to make care more accessible, and address the challenges of today’s healthcare landscape.

The Virtual Care Reimbursement Conundrum: Overcoming the Final Obstacle to Provider Adoption

Excerpted from remarks by Dr. Hafner-Fogarty at the C-Tel conference, December 1, 2017

Telemedicine reimbursement puzzle

Virtual care holds enormous potential to transform the healthcare landscape. Since you are here, you most likely agree that virtual care (and telemedicine) can be of great benefit for patients, providers, and health systems. In today’s digitally focused landscape, virtual care is truly on the cusp of having a dramatic, positive impact. But – and of course there’s always a but – there’s a big obstacle standing in the way: provider adoption, fueled by inconsistent virtual care reimbursement .

I’ve noticed huge disparity in statistics associated with provider adoption of “telemedicine”. For example, a KPMG survey earlier this year found that about 30% of clinician respondents were using some form of telemedicine. However, a 2016 AAFP survey showed only 15% of respondents had used telemedicine tools in the previous 12 months. Maybe most telling is that the KPMG survey listed provider reluctance as a top barrier to health systems implementing a telemedicine solution.

So with all the benefits that we know telemedicine brings to the market, why are providers balking? Market research is more consistent on this point. Among others, the AAFP survey listed the top reasons providers hesitate to embrace telemedicine is lack of education and lack of reimbursement.

Clinician education is important and worth discussing, but let’s focus today on the elephant in the room, which is reimbursement. This is where I personally believe strategic policy work can make difference.

Reimbursement and Regulatory Complexity

The first step toward eliminating reimbursement barriers is to understand why reimbursement is  a barrier in the first place. One factor getting in the way of eliminating regulatory barriers is the federal and state regulatory environment is amazingly complex and extremely fragmented.

Currently, CMS offers little coverage for telemedicine and has been sluggish to respond to innovative telemedicine technologies, leaving it up to the states to address an evolving regulatory landscape as best they can. A majority of states have attempted to advance telemedicine-specific legislation in recent years; however, key elements, like the definition of telemedicine, establishment of a provider-patient relationship, allowable modalities, and e-prescribing differ from state to state. Even within the same state, one regulatory office’s telemedicine definitions may differ from another regulatory office. CMS’s Medicare reimbursement rules for telemedicine care can add yet another layer of complexity, and to further complicate matters, many states have a different set of Medicaid rules.

The hodge-podge of modality and site-based restrictions for reimbursement has only added to the complexity of the regulatory environment. According to the Center for Connected Health Policy, 48 states and the District of Columbia currently require reimbursement for video-based telemedicine visits, while only 15 states require reimbursement for telemedicine services provided on a store-and-forward basis. Not surprisingly, reimbursement is less clear for other modes of telemedicine.

Site-based restrictions on reimbursement offer even greater challenges. Such restrictions, designed in the days of telemedicine’s infancy and no doubt with the best of intentions, focus reimbursement on rural areas, leaving physicians and patients in cities and suburbs without a reimbursement mechanism for healthcare provided virtually. Furthermore, in a prime example of legislation that’s been outpaced by technology, some states have language requiring a healthcare professional be present on both sides of a virtual visit. These requirements create roadblocks because they fail to account for the explosion in use of personal mobile devices that allow patients to connect directly to their providers regardless of location.  

Providers, quite understandably, look at the complexities of the regulatory environment and the likelihood of being reimbursed for virtual visits and say, “no thanks.” Fortunately or unfortunately, that’s not really an option anymore. Telemedicine and virtual visits are growing exponentially. According to the Advisory Board, more than 70% of patients are interested in receiving services by telemedicine. As patient expectations are increasingly set by other industries and online experiences – think Amazon, Facebook, or meal delivery services like our local Bite Squad – demand for online care delivery is only going to grow.

Policy Fixes for Virtual Care Reimbursement

Now, for some good news. There are several reasonable, non-controversial measures we can take on at the policy level that can reshape the regulatory landscape.

First and foremost, I want to note that there are policy makers at the federal level who are taking what I hope are the first steps toward addressing some of the challenges, specifically around CMS coverage and guidance. The good work Senator Brian Schatz of Hawaii has done on the CONNECT Act will hopefully signal a move to a more provider-friendly Medicare regulatory environment.

At the state level, boards of medicine and state legislatures still have a phenomenal opportunity to open the door to telemedicine and bring its benefits to their constituencies. Going forward, healthcare policy needs to reflect the eventuality that all providers will need to use telemedicine in patient care, the same way they use other tools of modern medical practice. Here are a few simple steps to developing policies that can help overcome the reimbursement barrier to provider adoption:

Appropriately Define “Telemedicine”

Policy that defines telemedicine should not limit it to specific modes of care; telemedicine definitions need to be inclusive and forward-looking. Technology moves quickly, and creating rules and legislation that stand the test of time is paramount to ensuring patients and providers receive the benefit of new technologies when they become available. Providers need to be free to choose the mode of care that best suits their practice and their patients, while maintaining the standard of care.

Allow Online Doctor-Patient Relationship Establishment

Regulations and policy around establishment of the doctor-patient relationship should focus on the care and service provided and not the technology. Again, the goal here is not to facilitate shoddy care, but to give providers the flexibility to meet individual patient needs within the standard of care.

Specifically Address Reimbursement

Legislation should explicitly include language addressing both coverage and reimbursement parity for all modes of care. It should also prevent insurers from requiring patients to receive online care from the insurer’s contracted telemedicine company in order to qualify for reimbursement.

Promote Continuity of Care

Policy makers and regulators can help drive physician adoption of telemedicine by supporting policies that promote telemedicine models that foster continuity of care, without impacting health systems’ ability to choose from innovative care delivery technologies.