The Covid-19 pandemic has catalyzed the adoption of telecommunications as a substitute for in-person encounters across many industries, including health care. Already a growing practice, telehealth services that remotely connect doctors and patients have surged in recent months, promising convenience, efficiency, and safety.

Questions remain, however, as to telehealth’s impacts on the long term cost and quality of care, the limitations of remote practice, and the adequacy of conventional health-care policy to address this growing service. The pandemic has brought about ad hoc adjustments in payment systems and privacy regulations, but what changes might or should accompany a return to normalcy?

On July 8, the Manhattan Institute hosted a discussion with health-care policy and industry experts about telehealth’s promises and challenges, and what implications this innovation has for public policy and medicine in the United States.

Event Transcript

Chris Pope:

Hello, and thank you everybody for tuning in today to our event on the Challenges and Promises of Telehealth. Now, the whole COVID-19 pandemic has given everybody a chance to reassess a lot of things, whether they wanted to or not. This is definitely true in the health care industry, as it is in every other sector of the economy. Health care is obviously traditionally a very high touch personal service oriented sector. But what we've noticed is that as primary care providers have been forced to shut down over recent years, that this is really, sorry, over recent months with pandemic, this has basically forced them to move to telehealth in a way that they never have before.

Chris Pope:

Telehealth has been a discussion that people have been having for at least a decade, probably more, and people are now trying to figure out how it is to go from ideas and concepts that people advocated for many years, the idea of more convenience, the idea of medical visits fed around people's schedules, to an environment where telehealth potentially displaces in-person care, makes health care easier to access and becomes a long-term way of delivering care to people rather than just to stop gap where people are trying to social distance. Now, we've got some challenges though in the way of this move to telehealth. Big one is really the reinvestment challenge. It's one thing to say that people are allowed. The doctors, the nurse practitioners are allowed to deliver care by telehealth, but at the end of the day, if they're not getting paid for it, that's not going to happen.

Chris Pope:

Temporarily, CMS has waived a lot of the restrictions around telehealth, private insurers has done this as well, but in the longtime, if telehealth is really going to make it to the big time, there has got to be some structural change in terms of the reimbursement opportunities and rules, especially in the Medicare program. There are a whole host of associated regulations associated with that. Changing regulation, obviously is a political decision that needs to be made. That gets pretty complicated at some times. There are winners and losers for many kinds of change. There are a lot of complicated calculations again, made by political actors, by business, by government, by people in Congress.

Chris Pope:

Our guests today are really going to try and filter through firstly, what is the promise to telehealth? Secondarily, how far are we getting down this route to transforming essentially our delivery system. And then thirdly, how do we think about the political challenges and getting past them? Today, I'm delighted to invite three guests. Firstly, Ateev Mehrotra, from Harvard Medical School who is here to really give us a sense of the research background on telehealth. How telehealth is doing currently, where it might go, what is potential impacts on costs and access to care might be? Dr. Mehrotra is a professor of healthcare policy and medicine at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center. His research focuses on delivery system innovations with attention to the quality of care and has been really a pioneer thinking about telehealth and investigating really what the evidence says here in terms of how it might transform the delivery system in terms of quality and costs and what the opportunities and realities are going forward.

Chris Pope:

I also like to welcome Peter Antall, who's the chief medical officer at American Well. Peter Antall is experienced [inaudible 00:05:54], a healthcare entrepreneur and a physician manager. American Well is one of the nation's, if not the nation's, leading telehealth provider and platform. Dr. Antall is also president and medical director of the Online Care Group, primary care group that really works through the American Well telehealth platform. So he can give us a real sense of really what the challenges are from a business point of view, but then also from a clinical point of view, like from the docs that are participating in this and how it feels really from provider side.

Chris Pope:

Then thirdly, I like to welcome Robert Horne, to really give a sense of the policy aspects of this. Robert is president of [inaudible 00:06:41] Health Consulting in Washington D.C., an organization that advises institutional clients on how to navigate the health care landscape on Capitol Hill. And then also in the regulatory agencies, CMS and FDA. Robert has an extensive experience in health policy, FDA issues, payment policy issues. He was one of the leading forces behind the Macro Healthcare Policy Reform that went through Congress a few years ago. And then also to the 21st century CARES Act, which was a big priority of Manhattan Institute with Peter Huber, really trying to speak the innovation on the pharmaceutical and device sites, which has obviously a huge relevance right now with the pandemic. Robert spent over a decade on Capitol Hill, firstly with Congressman Gingrey and then with the Energy and Commerce Committee where he dealt extensively with Medicare payment policy issues and FDA reform.

Chris Pope:

I'd like to invite our guests. Thanks for joining us. Also, thank you to anyone who's listening, for joining us. I want to remind everybody that they can submit questions for our guests. There will be a Q&A session and people can submit questions through the on-screen prompt. I think we'll start with just really getting, this is obviously a big issue area that our guests have thought deeply about. I'd like to introduce them and having introduced them, I'd like to give them a chance to offer their thoughts. Ateev, would you like to lead off?

Ateev Mehrotra:

Yeah. Thanks for having us and I look forward to the input from those listening on the phone online here and their input. We thought it might be useful to just take a couple of minutes just to lay the foundation on how the pandemic has impacted, how Americans get care and specifically related to telemedicine. So I'll just go through a couple of data points that I hope will be helpful to the conversation.

Ateev Mehrotra:

What I'm showing you here on this graph is really what happened on the visit side in the United States. What you're seeing is each of the weeks on the X-axis of starting prior the pandemic, and then that baseline week as orange is when things really went south in terms of both the virus spreading as well as the impact on how patients got care. And through the course of just three weeks, we saw a dramatic decline in the number of visits we were seen to practices of all types across the country. Something I have never seen in my clinical career, where there was almost a 60% decline in just four weeks from the baseline. Then subsequent to that, as the pandemic has progressed, we have seen a rebound that has now where roughly as the last time we checked, the week of June 14th, we're now roughly 11% down from our baseline in terms of the number of visits we're seeing per week to doctors in the United States. It's highlighted, is a cumulative visit deficit because I'll get back to, it's a big concern is, is that our patient's health care needs not being met.

Ateev Mehrotra:

Now, the conversation today is focused on telehealth. So I wanted to turn to that. What I'm showing you here is the same time horizon, but on the Y axis, I'm now showing you that of all the number of visits we might see prior to the pandemic, how many are provided by telehealth in that given week? So prior to the pandemic, people were using telehealth, but it was a very niche part of the health care landscape. Relatively few patients had experienced a telehealth visit and most doctors were not using telemedicine. At the same time we saw the dramatic decline in total visits. We saw this dramatic rise in the number of telemedicine visits or telehealth visits.

Ateev Mehrotra:

To the point of by mid April, we were seeing about 14% of all visits that we would see at baseline provided via telemedicine. These are huge numbers. I should just give you a sense of that, which is that they're roughly a billion doctor visits in the United States per year. So if that 14% had continued throughout a whole year, that's roughly 140 million telemedicine visits. Changes that people have been talking about for decades, we're expected to take years, all of a sudden happened within the course of just several weeks. Then it's interesting, since that peak in April, as economies have opened up, communities have opened up, we're interestingly seeing a decline in the number of telehealth visits in a given week. I think one of the things that we'll come back to in our conversation today is why and how is policy playing a role with that?

Ateev Mehrotra:

I just wanted to add two last data points. The first is that while telehealth has helped, it hasn't affected that overall decline. So I wanted just to explain that to make sure we're clear. What I'm showing you in the turquoise line here is what I showed you previously, that big decline up to almost 60%. In terms of in-person visits, it was down even further. That gap between those two lines is provided by telehealth. So it has played a critical role in the health care landscape, but I want to make sure I emphasize that there's still overall was a huge decline. The last data point I wanted to add was that it totally depends greatly on the type of care being provided. That's illustrated a bit here by the specialties and their percentage decline. If you look at our psychiatrists or psychologists or social workers, they've really embraced telemedicine to a much greater degree and subsequently have not had as much of a decline as some of our surgical colleagues where telemedicine is a lot harder to use.

Ateev Mehrotra:

When we think about the impact of both the pandemic and how patients are getting care, as well as which type of care they're getting, I think it's really important to emphasize. I'll just end by just highlighting why this is so critical as we think about the impact of COVID on the health of the nation. We're obviously focused on those that are infected, but I also want to emphasize that these spillover or secondary aspect is critical. Patients were scared, very scared to go and get care. We are seeing the health consequences of that. For example, we have seen a dramatic drop in heart attacks and strokes that are coming into the hospital.

Ateev Mehrotra:

As one of the doctors in this article highlighted, its patients are saying, I'd rather die at home than going into the hospital. Other patients, in particular those that have chronic illnesses or immuno suppressed are very scared to even get some blood work done. I think that's important to emphasize why telemedicine has played such a critical role. It hasn't been a panacea, but it certainly has been again, the lifeline for these kinds of patients to at least get some care and potentially address their health care needs. I'll stop there. Look forward to the conversation.

Chris Pope:

Thanks, Ateev. That was very helpful. Peter, it'd be great to hear your thoughts from on the ground perspective.

Peter Antall:

Sure. Great, great. Thank you. Maybe I'll say a couple words and then I'm also going to go into a couple of slides and bring in some data from our experience in the private side. First of all, it has been quite a year. I'm sure you've all seen it, particularly COVID, but not only do we have COVID, but we have the economy and we have the social unrest and everything else that's going on. I would say, in the world of telehealth, it's been an incredible year. It's been one of those inflection points that's totally changed the industry.

Peter Antall:

My name is Peter Antall. I'm the chief medical officer at Amwell. I'm also the president of Amwell's affiliated, but separate medical group called the Amwell Medical Group. I'm a pediatrician originally and based in Southern California, I've been around this industry since 2008, back when it was only very expensive fixed end points. We're in a whole different world now in which care can happen right on a smartphone or really a consumer grade device that people carry around all day long. We're excited that we could play a meaningful role here during COVID. If you remember back to early March, our health care system really was on the ropes and things got bad really quickly, especially beginning in Washington state, up in Northern California and then progressing across the country.

Peter Antall:

We quickly realized that we could play a meaningful role in that robust care could be delivered by us or by other known providers to patients through telehealth, but the virus can't travel back through the internet. That notion of social distancing really made a difference. In particularly, as Ateev has mentioned, as ambulatory care somewhat broke down or significantly broke down, patients needed other options. They didn't want to be in the emergency department. They couldn't see their PCP in many cases, especially for ill visits. They needed other venues and other ways to receive care. Care for COVID related illnesses, but also normal care for their diabetes and their hypertension and whatever else is going on.

Peter Antall:

If we transition over to some slides, this was the view back at 2017. Eric Topol and Ray Dorsey were really talking about, and this was really considered very aggressive and very forward thinking. That crossover point at which more visits in the future would be delivered electronically than in person. I think I was on another panel recently with someone from CMS and they said, what COVID did is accelerate the timetable like this by at least five years. This was, if we can see this next slide, this was our view. These little blips, 2015, 2016, 2017 look really modest. But when viewed on a smaller timescale, these were hockey stick shaped. So each year, and these peaks are always during the winter, when we're talking about Amwell as a cure delivery engine, not just a technology company, a lot of our care delivery is acute urgent care and things like this that tend to be seasonal. Each of these blips represents a flu season, and each year we were jumping up to X or so, sometimes three X in volume, but you can see what happened this year.

Peter Antall:

In three weeks, we went to nine times or 900% increases in volume and not just in urgent care of course, and that's just our clinical group. I want to pause and say, keep in mind that you all may know us as an organization that delivers care directly with clinicians, but we see ourselves more so as a technology company. We provide software and hardware that allows providers to see their own patients electronically. And really, that's our longterm vision. As we've alluded to, there are barriers along the way that have inhibited engagement of the providers on the ground and caused them to be a little resistant to change. And we're going to talk some more about those in a moment.

Peter Antall:

If we look at adoption over the last five years back in 2015, about 5% of providers in our surveys disclosed that they had used video visits before. By 2019, that had jumped at 22%. And finally, as we got to this year, we've got that quantum leap. We got up to 80% or so in this survey that now claim they have used video visits. There are a variety of obvious reasons for that, offices being closed down, patients needing care, waiver of enforcement of HIPAA played a role, allowed providers to just jump on and see patients using FaceTime and other non HIPPA compliant vehicles. But what a change? Now we have all of these providers experiencing telehealth, engaging in telehealth and understanding how it happens, how it's done and what it might mean for their future practice, which we think is exciting.

Peter Antall:

On our health system platform, so again, keep in mind when we provide software technology, we provide a white labeled enterprise. I'm not here to sell anybody, but just trying to explain our business to various entities. Those might be health plans, those might be health systems. They may even be employers or other technology companies. The purple line here represents our increase in visits basically from weeks nine through 14, 15 of this year. Our visits within a three week period went up three times in urgent care. So we tripled our volume in three weeks and had to adjust accordingly. Visits on Amwell platforms by other provider groups, by Cleveland Clinic, by Intermountain, by UPMC, they went up 22 times or 220%, sorry, 22000% I think, if I'm saying that correctly, but 22X increase. So it was shocking growth, so much so that we were scrambling and on the phone with CEOs of technology companies, trying to get emergency servers to beef up our technology capability to host such an increase.

Peter Antall:

Now, you can prepare for doubling, tripling, maybe 4X, but nobody's prepared for 22 times the hosting capacity of video hosting in three week period. To Ateev's earlier point, overall, what did that mean? Amongst our providers, amongst external providers that were supporting 7X increase in urgent care across all those platforms, but then we went as high as 50X increase in scheduled visits. And what scheduled visits basically means is, these were not one-off visits with an unknown provider. These were visits with known providers and with their own patient panel. Those might be primary care, those might be specialty, might be proceduralist. Again, that 50X, while that looks funny on the screen in terms of the magnitude, what that really represents, if you look back to baseline, there weren't a lot of those happening prior to week 10, and week 10 really represents that shift from ambulatory providers embracing telehealth and seeing their own patients.

Peter Antall:

Again, to Ateev's points, those are coming back down. Primary care and ambulatory care is back open for business. So we are seeing some of this go back and reverting back to normal state. But we're still at, I believe, I don't have that number on here, but I believe we're still at about 20X above baseline prior to COVID. So we're still seeing a dramatic increase and a lot of providers still using telehealth as a normal part of their service. I'll go very quickly here. Pre COVID, average, a hospital system had two or three use cases. Now average six to seven. Average hospital system had about 30 providers using their version of our platform. Now, up to average of 230. We've had some organizations that have enrolled their entire ambulatory enterprise on to telehealth as well.

Peter Antall:

I want to just highlight consumers as well. Consumers have already enjoyed telehealth when they've had the occasion to try it. What we see now is we've seen a shift from 55% of our visits occurring with a first time patient now up to 75% with the new onslaught of all of these new patients trying out telehealth during COVID for the first time. Just to understand our case mix, we've seen anywhere in the last three months, from eight to 12% of our urgent care visits are suspected COVID or CLI. Of those, 92% were patients that we were able to manage successfully in the home, what we call COVID-like illness stable, and 8% were COVID-like illness unstable. Patients who needed immediate care, usually due to significant breathing difficulty. The States that have been hit the hardest with those unstable serious cases so far in our experience had been Florida and New Jersey and New York.

Peter Antall:

Then last slide, I just wanted to highlight, don't forget behavioral health. We also are a behavioral health company, both in terms of providers that we support as well as our own clinical operations. And in combination of those two, we're seeing 44 times the volume for talk therapy and 27 times the volume for psychiatry. These are explosive numbers. We can't recruit behavioral health providers quick enough, as soon as we recruit them, they end up with a full panel within days. So not only do we have a COVID pandemic in this country right now, we have a behavioral health pandemic in my opinion. I will stop there. Let me just say, it's an exciting time to see telehealth being engaged. There are still a lot of work to do, especially on the regulatory and reimbursement front. So, look forward to discussing that more.

Chris Pope:

Thank you, Peter. That was great, very illuminating. Robert, from a policy point of view, how does all this look? Obviously people have been working on telehealth for many years. Well, let's change this year and where might we be going or not going?

Robert Horne:

Well, Chris, thank you. Honestly, the last two speakers have been very informative and really helped set up this part of the conversation. I think from a way forward standpoint, it's a mixture of good news and bad news. I think the bad news is that reform, legislative reform is still needed to realize the full vision of telehealth. The good news is that we really have advanced a lot in our mission to achieve that goal over the last couple of years. A couple areas I might highlight real quick. First, Congress has promoted and passed a number of expansions for the use of telehealth over the last couple of years. Unfortunately, they've been largely focused in certain areas of medicine, home health and some others, but certainly representative of Congress's support. I'm here to tell you Congress's support is ongoing.

Robert Horne:

Number two, the administration has been given recent flexibilities by Congress to really expand the use of telehealth during COVID. I think to the last speakers points, COVID has created almost a national demonstration opportunity for us. We are realizing a place in which access isn't normal, access to care that is, isn't normal anymore. To the previous speakers points, we've got patients with illnesses and conditions and situations in which normal access is not appropriate. All of that has led to both a greater embrace of telehealth as the previous speaker spoke about, but it also in conversations that I've, and others have had, it really, I think the feeling for both Congress and the administration is we want this to continue. We don't want to take a step back. We don't want to release some of what we're doing or stop some of what we're doing in telehealth today. We'd actually like to find ways to do more of it. That's all good news.

Robert Horne:

The rest of my, I think my presentation, I'm going to focus on maybe how we can do that. In our time, I'll try to be as specific as possible, understanding that there are some details that we just don't have time for. But in thinking about really the argument for telehealth and then the way forward, it really, this argument of it increases care access and use and makes individual cases for care access and use easier on individual patients, that is an argument that policymakers understand. I think the recent advances in digital technology have also, I think, helped telehealth as well because people are starting to realize the efficiencies that can come with a digitally supported medical access and care model.

Robert Horne:

From the vision of the future standpoint though, the good news is, the one area I didn't mention in my support is the market. The market's already starting to move into a future of pandemic preparedness and ensuring that there are access avenues in place for patients no matter what happens. A good example of this really is something that I'm starting to hear of, is a virtual hospital where really, if you could think about it, it's a whole suite of services supported by face-to-face interactions, digital interactions, all molded together with a payment system that really does present new opportunities for patients and for payers and providers to really facilitate care both in normal times, but also emergencies. Largely, the issue continues to be this, in areas where telehealth policy needs a change, and that changes legislative, how the congressional budget office views the spending and use of any new law weighs heavily on the minds of politicians.

Robert Horne:

Just to cut right to the chase, what CBO was really going to be looking at is how does your policy impact spending? Does it go up, does it go down and how does your policy impact the quality of care available to patients? As you think about ways forward, there were really five buckets that I'd like to focus on and then talk about a couple of thoughts to address those. The first two buckets are probably the most important. The first bucket is payment. And as Chris and others hit on, the payment mechanism that you use to fund telehealth will be of import to CBO. It will in part, it has in the past presented an obstacle to care. And what do I mean by that? Specifically, if you think about telehealth and attaching it to the current system as it exists right now, this is a fee for service. This is every time you use a service, you pay for it. CBO has tended to look at those a little bit negatively.

Robert Horne:

Now, Congress has found a way through that. And as I mentioned earlier, Congress has been successful in some very targeted legislative packages. That's almost their way of dealing with some of these cost implications. The neat thing about the market though is, and I think in saying this, there doesn't need to be a departure from fee per service, per se. But really you can think about taking fee for service philosophies and applying them to new payment models, like global payments and other types of arrangements like that, that frankly better support the benefits of telehealth, easier use and potentially lower costs. The issue isn't to suggest that telehealth should save money. In fact, what's been going on right now, there may be some appetite in Congress to spend money on telehealth expansions, but it's just important to note that that's where CBO comes from.

Robert Horne:

The second main bucket is something that is multidimensional. I don't have a lot of time to get into it today, but that's really around functionality. From a policy standpoint, policymakers want to know what are you using the technology for? What does it compare it against in terms of the clinical model? And then what are the benefits or negatives, let's say, for the patient with that new technology in lieu of what happens today? As you think about functionality, the reason that functionality is important is twofold. One, Congress is very worried about privacy issues. But how does the technology facilitate care and how does the technology address any privacy concerns that come up? That's a policymaker consideration. The second side of functionality is really one of the medical service itself. Is it being generated from a living person, or is it being generated from a technology platform?

Robert Horne:

In areas of behavioral health, as one example, we're already seeing where both are available. So from a policy maker standpoint, it's not only just the mechanism to share care or to access care, I.e. telehealth, but really policymakers are starting to get into the functional aspects of digital health and how to incorporate those into new models of the future as well. Last couple of issues, then I'll get into a couple of next steps and suggestions. But number one is really fraud protections as we hit on earlier. Do these policies make it easier or harder for people to defraud the government? Unfortunately, CBO's view of CMS is that it's not excellent at protecting against fraud. While the technologies and all of the operations that are happening in the market are above board, CBO may have a negative view of CMS that way.

Robert Horne:

That's all pretty wonky background. What I'm going to do now is just wrap up in a couple of next steps. Number one is, treat what's going on right now as a national demo, gather data and really think about that data as helping to inform policy makers of where problems don't exist or already being addressed. Number two is create legislative strategies that help policymakers address the buckets that I just covered. And the number three, don't be afraid to embrace new policy ideas. The good news is policymakers want to solve this. They have some material problems, but innovative policy can really advance telehealth without sacrificing anything, and do it in ways that make it easier for Congress to pass it. I'll stop there, but thank you very much.

Chris Pope:

Well, that was very helpful. Thank you. You certainly raised a bunch of issues that we'll circle back on in a few minutes. I think what we've seen with a lot of the changes that are happening with the pandemic, especially for example, tele workers, we've seen an immediate shock. We've wondered, is there an enduring change in norms? Will there be, say for instance, millions more tele workers than there have been in the past? It's a similar question with telehealth as well. Peter, I'd just be interested to have you flesh out, what is the best case scenario that we can hope for in telehealth? What is it that people in the industry are excited about? What is it the patients are excited about? What are people really working towards and hoping will happen in the long run or even the medium term?

Peter Antall:

Yeah, thank you. Great question. Sorry, I just jotted some notes there. Listen, I want to clarify, I think there are misconceptions sometimes that telehealth is a distinct specialty or that it requires some level of a special training. Our view is that telehealth is another venue for care. Simple, stop right there. Providers provide care in a number of settings. When I was in practice, I saw patients in my ambulatory setting, I saw patients in the ER, I saw patients on the inpatient side and I did telephone calls. I adjusted my care based on what the needs were in each of those settings. So patients have a variety of needs. I think what telehealth does is it allows us to think differently about how we project the abilities of providers in new and more efficient ways.

Peter Antall:

Number one, how we build new models of care, team-based care, collaborative care. Number two, how we improve access by doing things like solving for geographic disparities, specialist to rural areas, all of those things. Also, at the same time, what we're able to do is make care really patient centric. We talk a lot in hospital settings about patient centric care. It's been a big buzzword for a decade or more. What's more patient centric than a patient who has a minor need for a known condition, connecting by video with their primary care provider who has a chart in front of them, knows the patient, has all their information, is able to adjust a medication or go over a lab test, patient never asked to leave the house, never has to go to a waiting room?

Peter Antall:

We can improve compliance potentially. There's potential to improve compliance research by people like Ateev, need to be done to demonstrate that. There are certainly some emerging evidence that we can decrease no show rates in certain areas like psychiatry where they're very high. I think we're very excited about that, about more efficient utilization of our provider supply. That's one thing. I would add just two other things. One is that new models of care are being built today. I would highlight Joslin Diabetes Center has demonstrated even amongst their own patients, A1Cs are still climbing and amongst our country, our standard of care, the wonderful brick and mortar standard of care that we have is still experiencing increasing population A1C levels. So we need to do better. We need to build models. Telehealth affords us.

Peter Antall:

It's one tool in our toolbox and Joslin used it to do more frequent touch points with patients. They didn't say come back and see me in six months to find that the A1C hasn't budged. They said, let's check in every two weeks. Sometimes you'll check in with me, sometimes you'll check in with my diabetes educator. Sometimes he'll check in with my dietician, and let's keep on you. Let's keep nudging you along so that we make real progress. I think that's exciting. Then the last thing I would say is there is a lot of disintermediation, a lot of noise, a lot of interoperability challenges that are inherent in our health care system.

Peter Antall:

There are opportunities. We're not going to solve all those problems, but there are opportunities to bring patient specific data into encounters to analyze that data, remote patient monitoring, through algorithms to have an escalation to a live visit right where the patient is, and to continue to nudge that patient through texts or other mechanisms on an ongoing basis. So bringing in data, analyzing that data, using AI, using chatbots and having ongoing nudges and touch points with the patients. So we're excited about the future. We think there's so many ways this tool can be integrated. It's not going to replace in-person care, but it will replace some of in-person care. Then we think we can do a lot of exciting things.

Chris Pope:

That's very intriguing. Well, firstly, I'd like to remind everyone that they can submit questions online. If you have a question for either of our guests, please send that in. But one question that we've received and it really brings up the issue that I think is an issue with a lot of these remote work arrangements, like we've noticed the tele schooling has been a bit of a disaster. People really don't like having kids at home and trying to do K through 12 education. With telehealth, it seems like something we might want to do anyway. There are some quality advantages potentially, especially on chronic disease monitoring. It allows a quality of care that we haven't had so far. But then, Ateev, in your presentation showed that as people were able to go back to the in-person consultation, that telehealth utilization has fallen off a bit. Are we seeing that telehealth is an inferior good? Or is there a quality drop-off? Is this inevitable? Is this likely to go away or does it really depend what we're talking about? How does the quality aspects of this look?

Ateev Mehrotra:

Yeah. I think that there is a premise and sometimes you'll hear this idea that, Oh, because telemedicine has all these positives, it can be used. There are a lot of applications where telemedicine is a high quality option that can provide care, but I worry that some folks may be some telemedicine advocates are saying it can be used for everything. I think it's very clear to me as a clinician, I think almost anybody else, there's a lot of applications where telemedicine is just doesn't work. For example, one of the listeners said something about a cardiology visit. I think that's another example of where it doesn't play a role. So we are still trying to figure out when it can be used effectively and when it can not be used effectively.

Ateev Mehrotra:

We're going to try to figure that out just as we are going to think about with teleschool, when can that option actually add value or not? I do think it's important to emphasize, this is not a binary we do tell a health, or we don't do telehealth. To maybe echo what Peter said, it's going to be part of the larger ecosystem that we provide. The other point that I think is really important, and that one thing I do get worried about right now when we have this conversation about telehealth, the conversation is about video visits. Video visits are a small part of a larger idea of what telehealth can be. There are a lot of really innovative models out there that go way beyond a video visit. The example that was just provided about diabetes care.

Ateev Mehrotra:

We have some new tele endocrinology providers are coming in and they're doing some really innovative models. They're giving diabetic patients monitors that they can do 24 hours a day, continuous glucose monitoring. They're giving them apps so that they can track their glucoses. Those apps can give them feedback every day, every couple of hours about what they should be doing. They add that with text messages, phone calls, video visits, and they add a full package of where they are using technology to improve the care that patients receive.

Ateev Mehrotra:

I bring that up in this context to make sure that we don't lose sight of that innovation, those really interesting models, but to also explain why it's so complicated once we think about the payment rates for these kinds of telemedicine. Because you can see how you could pay for a video visit, and we are paying for video visits, but there's no way that we could pay for every text message and every phone call and every video visit and every hour we monitor someone. That's when we have to think really outside the box and think about, okay, if we want to encourage that kind of innovation and those really interesting new models, how do we pay for them in a way that goes outside paying for a video visit?

Chris Pope:

Thank you. I think that's the really key question that I think we'll probably circle back on in a little while, because I think the key theme here is really the payment is going to, you get what you pay for in health care. And this is going to be true in telehealth as for anything else. But I think another thing that I certainly noticed in health care policy, I think everyone who works in the area notices, is that we have the same debates over and over again. If you pick a book off the shelf that's 20 years old about a policy debate, pretty much the arguments are the same and the challenges are the same. Yet we still have this radical hockey stick graph that Peter showed us of interest in telehealth.

Chris Pope:

Robert, is the politics different this time, or is there a sense in which we can move beyond what you were saying as a CBO constraint or regulatory constraints? Has anything really changed or are we going to look back at this and in two years time and say, Oh yeah, we had these fun discussions where we thought telehealth was going to take off and nothing actually happens?

Robert Horne:

Yeah. Chris, it's a great answer. I'll give it in three parts and I'll try to be concise here. Number one is, I don't think we're going back. I think the question is how far forward do we go? As long as preparedness for future national health emergencies is a political priority, telehealth is just really, it's such a solution that it'd be hard to walk away from it. Again, I think the question is how do we go forward and how much forward can we go? Number two, I just want to touch on the last point really quickly. Then I want to get into just your question, Chris. On tele-health too, as you think about a way forward, and just to go back to Ateev's point, the telehealth story you tell is really key to success here. It's not a cure all, it's not, at least it's not today. But as you think about it on the positive sides, there are some areas of telehealth that are showing improvements over standard of care. Behavioral health is one of those examples.

Robert Horne:

Again, I've heard this from a couple of clinicians, but just the ability over Zoom to look into a patient's surroundings, how they live, is really helpful in the care that they provide. Again, as people engage Congress, find those areas that are really conducive, I think, to improvements in care. Lastly, let's just anticipate that technology will continue to evolve and get better. So from a policy standpoint, yes, it is true that there are things that telehealth can't do today, but my expectation is in 10 years, I think we're going to think about telehealth differently than we have today and just like we did 10 years earlier. Chris, I think that the way forward in Congress right now is, I think if there are opportunities for different communities to work together, I think that's going to be key.

Robert Horne:

The second thing is, I think the market's doing a lot of neat things around payment and other types of governance issues that really address some of Congress's concerns around privacy and things like that. Really, I feel like the opportunity is ripe. And I feel like if there's the right policy in front of Congress, you're going to get Congress excited. You're going to get the administration supportive and it could be one of those quick acting, let us [ride 00:45:17] vehicles.

Chris Pope:

Excellent. Sorry, did anyone have any further thoughts on that or? [inaudible 00:45:24] to tend to the questions that people have been submitting online. We have a question from Jeff Fly, who's asking, which institutional actors will resist increased telehealth, and why might they be doing so? Is there a way to avoid that, resist that to get around that? Robert, I guess this is a political question again.

Robert Horne:

Short answer is yes. I think there's some real pitfalls. I know folks have talked about HIPAA before, but really it's the way to think about privacy policy, it's very, very important obviously to protect the privacy of patients. Any times you take individuals and you put something in between them like technology, there's the chance that privacy and safety of data could go down. So as you think about the actors of the institutions, you can really think about some of those policy inflection points that may help identify them. Consumer groups obviously are very concerned about digital use and they're trying to apply, I think, some HIPAA protections there. I think largely, CMS had been a little bit hesitant. That seems to have been eroded. Arguably, I think the last thing is some of this disruption has the potential to change the provider model of care.

Robert Horne:

I think you're going to see not the entire industry, but within subsets, you're going to see this tension between no, we want to keep the system we have versus no, we want to do this. And I just think back to Ateev's point, the way forward really maybe one in which it's a flexible system that allows for people that want to use it to use it in ways that are allowed for. And that those that do not, let's say cannot, so I guess maybe the point is this doesn't have to be a zero sum conversation, and it has been in the past.

Peter Antall:

I would just add, in the industry side, I think we see, we work with lots of hospitals systems and health plans and employers, and those that are embracing outcomes, those are embracing risk, those that are interested, most interested in consumer experience are the ones that the organizations tend to engage. Whether that's a health system, whether that's an employer health plan. The lack of alignment is still a challenge. You have a health plan who is paying the bills, or an employer, they see those ER claims for unnecessary ER visits, for example, in the urgent care space, and they see utilization of out of network specialists and all the other things that happen. They're really motivated, but then you have to get the health systems aligned with that. The best way to do that is alignment on value based care. And when we see those organizations that are thinking in that way, or that are integrated and have their own health plans, are taking on risk based contracts, those are the ones that we see engaging and engaging vigorously these days.

Ateev Mehrotra:

I might make two quick points to add on that. The first thing I should, going back to Jeff's question, which is about who are the people who are going to resist this? I think a lot about the large existing in-person provider, your big health systems, as well as your practices. I think there's a lot of hesitation there. Certainly within the context of pandemic they're using telemedicine, but I think there are some concerns about how this will play out. And there's two pieces of regulation that really I think about. The first one is a requirement that many payers have introduced, which is before you can provide a telemedicine visit, you got to have an in-person visit and also licensure laws, which require the physician to be licensed in the state that the patient is located. Both of those are very problematic from an innovation perspective, because they limit companies that are introducing new clinical models, that are trying to provide national care. I'll just give one example of that.

Ateev Mehrotra:

We were working with a number of opioid use providers. We have an epidemic right now, they're introducing this really interesting models, but it's very, very difficult to set up a model where you need to have an in-person visit as well as then getting each of your providers licensed in 50 States. So I'm particularly enthusiastic about as we move forward, first to remove that clause about having to require an in-person visit as well as there has been some calls, and this might be too far and Robert can mention this, but to think about interstate commerce and really whether we need to move to a new framework of not having a single licensure in each individual state, then moving to a larger national framework. That's a big call, but I think we're at that point where we have to recognize that's a major issue.

Robert Horne:

If I can just add to that, I guess, Ateev, we completely agree. The ideal way forward would be start with a white piece of paper so we don't have to deal with all of these restrictions and weird things that have been layered on telehealth because that's the issue. Innovation hasn't waited for CMS policy to change. The market hasn't waited, but this certainly is a huge inflection point that it has to be addressed for, I think for the vision to be realized.

Peter Antall:

I would just add, we're a member of the Alliance for Connected Care, [inaudible 00:50:27] organization in Washington, and the stance we're taking these days on licensure, first of all, the license reciprocities that came up during COVID were incredibly valuable. We were able to project our entire network of thousands of providers all into New York because New York gave license reciprocity during the period where they were in such trouble. It allowed us to really help them. But the Alliance is moving towards a stance in which we're going to be advocating.

Peter Antall:

It looks like for a federally sponsored licensure compact, the Federation of State Medical Boards existing compact is halfway there, half pregnant and not enough leverage. So we're really looking at some of the models in the past around adoption, around drinking age, and some of the other things in which the feds push the States to come up with a unified position in order to gain federal dollars or things like that. So there still a work in progress. We're still floating that out there as an idea, but it's only one solution. A federal license would be wonderful, but I think the belief is that might be a step too far for Congress.

Robert Horne:

Peter, I'll tell you what? If I can just share a thought maybe, if it's couched within the preparedness plans for a future pandemic or national emergency, you might have some area there. Again, this goes back to pick the best environment to have the conversation and then see what you can get done. I think in behavioral health, I think especially on pandemics, they don't have a solution. So they might be more willing to support something like that in that case.

Peter Antall:

It makes sense.

Chris Pope:

We have a question from Donna Rosato, which I think gets to the crux of a lot of these questions. The question's suggesting that giving people access to telehealth that they didn't previously have, that's giving them more things. Isn't that just going to bring more costs for consumers, but also potentially for taxpayers? We have this concern with cost. Robert, you mentioned that CBO is very concerned with cost. If we're giving people more convenience, are they just going to go to the doctor for more routine visits for things that are really not that borderline? It's not necessarily going to mean better outcomes. It's just going to inflate the expenses that are [inaudible 00:52:51]. Ateev, curious to hear your thoughts on that?

Ateev Mehrotra:

Yeah. I think it's a very significant concern. When we think about the impact of telehealth, some people have advocated that these are going to be substituted for doctor's visits, but then the question that Donna is raising is, are the patients going to get more care? So we published some research documenting that the vast majority of the telehealth visits that we were looking for in that particular clinical area were new visits. People getting care, about 90% of those were in that increased health care spending. I told my father about this amazing research that I was doing and I said, "Dad, when you make things more convenient, more people will use it." My dad, only has a dad can do, looked at me and said, "Ooh, fancy Harvard professors proving the obvious." So it makes sense that that would actually play out.

Ateev Mehrotra:

I think it is a very significant concern. That's why I think we have to be extremely cautious about laws that are just going to open up this telemedicine to everybody across the country. That's why I'm much more enthusiastic about smaller expansions of telehealth into certain clinical areas where there is substantial value. It's been already raised by behavioral health. I would bring opioid use disorder, maybe some chronic illnesses, but the idea that we can provide telemedicine and we as the taxpayers should pay for telemedicine of all types, I think I have a lot of concerns about that over utilization problem.

Peter Antall:

I would just add that you have to look at each different use case differently if you're talking about follow up visits with a PCP, that there is a normal level of titration based on the availability of a primary care provider in the cadence in which they suggest follow up visits. Also, [Anthem 00:54:38], we work with Anthem, they published an article with Health Corps looking solely at a three year experience in urgent care alone. Telehealth by urgent care, they found a net savings of $140 for every visit that occurred. The way the math worked was yes, there was a slight bit of increased utilization. I think it was 5%, 4% or 5%. But these were lowest cost visits, lower than the cost of a visit in-person in an ambulatory setting, much lower than an urgent care setting and a heck of a lot lower than the cost of an ER visit.

Peter Antall:

They found that there was enough ER diversion, for unnecessary ER care that there was a net savings at all times. So again, over utilization needs to be studied more. It needs to be understood. I understand all the points being made. Keep in mind that telehealth, there are efficiencies, there are cost efficiencies as well as other efficiencies, number one, and number two, our current health care system in which patients go to the emergency department for sore throats, there's a lot of waste. So there are efficiencies to be gained as well.

Robert Horne:

And Chris, just quick 15 seconds. From a policy standpoint too, if you think about approaches that have been successful in the past, people have largely focused on populations or subpopulations for policy. Then they've also focused on sites of care. A third area that may prove up some benefit to policy makers who are in certain areas might be to focus on functionality where you're developing policy around a function of telehealth in ways that addresses some of the buckets that we identified earlier. I say that because it's really how the FDA regulates products too. So there are some harmonization opportunities between those two that may make sense.

Peter Antall:

And maybe one other point to make just in the context, it's not quite about costs, but tangentially from the question, COVID was a unique situation. In March and April, we all remember our ambulatory systems were breaking down. Our ERs were overwhelmed, our ICU in many places were overburdened or over capacity. The use of telehealth by many different entities on many different platforms played a meaningful gatekeeping role during that time. Not only were we seeing patients who had other chronic diseases that needed care and couldn't get care, but we did a lot of work and we coordinated in our organization with the CDC directly on policies to get people to the emergency department safely if they need that care, and to do a white glove transfer so that they don't infect the whole waiting room.

Peter Antall:

But at the same time, as I showed in the slide earlier, to keep that 90 or so, 92% or so that might have COVID-like disease but that can be at least for now safely treated in the home, to keep them in the home and keep them out of the emergency department. Our ER partners were asking us for help because they were overwhelmed. They were four and five and six hour waits to get seen in the emergency department, even if you had something relatively severe. I would just keep that in mind as well in the context of a pandemic there. It's slightly separate from the cost question, there was an incredible value in using telehealth solely as a gatekeeper.

Chris Pope:

We talked a lot about patient to provide a telehealth and obviously in the context of social distancing and pandemic, this has been the big challenge that's changed the game, but it seems like a big part of the telehealth opportunity is almost provided a provider. Dr. Joaquin with a specialist or nurse practitioner walking with a doctor at distance, and you don't necessarily have the same volume challenges or convenience concerns about utilization associated with that. Is there an opportunity almost under the hood there that's bigger or is that overblown? What potentially is the opportunity out there under the hood in the provider side?

Ateev Mehrotra:

I would, I'm sorry for jumping in, Chris, but there is a great opportunity for both on the outpatient side and in the emergency department, and it's already happening. Let's be very clear about it. In emergency departments across the nation, they often don't have the specialty care that they need. So we see almost half of all emergency departments now are using telemedicine to provide, to get in a psychiatrist who they need, or a stroke expert who they need for treatment, and those are all happening and they're paying for it out of their own pocket through the payments that they're receiving because they see the value.

Ateev Mehrotra:

I think they're in that particular context, it's already happening and we should just keep on encouraging it. The one thing that is out there that is a little problematic is our smallest rural hospitals are least likely to use it because it is expensive. So that may need to be addressed from a policy perspective, but I just wanted to emphasize in many ways, that model that you're just describing, Chris, is already happening.

Robert Horne:

Yeah. And if I can just put a plug in real quick, I think too the broadband issues come up a couple of times on this call, hugely important. And I do think there are some areas on the hill, Drew Ferguson is one that comes to mind that very much sees the connection between broadband and telehealth. So, just some very good opportunities to have a broad conversation on this very exciting times.

Peter Antall:

Yeah. A couple of real quick points. One is, I would highlight there are some organizations, Avera for example, health system in South Dakota that is doing an incredible job of projecting support to rural hospitals through telehealth for ER based support, running codes and things like this for geriatrics to sniffs and various other supports to critical access hospitals. So very successful work being done. There's a hub and spoke model. I would highlight behavioral health and psychiatry, such a shortage of psychiatry and ER settings and inpatient settings and the ability to project them in electronically is happening. We purchased a company recently called the Line Telepsychiatry that is in this business, the inpatient and ER psychiatry business provider to provider.

Peter Antall:

I would just also highlight, there's an ability to an extended provider's career. If you have a neurologist or an orthopedist, especially we've seen orthopedist who are getting past this stage in which they can't be in the OR anymore, but they can still do consults in the ER by telemedicine. It really is a unique opportunity to extend careers and get a little bit more specialty availability out there in the community.

Robert Horne:

And then, Chris, just one last thing. As you look into the future, the success of models in part is predicated on the ability of providers to accept and succeed in a risk environment. The ability of technology to allow a provider to work with other providers to better manage that risk could help models succeed today. But frankly, also could help establish new model opportunities in the future.

Chris Pope:

Any final thoughts from anybody to add on to that? Well, thank you everybody for joining us, we were finishing just in time. This is really given everyone, I think, what is a nice little sample of the debate. It's obviously a debate that has many aspects and Congress will revisit it, the administration will revisit it and the health care system will certainly be influenced by this changes over the years.

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