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Navigating the Next Generation of Telehealth

Coordination of care is an area that needs improvement

A man is watching a doctor on a computer screen.

By any measure, the growth and acceptance of telehealth over the past two years has been impressive. Data from private insurers shows that telehealth represented 13 percent of all health claims in the U.S. in April 2020—during the height of COVID-19 lockdowns—an increase of more than 8,300 percent over the year before, according to the nonprofit FAIR Health's database of privately billed health insurance claim records.

Telehealth use has returned to earth a bit. By October 2021, telehealth claims had declined to 4.1 percent of all health claims, according to FAIR Health's data, still significantly higher than pre-pandemic use but well off that 2020 peak. The one area where telehealth has maintained its gains is virtual therapy for mental and behavioral health issues, which represented nearly two-thirds of private insurance telehealth claims last October.

"Telehealth had its moment in the sun during the pandemic," said Steve Blumenfeld, head of strategy and innovation, health, and benefits at consultancy WTW (formerly Willis Towers Watson) in Short Hills, N.J. The question is, can the industry sustain and grow this success?

Growing Pains

Rapid telehealth growth has created challenges for the industry. For example, all segments of the population have not benefited from greater telehealth availability. A 2021 study by the Rand Corp. found that the growth in telehealth during the pandemic was driven by adults with higher incomes, mostly in metropolitan areas. Telehealth use for children and lower-income adults lagged by comparison. Similarly, due to the digital divide, rural and lower-income workers may lack broadband Internet service.

Staffing issues are another challenge. Like many health care organizations, telehealth clinical staff have experienced burnout and are looking for less-demanding opportunities.

State-licensing requirements that prevent telehealth providers in one state from treating patients in another have been another hurdle, explained Faisal Khan, hospitals and health systems practice lead at law firm Nixon Gwilt Law in Shaker Heights, Ohio. These roadblocks have hampered telehealth vendors' ability to expand their clinical workforces, he noted.

Working together, however, some states have developed reciprocity agreements that allow out-of-state health care providers to practice within their jurisdictions. Also, due to the COVID-19 pandemic, a number of states loosened their state-only provider requirements, although many of these waivers were temporary.

Innerbody Research recently evaluated the 10 Best and 10 worst states for telehealth, according to best practices.

The lapse of other pandemic-related relief, such as allowing health savings account-eligible health plans to cover telehealth services outside of the plan's deductible through 2021, has also stymied greater access to telehealth services, the Society for Human Resource Management wrote to congressional leaders in January.

Lack of Care Coordination

Coordination of care is an area in need of significant improvement to avoid unnecessary duplication of services, health industry analysts say. For example, if patients need certain tests to finalize their diagnosis, they often must follow up with their primary care providers for an office visit to receive authorization for the necessary lab work.

Thompson Aderinkomi, CEO of Nice Healthcare, a health care provider in Minneapolis, likens this situation to watching a movie on Netflix only to have it arbitrarily end at the midway point. "In order to complete your movie, you have to go to the movie theater, pay the full ticket price, watch the entire first half of the movie again in order find out how it ends," he said. "Consumers intuitively know that with telehealth, there is a high probability they are going to have to redo the entire virtual visit in a traditional setting—and pay for it as well."

Overprescribed Antibiotics

A lack of coordination between telehealth providers and locally available lab testing services has worsened the overuse of antibiotics, warned Al Lewis, co-founder and CEO of Quizzify, which educates employees about health care issues. Citing a National Institutes of Health alert, Antibiotics Prescribed More Often During Telemedicine Visits, Lewis recently blogged: "If a telemedicine doctor prescribes [an antibiotic], consider this: How can they possibly be sure you have a bacterial infection? There's no in-person exam and no culture. You guessed it—they are also major overprescribers."

Monitoring Chronic Conditions

As telehealth works through its growing pains, employers should keep in mind what telehealth gets right—and its significant potential for payers (self-insured employers and insurance companies), health providers and patients. Chief among these prospects is care monitoring outside of office appointments for people with diabetes, heart disease and other chronic conditions.

"We need to get away from the idea of provider visits only occurring three or four times a year," said Wei-Li Shao, president of Omada Health in San Francisco. "It is care in between office visits that can move the needle toward better outcomes."

Using telehealth, for instance, providers can collect data on the patient's condition, review results and make necessary changes to medications or the patient's behavior immediately, instead of waiting weeks or months for a pre-planned office visit.

Digital health technologies that use smartphone apps and link wearable devices to telemedicine platforms could transform disease monitoring and diagnosis in coming years, health care analysts explained during an online panel discussion. Along with blood pressure and oxygen-level monitoring, for instance, connected home health devices now include electrocardiogram apps that detect and notify health providers of irregular heart rhythms as they happen.

In January, virtual care provider MDLive announced plans to expand a monitoring program that uses digital devices to transmit patient data automatically to its portal. The program lets patients track and report key biometrics such as blood pressure and glucose levels for their virtual primary care doctors to review with them during their visits.

"This is a down payment on the future of virtual care, where patients work with providers to manage complex chronic conditions from the comfort and privacy of their home, or wherever is convenient for them," said Eric Palmer, CEO of Evernorth, parent company of MDLive.

Telehealth has also shown promise in unexpected areas, said Dena Bravata, chief medical officer at Castlight Health in San Francisco, including palliative care for hospice patients and care for patients with Parkinson's disease for whom travel to a doctor's office can be challenging.

"In-person office visits serve as the clinical glue that can be maintained by virtual means," she noted.

Adding Mobile Nurse Visits

Working to bridge the gulf between patient services delivered virtually and in person, online e-commerce giant Amazon last year launched Amazon Care, combining access to virtual care clinicians 24/7 with an option to schedule at-home appointments with a mobile nurse, for an extra fee.

The Hilton hotel chain and fitness equipment company Precor were among the first companies to offer this benefit to their employees, joined recently by companies such as Silicon Labs, TrueBlue and Whole Foods Market.

Amazon Care's virtual health services are now available nationwide, with nurse visits offered in select U.S. cities. In February, the company announced plans to expand in-person services to more than 20 additional cities this year.

Managing Telehealth Vendors

"The explosion in telehealth happened so quickly that it was difficult to understand how to measure quality of care," Bravata said. "Do the old metrics work? How can bedside manner translate into video manner? How can providers develop an effective relationship with patients?"

This is also a good time to set expectations of what telehealth providers should be able to accomplish, such as improving the transfer of records between general and specialty providers, reducing waiting times, and navigating to the next step in care, Blumenfeld suggested. Check if providers can pull up information on the patient's formulary and in-network specialists and testing centers, for example.

He also recommended that employers look for ways to create performance standards for telehealth vendors such as responding to patient texts within a certain amount of time. Employers should push for improvements against stated performance metrics and follow up to make sure vendors have addressed any issues, Blumenfeld advised.

Marketplace Changes Ahead

Employers should expect additional and continuous change in the telehealth marketplace, according to health industry analysts. As a result, it's best to avoid long-term contracts in favor of two- or three-year contracting, in order to keep pressure on telehealth vendors and hold them accountable for performance improvements.

Nixon Gwilt Law's Faisal Khan expects the market for telehealth vendors to shrink as mergers and buyouts reduce the number of providers. This makes it necessary for employers to discuss what will happen in the event their telehealth provider merges with another or is bought outright, he advised.

Given changes in the market, even when telehealth vendors are responsive to employer concerns, "they may lack the capability and scale to put improvements in place in a timely manner," Khan said.

Joanne Sammer is an award-winning business and financial writer based in New Jersey. 

Related SHRM Articles:

Virtual Mental Health Care Presents Opportunities—and Potential Risks, SHRM Online, February 2022

SHRM Seeks Continuation of Pre-Deductible Telehealth Coverage, SHRM Online, February 2022


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