re: Cigna payment model/denials - this is not surprising at all. I had a client sue another large national payer…
HIStalk Interviews Sanjula Jain, PhD, SVP, Trilliant Health
Sanjula Jain, PhD is SVP of market strategy and chief research officer of Trilliant Health of Brentwood, TN.
Tell me about yourself and the company.
I am a health economist by training. I’ve spent my career doing applied research both in academia and supporting provider organizations. I’m chief research officer at a predictive analytics company called Trilliant Health.
Your recent analysis found that telehealth enjoyed a temporary COVID boost that was driven more by provider supply than consumer demand. What will telehealth’s long-term place be?
The supply and demand is pretty telling. Does telehealth have a role going forward? Absolutely. But its use cases as the system is currently designed — for incentive structures, payment models, and the consumers it is reaching — are pretty narrow. We need to zoom out to say, what is the intent of telehealth? We’ve talked about it as an industry as a tool to expand access, but the data is showing that it is expanding access for those individuals who already had access to healthcare. They are your proactive healthcare people who have more resources and are slightly more affluent.
If we want to move the needle in terms of who is using the technology, We have to think about payment parity. Who are the individuals we need to reach, and why are they not using telehealth? Is it a preference thing? A lot of the data right now suggests that they like the in-person interaction with their provider. The exception is behavioral health, which makes sense as a sensitive topic where it might be OK to talk about it with someone on a phone as opposed to in person.
Physician incentive structures and patient preference is a big part and it remains to be seen. Are there patients out there who are not using it today who actually want to use it? Once we start unpacking that, we will expose the market opportunity.
What is the impact of telehealth commoditization, where patients initiate the least-expensive visit with whatever provider is sitting on a couch somewhere waiting to pick up a call?
I’m not a clinician, but wearing my health policy hat, I have concerns that it could create waste in the healthcare system. Where does quality fit? Even if it becomes so ubiquitous the way you described, how do we know if it is actually delivering greater value clinically?
We are seeing cases like the COVID testing analogy, where you had to get the pass or appointment to then go get tested. You are being vetted in an additional step. I would argue that could be a sign of waste if that model applies going forward. It remains to be seen where that utilization comes from and how it’s being used.
From a clinical perspective, how many use cases are actually delivering value? So much of healthcare requires touch and running ancillary services to be able to evaluate a patient. That’s why behavioral health becomes an exception. But even if someone can quickly dial in, what will you be able to get from that interaction beyond a prescription refill or a very limited set of services?
An early concern about telehealth that it would create new costs or, at best, move the same care for the same people to a less-expensive venue. And in the US healthcare system, today’s insurer might be saving a competitor’s future cost of treating an avoidable chronic condition. How do you see telehealth impacting overall healthcare cost?
It is yet to be determined , but the initial data is a little bit skeptical. It goes back to the downstream cost of care looking at that patient longitudinally. What else are the individuals who use telehealth regularly doing in their care patterns? What is the lag time when they go see a specialist? What are their actual broader healthcare behaviors?
The initial signals don’t suggest that it is catching things earlier, therefore leading to early intervention. Behavioral health is once again the exception, and that’s maybe an opportunity to improve outcomes from that perspective. But from a cost savings, it’s hard to see where that proves to be true.
Telehealth has created a business model of healthcare convenience, where startup prescription fulfillment services will throw in a free, rubber-stamped telehealth visit to sell birth control and hair loss products. What does that say about how consumers value clinical evaluation?
There are two pieces to that. On the consumer point, to what you are saying and what our research shows, telehealth is being treated like a commodity good. We are in an era where many of us order our groceries online or do Amazon Prime, We like that instant access and convenience. Consumers, to some extent, want that in their healthcare decisions. Those individuals are not thinking about what that means from a quality of care perspective. They are looking at it from a convenience perspective.
But we see that some consumers make different healthcare decisions. A section of the report covers psychographics, a construct that there are five profiles, and each of us by the age of 18 formulates what that is. That defines how we make decisions. Some people are brand conscious and would drive an extra hour here in the DC area to go to Hopkins and bypass the five-minute drive to Inova or MedStar, because in their psychological profile, they have a different brand perception. Those consumers may be ones who don’t engage in some of these commodity-like services. It remains to be seen whether they perceive the quality of a telehealth visit or something like an Amazon Care service to be on par with a traditional visit.
Every consumer is different. With a grocery store analogy, some consumers shop at Whole Foods versus Kroger or Safeway. Everyone associates a different value to it and the outcomes that are associated with it.
To your second point, there just is no quality data out there yet. Consumers have always struggled to make informed decisions because our system makes that hard, where it’s different from shopping for a healthcare service or finding the price of a service. We are in early innings to expect consumers to think through the advanced quality pieces of that. But we as an industry have not even begun to scratch the service there. That’s going to be the next wave, the downstream implications of this new way of interacting with the care system in being able to call in and get a bunch of prescriptions.
Despite lots of chatter about consumerism, patients aren’t entirely free to make their own decisions because they are limited by insurance or geography. Is consumer preference and satisfaction really becoming more important?
I don’t think it’s that black and white. Consumer preference is certainly important, but the way to think about it is, how do you influence consumer decisions? Assume you have two diabetes patients in a given market. One has consumed information only via text messages and virtual modalities. How a provider or health plan encourages that person to to engage in A, B and C healthy behaviors is very different than with another diabetes patient who is old school and likely to respond to things sent in the mail.
We don’t think about our healthcare patients as people who make decisions, so when I’m talking about decision making, a lot of it is a product of the choices in your market and the financial incentives. But each of us weights factors differently — convenience, price, geography, location, and distance. That’s where some of those opportunities lie. The more you understand those and understand your market of individuals, the better you can cater your offerings to your population.
How do you react to investors putting a lot of money into digital health companies whose business model requires employers to buy their apps, chatbots, or coaching services for their employees in hopes of saving healthcare costs?
I’m not as deep on the employer market, but looking at what the trends show, the employer market is the opportunity for growth within the telehealth opportunity. We are seeing that with existing players like Teladoc and others who are shifting their model from a direct-to-consumer sale to making it an integrated benefit. That is why we made the point in the study around the margin costs being effectively zero.
The opportunity is within that population, but let’s think about who the employer population represents. It still is your commercially insured, healthcare-proactive individuals, for whom it is just an additional service. Without going too deep in a rabbit hole, I think that will be the opportunity where people are focusing, but once again, who is your market and who was telehealth intended to expand access for? Is it those who have great coverage and have a lot of access to services, or the people who with not as great health outcomes and are not regularly seeing a provider who need to be seen them more?
Compared to typical disruption, how might telehealth change the value of brick-and-mortar healthcare locations that have traditionally provided competitive advantage?
Where that is intertwined is this concept of the digital front door. Particularly for a lot of these retail players, but also traditional players like hospitals and health systems, the operating assumption is that if we have a way to engage with individuals on the front end — whether in a retail store and they come into the health system for more serious conditions or they use a digital front door like telehealth – they are going to come to us. That’s usually the operating premise for making those investments.
Analysis that I’ve done previously looked at health system traffic for what percent of patients in their market engaged with them through a telehealth encounter, then continued by seeking downstream care services at that health system, such as specialty care or other services. It’s not actually that strong of a connection, meaning there is a fair amount of leakage. Consumers want choice and options in hybrid models of care, but the data doesn’t support the extent to which telehealth investment will bring more patients to my brick-and-mortar location.
As a health economist, what technology trends do you follow most closely?
I’m spending more time on home care and some of these ancillary services and therapeutic technologies, at-home testing and things like that. It will be interesting to see whether that changes the practice of care and how that the data coming out of those technologies for treatment changes the whole system.
But ultimately, what I think about from a macro perspective is what I call the healthy tension between technological innovation and the payment model and the policy to meet that where it is. The largest payer of healthcare services is the federal government, and that share is growing. We have a lot of private sector innovation, which is great, but how does the incentive structure and the payment model support that innovation? Where does quality fit in? Where do the outcomes fit in? How do we measure that it is working and are we reaching people? That will be, no matter what the technology, the heart of how we know if it’s transforming the system or not.
I don’t think payment parity is a good idea. Payment parity is just going to drive more money to big regional health systems. They can manage physician recruitment to address supply, they can afford to buy the technology to do the visits and they can afford to buy the marketing to find those existing high spending consumers. Pairing telehealth visits with marketing materials makes a lot of sense, which is why you see health systems talk about telehealth in the same sentence as digital front door aka the health systems website.
If you make telehealth pay less than in person visits, you’ll keep it cheaper and drive the organizations doing telehealth national. Listen, I know rogaine, antidepressants and ED medication isn’t holistic healthcare but undoubtedly those things ARE increasing access. People don’t want to talk to their health system provider about that or their health system charges at least 500 dollars more for that stuff than the national telemedicine company. Doctors can look down their nose at that stuff but that’s access right there and it’s something it’s something patients need. If you drive payments to parity, then regional health systems start throwing money around and local health systems are a quagmire. Nothing gets done except some consultants get paid (KLAS or trilliant.) And money gets funneled to a couple crappy enterprise software vendors. And patients remain bald and sexually unsatisfied. I don’t like national chains either but at least they can get things accomplished within the constraints of the American consumer market.
Thank you for this interesting Q&A with Dr. Jain. There is no doubt that telehealth usage has declined since the peak of COVID-19. At this point no one can say for certain what future demand will look like, other than what we are seeing in behavioral health where demand continues to skyrocket. It has been surprising how well telehealth was accepted across the U.S. population during the pandemic. Two key drivers were safety and convenience. No need to be in a waiting room with other sick patients and no need to drive to a location for care. Of course, the big hurtle was reimbursement that was quickly dealt with in the 1135 waiver. Providers want paid the same amount whether in person or via a video screen.
As we look forward, telehealth is vital to serving at-need populations, those with chronic care conditions, and people living in rural areas. Continued new technologies will provide better diagnosing mechanisms, more effective sensory monitoring, and better technical interfaces. We are now even seeing telemedine showing up in the curricula at medical schools and we may even see “virtual health” emerge as a medical specialty.