Curbside Consult with Dr. Jayne 3/1/21

My calendar made me smile today with an appointment reminder that had 2020 been a normal year, I would be in Las Vegas attending HIMSS21 and drinking martinis with all of my healthcare IT friends. Alas, it was not meant to be. Instead, I’m ever-present in my home office digesting a constant stream of email, press releases, and journal articles.

The theme of the week seems to be telehealth, with different companies in the news. MDLive, which was thought to be setting up for an IPO, was instead acquired by Cigna’s Evernorth subsidiary. At the same time, Mercy and Humana teamed up to expand access to telehealth services for Humana Medicare Advantage members. The latter agreement is particularly interesting because it specifically called out a value-based care component of the relationship. Once the US healthcare system begins to fully process the burden of COVID-related care, I suspect there will be a greater drive towards value-based care.

Due to the fragmented testing strategies across the country, many patients are receiving high-cost testing at urgent care centers that require a physician visit to justify the testing. A better strategy would have been to enable public health-based testing, where patients could have been tested under standing orders from local public health authorities, reducing the overall burden on the system. The nation has been walking a tightrope, balancing the need to ensure access to testing with the potential for out-of-control testing costs.

I see this in my urgent care practice, which is one of the organizations requiring a provider visit prior to testing. Patients are seen and examined, then the most appropriate test is determined, ordered, and obtained. Over the last few weeks, we’ve seen a shift in testing behavior. Previously, the majority of our tests were done on symptomatic or exposed patients, with rare testing for travel. Now we’re seeing a boom in pre-travel testing, and doing that kind of testing in an urgent care setting is a significant waste of resources. We are also seeing people just coming in to be tested weekly because they can, and because they don’t have any financial skin in the game. They’re going about their lives unmasked and practicing unsafe behaviors and the rest of us are picking up the tab.

Out of necessity, we don’t want to create barriers to testing, and as a physician, I totally get that. Recent executive orders and subsequent guidance from federal agencies make it clear that patients must be tested with no cost sharing or utilization management oversight. As someone watching the costs mount, especially in states that didn’t bother to prioritize low-cost testing options, it’s anxiety-provoking.

Fast-forward then to a new world where payers are going to be looking to make up for all of those expenditures. Premiums are certainly going to rise, and they’re going to crack down on payments for other services. I predict that use of low-cost telehealth services will be pushed to the forefront. That’s good for patients who are technology-savvy and value the convenience. It’s not so good for patients who don’t have access to technology or aren’t skilled with it, or for whom an in-person visit would be better. Telehealth may become an additional layer of triage that helps control which patients receive more expensive in-person services, and this is most certain to happen if payment parity for telehealth services does not continue.

Practicing in a telehealth environment doesn’t come naturally to physicians, and few schools taught telehealth skills prior to the pandemic. I enjoyed reading a recent article in the American Family Physician journal which explained how to do high-quality management of musculoskeletal issues through a telehealth encounter. That’s the kind of practical retraining that many physicians are going to need if they’re going to be expected to practice in that world. They shouldn’t be expected to just figure it out on their own, as most have had to do.

But if they are going to be held to the same value-based care metrics and standards that they are held to in the brick-and-mortar world, they’re also going to need adequate telehealth infrastructure to deliver it. This means being able to coordinate visits with ancillary providers such as registered dieticians or certified diabetic educators and being able to leverage high-quality remote patient monitoring services. Although these are great concepts, we’re not remotely close to delivering that level of care to most of the US.

I’ll be watching the recent telehealth acquisitions, agreements, and expansions closely to see who is hitting the mark and who starts drifting off course. Many organizations will be forced to migrate from make-do virtual visit platforms to robust telehealth solutions that integrate with the EHR. Physician groups will have to determine how they figure telehealth into evolving physician compensation strategies. Much like groups might pay physicians less when they stop taking overnight call, will they pay physicians less if they elect not to come into the office? Will they create different kinds of practice-share arrangements for teams of virtual and in-person physicians to partner together? Will telehealth be part of a continuum of care, or will it continue to be a bit siloed?

I’ll also be watching lab and other ancillary businesses. Will the big lab vendors start performing COVID testing in person, so that a patient could receive a telehealth-driven order for testing and go to a lab patient service center to have it collected, just like they might go for a blood draw or a urine culture? Or will local public health agencies step up to fill that void, especially since those states that had mass testing centers are starting to close them down? Will we see COVID testing booths on street corners like you might see in other countries? The devil will be in the details as far as how we try to contain costs and deliver the medical services that provide the most value to our patients without breaking the bank.

Looking in your crystal ball, what do you think are the next steps for telehealth in the US and around the world? Will we see massive shifts in utilization? Leave a comment or email me.

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