During the pandemic, nearly every healthcare provider in the country had to execute a rapid, unplanned switch to telemedicine for the majority of their consults and activities. According to one study from the RAND Corporation, there was a 20-fold increase in the rate of telemedicine utilization after March 2020. For the most part, this transition was executed well and successfully, but only due to heroic levels of creativity and dedication by clinicians in every field.
With few established practices to rely on, it fell to each hospital, each department, each clinician to more or less invent ways to conduct virtual consultations in dermatology, cardiology, oncology, and more. There was much trial and error, but a commitment to rapid learning meant that the community as a whole was able to achieve a reasonable level of healthcare delivery quality to patients via the web.
Now, however, it is clear that telemedicine will be a permanent and sizeable segment of healthcare delivery; some estimate that more than 20% of healthcare from 2021 onward will be virtual. As a result, every aspect of the healthcare ecosystem must move out of an “emergency” mindset when it comes to telehealth and focus on establishing scalable, sustainable processes that ensure that a steady shift to telehealth drives equity, access, and quality. Healthcare providers themselves are actively engaged in this effort, and medical schools also now need to evolve to reflect this new normal.
Medical schools have incorporated some telehealth training into their programs in recent years, but it has tended to be ancillary. Now, it will be critical for telemedicine training to be incorporated more structurally into core curricula. What is being called “webside manner,” for instance, is significantly different to “bedside manner” and needs to be taught explicitly ?— in both a classroom setting and during clerkship rotations, as well as residencies.
Clinicians need to be taught how to establish rapport with patients whom they don’t see face to face, how to assess possible domestic abuse threats when the patient may not be able to speak freely, and how to gather emergency contact information in case there is a critical event during the consult for which the clinician needs to call emergency services. They also must learn how to take advantage of the unique opportunity that telehealth presents to closely observe and document social determinants of health by, for instance, asking patients to show the contents of their refrigerator. And they must be taught how to navigate the “digital divide” and ensure that patients without access to broadband or smartphones aren’t consigned to a lower quality of telehealth care.
Telehealth, telemedicine, and virtual care are often used interchangeably to describe remote healthcare visits. But virtual care means something much more than just telehealth or telemedicine. In fact, virtual care is in a category all its own. It is the logical, necessary next step in providing access to healthcare for all.
Telemedicine is Evolving
Remote monitoring and telehealth are nothing new. For decades, doctors have been able to monitor patients remotely or provide medical consults over the phone. Anxious parents have called in to 24-7 nurse hotlines to get advice about childhood illnesses and accidents. More recently, with the advancement of smart phones and web cams, new business models were created to connect patients with doctors over the internet.
However, most people still preferred to visit their doctors in person, and most doctors and healthcare centers weren’t considering a major shift to video any time soon.
Then COVID hit. It accelerated peoples’ desire for virtual healthcare visits and helped them feel more comfortable using video conferencing technology. Zoom, FaceTime, Google Meet and Skype became the go-to solutions for clinics large and small that didn’t yet have telehealth in place.
Video conferencing did good things for healthcare:
• Prevented even higher rates of delayed care
• Enabled providers to triage patients from a distance
• Gave quarantined providers a way to treat patients remotely
• Kept more clinics open and providers working
• Improved access to care for more patients
And while these video conference technologies solved an immediate problem, they quickly showed their limitations. These bandage solutions solved one issue while encountering (and even creating) many more problems.
Rapid expansion of video conferencing for healthcare exposed its weaknesses from HIPAA compliance issues, non-secure connections, the inability to bring a third party onto the call, wasted time as patients and/or doctors wait for the other party to join, limited number of users, concurrent calls, and call minutes and even the limited length of calls. The pandemic accelerated everything, even the “bad habits” of telemedicine.
Healthcare consumerism was already on the rise before the pandemic hit. The provider-patient power differential was already beginning to shift, with more high-deductible health plans being offered and employers shifting the burden of managing healthcare expenses to individual employees. Before COVID-19 entered our shared lexicon, patients were beginning to take a more active role as purchasers and managers of their own care.
This year’s explosion in telehealth, brought about by the COVID-19 pandemic, has dramatically upped the ante in terms of competition, enabling budget- and value-minded patients to shop for their care unfettered by geographical restraints. The turn to digital care isn’t one that will be undone after the pandemic, either. Eighty percent of patients say they’re likely to continue utilizing virtual visits with their doctors, even after the pandemic ends.
Providing an ever-more-discerning patient population with a new, vast array of providers has disrupted the longstanding monopoly hospitals held over their local patient populations. The fallout has come in the form of widespread network leakage and lost revenue. By October, in fact, revenue for hospitals in the U.S. was down 9.2% year-over-year. Able to select providers from the comfort of home and with an ever-increasing amount of personal health data at their fingertips, patients have far more freedom in 2021 to choose the provider that works for them.
That means that to compete, traditional providers have had to adapt quickly, training staff on remote care and making telehealth an option for every patient. According to McKinsey, health systems, independent practices, behavioral health providers, and others have reported 50-175x jumps in the number of telehealth visits since the pandemic began.
Having the technology to compete in the telehealth arena won’t be enough, however, for mainstream providers to compete, not to mention recover any lost revenue. Patients often don’t feel the same kind of brand connection or loyalty to hospitals that they might to other products or organizations. To keep patients in the network, we’ll see a new push in 2021 toward marketing, patient experience, and most importantly, loyalty.
By Troy Corley, executive vice president of service delivery, Proactive MD.
In an ideal world, individuals would be able to access health care services in a quick and convenient manner — regardless of where they live. However, entirely too many residents in rural areas face a variety of barriers to access, limiting their ability to obtain the health care they need.
For many patients living in rural areas, having to drive for more than an hour just to see the nearest primary care practitioner is entirely too common. Because of this and other barriers, patients are generally not equipped to be proactive and preventive with their health due to the significant investment required to receive basic care.
Making matters worse, rural patients often face traditionally higher rates of poverty and are less likely to have health insurance than their urban counterparts. These economic challenges, in combination with higher rates of underlying chronic disease, make rural patients more likely than city dwellers to face poor health outcomes and suffer complications from heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke.
Today, about 60 million Americans, or nearly 20% of the U.S. population, live in Census-defined rural areas. And with the U.S. Department of Health and Human Services reporting only 39.8 primary care physicians are available per 100,000 people in rural populations, the gap in care between rural and urban Americans is only growing wider. The provider shortage — coupled with increased transportation challenges, social inequities, and the additional access barriers brought about by COVID-19 — makes physical access to care extremely difficult for many rural communities.
The Rise of Telehealth
While the current pandemic has forced the U.S. health care system to face numerous challenges, it has catalyzed the rapid adoption of telehealth services to safely deliver care at a distance.
As patients embrace this digital transformation, health care providers are beginning to look outside of their traditional base to reach new patients in unexpected locales. Employing telehealth services reduces access barriers for patients in rural areas, allowing them to receive basic care regardless of how far they live from a physician’s office.
The digital age has changed our interactions and expectations in ways both big and small—from how we shop and travel, to how we communicate and connect with one another. As with all other industries, the pressures and the possibilities of these technological advancements has spurred digital innovation in healthcare.
However, with the additional stressors of COVID-19, the healthcare industry’s acceptance and adoption of these applications has skyrocketed, as has the opportunity to explore creative uses of these platforms while examining ways to improve both outcomes and experiences.
Virtual care, broadly defined as remote interactions between patients and healthcare providers, has been a part of the healthcare delivery ecosystem for years. It has been an option for some patients, particularly for low-acuity episodic care where convenience is the highest priority when resolving the clinical need, but it has not been widely pursued nor embraced by either providers or patients until now.
In a recent survey of 1,000 patients who utilized virtual care in 2020, 72% had their first-ever virtual visit during the pandemic. With the sudden onset of COVID-19, convenience was no longer the sole driver for pursuing virtual care, but rather a combination of safety, speed of access, and convenience.
Given that the majority of patients using virtual care are new to this care delivery method, health systems need to educate the patient community on both the availability of these types of appointments and on what to expect before, during, and after them. In the aforementioned survey, 52% of respondents received outreach from their established providers, with an additional 15% and 13% hearing from their health system and insurance companies, respectively.
By Scott Galbari, chief technology officer and CISO, Lyniate.
For as long as healthcare data has existed, so has the healthcare industry’s challenges with interoperability. The pursuit of healthcare data interoperability has been a longstanding industry challenge, and with the recently finalized interoperability rules from the ONC/CMS going into effect at the end of this month (though deadlines will be extended until mid-2021), interoperability yet again is at the center of many healthcare discussions.
The rules, which aim to provide patients with greater control over their health data and eliminate information blocking, has not been without its critics. Some argue this rule will put patients at risk by inadvertently exposing patient health data to security breaches. However, the spread of the coronavirus pandemic across the United States has underscored the dire need for seamless, bi-directional data exchange. The new rules’ focus on FHIR and APIs to enhance electronic health information sharing are proving to be exactly what we need in the current crisis.
The coronavirus has necessitated all kinds of changes — from rapidly escalating the use of telemedicine, to standing-up temporary testing sites and care centers, to meeting enhanced public health reporting requirements — all of which would have been much more easily addressed if the new rules’ requirements were already in place, and all of which have presented significant challenges amid the COVID-19 crisis.
Because of these unprecedented circumstances, healthcare stakeholders are being required to share health information and data at increasingly high volumes, emphasizing the importance of strengthening the internal infrastructures of these organizations to ensure they can properly send, receive, and analyze health information. However, because of the strain COVID-19 has put on healthcare organizations, the Department of Health and Human Services (HHS) has decided to push out the timeline for meeting the rules’ requirements. While the reasoning for this is understandable, in many ways it is unfortunate that these requirements were not already in place prior to the pandemic.
By Justin Hunt, MD, MS, head of psychiatry, Ginger.
From banking to healthcare to grocery delivery—businesses and organizations across multiple industries are pivoting to leverage text messaging as a way to reach consumers. And in behavioral healthcare, text-based coaching is paving the way for increased access to support. Traditionally, mental healthcare providers have only offered in-person appointments for individuals seeking care. Today, virtual services like teletherapy and telepsychiatry are gradually growing in popularity among an increasingly tech-savvy population. Now, services like text-based behavioral health coaching offer another meaningful way for individuals to get in-the-moment care.
Consumer Expectations Have Shifted
Consumers today expect instant access to mobile-first, on-demand services. A recent survey by the Harris Poll on behalf of Ginger revealed that Americans–especially Millennials–are more comfortable with the idea of being able to text for mental health support as a way to get access to care. Two-thirds of Americans (66%) say that if they were struggling with stress or life challenges, they would prefer to text immediately with a certified mental health coach who is trained to provide support if given the choice, while 34 percent would choose to wait three weeks to meet with a licensed therapist in person. This trend is strongest with the Millennial population: 69 percent would prefer to text immediately with a professional rather than wait to meet in-person.
For many consumers, a chat-based solution may be less intimidating as a first step than going in-person to see a licensed professional. Coaching is emerging as a way for individuals to access support in overcoming day-to-day challenges, reach goals, and learn skills to reduce stress. While not licensed like a traditional provider, coaches do have credentials like coaching certifications or master’s- and doctoral-level backgrounds in mental and behavioral health. And just this year, the American Medical Association approved new codes for health and well-being coaching. Individuals can work with coaches alongside a therapist and psychiatrist to receive support between appointments and sustain the progress they’re making toward personal growth. Coaching is also effective as a preventative layer of mental healthcare. At Ginger, 68 percent of our members are non-severe and don’t require intensive therapy or medication management.
Text-based Chat is the New Normal
The younger generations that are digital natives have grown up with texting and chatting online as a regular, highly expressive form of communication. It comes as no surprise that they would be comfortable expressing themselves in this way to mental healthcare providers. For them, text-based chat with a coach can help them find meaning and healing. Additionally, both therapy and psychiatry are episodic in nature—with clinicians meeting clients bi-weekly or monthly. But as I’ve found in my work as a psychiatrist, life does not operate on that schedule.
While clients might demonstrate an overall trajectory of improvement, unexpected mini-crises in between appointments can slow down improvement. Immediate coaching intervention at the exact time of need helps to address these natural setbacks that occur between therapy or psychiatry visits. In addition to handling acute issues, coaching can offer a helpful longitudinal approach to goal setting. For example, coaches can check in with clients between clinical visits and remind them of healthy sleep hygiene techniques or provide light motivational interviewing to help an individual reduce alcohol consumption.
Scaling Care to Meet Demand
As mental health stigma decreases, more people are actively seeking services. Earlier this year, in partnership with Dimensional Research, Ginger surveyed more than 1,200 U.S. workers and found that a growing number of workers are proactively seeking out mental healthcare. Fifty percent of workers said they are more likely to seek help now than they were five years ago and 85 percent reported that behavioral health benefits are important when evaluating a new job.
In the face of this growing healthcare demand, the supply of medical generalists has been consistently trailing the supply of specialists. By 2030, a study from the Association of American Medical Colleges estimates a shortfall of between 14,800 and 49,300 primary care physicians, as well as a shortage in non-primary care specialties of between 33,800 and 72,700 physicians.
Compacting this issue, the U.S. population is estimated to grow nearly 11 percent by 2030, with those age 65 and older increasing by 50 percent. As physicians begin to retire too, this problem will be exacerbated.
While digital technology has been positively impacting access to healthcare services for quite some time, efficiencies, such as virtual care, need to be implemented widely in order to address the impending physician shortage, and maximize the delivery of quality care.
This implementation will be somewhat natural as patient access and services continue to evolve from live voice interactions to leveraging digital solutions. Several healthcare providers have made this step toward virtual care already, and are showing strong results for patient satisfaction.
A virtual visit pilot program conducted by Brigham and Women’s Hospital found a 97 percent satisfaction rate among patients with access to these new communications and care options, with 74 percent stating “that the interaction actually improved their relationship with their provider.” They also found that 87 percent of patients said they would have needed to come into the office to see a provider face to face if it weren’t for their virtual visit.
Kaiser Permanente Northern California (KPNC) have a similar offering, providing a suite of apps enabling members to exchange secure messages with their clinicians, create appointments, refill prescriptions, and view their lab results and medical records. As a result, the number of virtual visits has tripled to 10.5 million over last six years.
At Valley Health, a tele-ICU has provided a viable solution to reduce mortality rates. During the first year of its implementation, the technology helped save 125 lives, reduce ICU length of stay by 34 percent, and also reduce the sepsis mortality rate.
These examples show how virtual care can aid patients for when they first need help, but the care journey does not stop there. It continues with prescriptions, labs, imaging, and referrals to other care providers. In these instances, virtual care can be used as a follow-up and check-in tool so that patients no longer need to visit their physician in-person, they can quickly interact with them from the comfort of home.
Rural healthcare organizations and their patients are up against a myriad of challenges, from minimal funding and resources to limited access to care, social determinants of health, and more barriers that stand in the way of effective care delivery. Unfortunately, nearly half of rural hospitals operate at a negative margin and are struggling to survive, according to iVantage’s 2017 Rural Relevance Study.
The number of rural hospital closures has risen to 87 in the last eight years, according to the National Rural Health Association (NRHA). The closures create a large gap in healthcare resources available in rural communities, as the residents cannot always drive or fly great distances to access needed care. Virtual care technology can address gaps in care and help rural providers continue to deliver care for the vast populations and geographies they support.
Increased re-admission rates amongst rural patients are driven by inadequate care and support after the patient returns home. Home health organizations now play a critical role in helping hospitals reduce these rates by providing care to rural patients, especially during the initial thirty days after discharge. Home health organizations are actively implementing virtual care platforms to automate the post-discharge follow-up with a rural patient by sending reminders to schedule appointments for post-discharge virtual visits via the communication channel of the patient’s choice – e.g., text, SMS, email or even a phone call. Follow-up care can be provided in a cost-effective video call (for home health providers and patients) which optimizes the caregiver’s productivity by minimizing excessive transportation time, travel costs and related liabilities typically associated with driving to/from patient homes.
To help home health agencies, there has been a longstanding Medicare rural add-on for home health services. Federal add-on payments through the Center for Medicare and Medicaid Services (CMS) have been crucial to these agencies operating in rural regions of the country. The 3 percent payment modifier to reimbursements for services provided in rural and underserved areas helps these agencies which face higher overhead expenses through factors such as increased travel time between patient visits and demands for extra staff. This payment modifier is imperative so that rural agencies will be able to keep their doors open and provide necessary care to home-bound patients.
However, the Centers for Medicare & Medicaid Services (CMS) has proposed payment rules which may impact the delivery of home health care in rural communities. The shift was mandated by the Bipartisan Budget Act of 2018. Under the new methodology, CMS is varying add-on amounts depending on a rural county’s home health utilization, population density and other factors. Unlike the current standard of a 3 percent three percent rural add-on, CMS’s proposed payment rule segments counties into “high utilization,” “low population density” and “all other” categories:
High-utilization counties are “rural counties and equivalent areas in the highest quartile of all counties and equivalent areas based on the number of Medicare home health episodes furnished per 100 individuals who are entitled to, or enrolled for, benefits under part A of Medicare or enrolled for benefits under part B of Medicare only, but not enrolled in a Medicare Advantage plan under part C of Medicare.” Low population-density counties are designated due to their population density of six individuals or fewer per square mile of land. The all-other category includes counties and areas that don’t fit into either definition.