Telemedicine has already proven its effectiveness in traditional acute care hospitals, providing consistent coverage in areas where physicians are hard to come by, guiding clinical teams and leading specialty programs. Now telemedicine is making inroads into a new model of care—micro-hospitals. The growth of micro-hospitals, where small neighborhood hospitals offer care tailored to the specific needs of a community, is dramatic—and telemedicine is helping drive it.
Communities in 19 states have micro-hospitals today, and the numbers are climbing. Cited as a new trend in healthcare by U.S. News & World Report, micro-hospitals typically have eight to 10 short-stay beds and a small ED. They can provide the imaging and lab services performed in larger hospitals, but they are geared toward moderately ill patients who don’t require the intensive care and longer stays required by patients in traditional hospitals.
Because of this patient profile, micro-hospitals can hire fewer physicians—a plus given today’s physician shortage—and can rely more heavily on nurse practitioners (NPs) and physician assistants (PAs)—whose numbers are growing—to assume key leadership roles, make daily rounds and provide hands-on coverage.
A Perfect Environment for Telemedicine
Telemedicine teams offer a cost-effective way to provide on-the-spot, expert guidance to NPs and PAs via web videoconferencing, telephone and secure texting. One could argue that the emergence and growing public acceptance of telemedicine has made the physician-lean, micro-hospital model possible, helping bring cheaper, faster care to moderately ill patients. To illustrate, one company we are working with plans to place 70 micro-hospitals across the country over the next four to five years, and telemedicine will play a key role in all of them.
A Range of Specialized Care
In micro-hospitals, telemedicine serves a function that is similar to the model for many critical access hospitals, where NPs manage hands-on coverage of patients with guidance from telemedicine teams. A videoconferencing cart or “robot” delivers expert physicians to patient bedsides, where the physicians can converse with staff and patients. With the help of the onsite nursing team, they can access diagnostic equipment on the cart to examine patients and make a diagnosis. The telemedicine physicians also work with ED physicians to admit patients, examine them once they have a bed, and develop a plan of care to be carried out by NPs and nursing staff.
The telemedicine physicians might be in the same state and time zone; they might be across the country or, in some instances, halfway around the world, but they must be licensed in the state and credentialed by the hospital in which they are practicing. If they see that a specialist’s care is called for, they can contact a team of specialists—cardiologists or neurologists, for example—who are under contract to examine the patient via telemedicine and provide a diagnosis and treatment.
Given the growing shortage of specialists in the United States—the Association of American Medical Colleges (AAMC) projects a deficit of up to 61,800 specialist physicians by 2030—being able to contact a remote team immediately via telemedicine is another plus for micro-hospitals. For example, teleneurology specialists typically achieve an average response time of 3.5 minutes (a fraction of the time it typically takes for a local neurologist to get in the car and drive to the hospital), and an average diagnosis and treatment time of 21.8 minutes.
Looking back at 2017, we see some of the same significant trends that have been gaining momentum, along with a few newcomers. Together, these top-five trends will impact hospital medicine in 2018 in both traditional and unexpected ways.
Growth Despite Reimbursement Parity Confusion
The telemedicine industry’s growth continues rapidly despite the widespread confusion over reimbursement for telemed services from state to state. Why? Because most hospital leaders understand they face far more significant costs from the lack of proper physician and specialist coverage than they ever would by a less-than-optimal reimbursement rate for telehealth. A teleneurologist consult in the ED might be reimbursed at a lower rate than an in-person visit with an onsite neurologist, but keeping the stroke patient in the hospital could mean a $10,000 DRG reimbursement that the hospital would lose if the patient had to be shipped to a tertiary referral center for treatment. Which is the smarter investment? And more importantly, which scenario better serves the patient?
Expansion into New Types of Inpatient Settings
As micro-hospitals and long-term acute care hospitals (LTACHs) grow, they are looking for single-source providers of solutions, with one point of contact, one operating system, and one set of tools and processes. Telemedicine fits their models very well, helping them avoid contracting with a wide array of specialists to meet their patients’ needs. Micro-hospitals are already established in 19 states, and LTACHs are growing since a federal moratorium prohibiting their expansion expired on Sept. 30, 2017. Being able to access a variety of specialists via telemedicine, depending on the needs of patients on any day, is something these facilities need in order to fulfill their commitment to the communities they serve.
Increasing Use of Telemedicine in Metropolitan Hospitals
Rural hospitals have long been a sweet spot for telemedicine. The physician shortage is certainly more acute in rural areas as community hospitals struggle to recruit physicians, keep beds filled and, in many cases, stay solvent. Recently, however, more metropolitan hospitals have seen the advantage of telemedicine in two key areas. When cross-coverage calls are handled by telemedicine teams, it takes considerable pressure off night hospitalists who may already be overwhelmed with admissions, and yet their phones are ringing constantly with requests to respond to patient issues on the floor.
By the same token, telemedicine offers “surge protection,” providing assistance with patient admissions during ED bottlenecks, and cost-effective relief from hospitalist overload.
Virtual Partners for Solo Specialists
Individual specialists in pulmonology, cardiology, nephrology, and other areas might be on call with a local hospital 24/7/365, with no backup for nights, weekends, holidays, or vacations. Telemedicine specialists share coverage with these physicians—individuals and small practices alike—to help ease the demands on them. For example, a community hospital has a local cardiologist on call 15 days a month, and a telecardiology team on call the other 15 days of the month. This is just one real-life example we’ve seen as hospitals find new ways to meet the challenges of another trend that just keeps growing: physician burnout, coupled with a greater value placed on work-life balance than in generations past.
Looking back at 2015, we see significant trends impacting inpatient telemedicine that will gain strength through 2016. Here are the Top Five: How they impacted healthcare, and how they will change hospital medicine moving forward.
More Legislation and Regulation Activity
A recent report from the National Conference of State Legislatures showed there were 200 telemedicine bills introduced in all but eight states in 2015. The federal government also introduced the TELEMedicine for MEDicare Act of 2015 and the Veteran’s E-Health and Telemedicine Support Act of 2015, which are aimed at creating an interstate license for those practicing telemedicine for these patient populations. Last year, 32 states and the District of Columbia enacted telemedicine parity laws, requiring health plans to reimburse telemedicine the same way—and at the same cost—as in-person service. We expect to see more of this activity as telemedicine becomes an increasingly integral part of healthcare in America.
Easier Licensure Across States
Currently, if you have a group of physicians caring for patients in hospitals in four or five states, they must become licensed in each of those states. As noted above, recent legislation (along with new telehealth licensing compacts between states) will make it easier for physicians to get a license across state lines. This will clearly help facilitate the use of telemedicine services
Growing Financial Support
Today, the payer response can best be described as a patchwork. Medicare typically doesn’t reimburse for inpatient telemedicine (except in rural areas as Medicaid), and the commercial payers tend to vary from state to state. There isn’t a uniform basis for reimbursements. Many hospitals end up financing most of the costs of inpatient physician services delivered with telemedicine?and we all know healthcare dollars are tight for everybody. However, the physician reimbursement is moving, albeit slowly. The state parity laws will help. So, too, will having more commercial payers recognize the value of telemedicine services. For example, UnitedHealth Group announced plans to expand coverage for virtual physician visits to employer-sponsored and individual plan participants, increasing those covered from approximately 1 million to well more than 20 million. Better reimbursement structures will help fortify hospitals’ financial underpinnings and alleviate some of the burden they’ve been forced to bear.