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Joseph C. Kvedar, MD shared his keynote before the 2021 American Telemedicine Association. He addresses a regression that is underway from local providers dominating the delivery of telehealth to the national providers once again taking over the top spot. 


When I talk to other provider organizations, I hear common themes dragging them back into an in-person-dominant care model. Themes such as filling beds and charging facility fees come up repeatedly, not to mention the threat of lower reimbursement for telehealth visits compared to in-person.

I recently talked to a friend who works at one of the largest national payer organizations, which led to an important insight. From January through October of 2020, local providers (i.e., ‘your doctor’) generated 96% of their telehealth claims, and only 4% came from national providers (i.e., Teledoc Health, Amwell). Compare that to 2019, when 54% of claims were from national providers – and the trend is moving back in that direction.


Is this inevitable? We still live in a fee for service world and the financials don't work without the government money. If the government money comes in is that really a good thing or have we just added one more arm to the Frankenstein that is the healthcare payment system.

The government is the largest payer in this market, if you can call it that. They will have to consider what works best for the millions of lives under their care and in so doing have downstream impacts on all other lives. 


 This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

  Today in health it, the story is telehealth's regression to the mean. We'll get back to our chime keynote recap next week. My name is Bill Russell. I'm a former CIO for our 16 hospital system and creator of this week in Health IT a channel dedicated to keeping health IT staff current. And Engage today.

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All right, here's today's story. On, uh, Monday's Newsday show, I actually discussed this story with Sue Shade. She shared it with me and brought it to the Newsday Show. And so we, we are gonna talk about it there, and if you want more on this, go ahead and tune in on Monday for that discussion. But I'm gonna go through it today.

There's just a lot here and I think there's, uh, a lot of detail to cover. This is a recap of Dr. Joseph K's. Address to the American Telemedicine Association Annual Conference, and the title of the story is Lessons Learned from 2020 Provide a Springboard for Increased Telehealth adoption. And I like how he searches off.

He searches off by talking about Daniel. Kahneman's Nobel Prize winning theory. His book was called Thinking Fast and Slow. The theory formed the basis for the field. We know as behavioral economics. What Kahneman describes as heuristics, pattern recognition or system one thinking drives most of our day-to-day behaviors.

System two, thinking by contrast, kicks in when we must learn something new or think carefully. About any action we will take. A year ago when we met at a TA 2020, the healthcare world was engulfed in system two thinking as we responded to the pandemic. And a big part of that was the rapid expansion of telehealth.

So we were thrust into system two thinking the numbers show that, and they really proved that out. Last year, at this time, telehealth was on top of the mountain. From March to June 20, 20, 30% of all outpatient activity was conducted via telehealth. In contrast with 0.8% in 2019, the virtual visit had become universally understood concept, and by all accounts, patients loved it.

Here are a few of the snippets from a COVID-19 Healthcare Coalition survey. 83% of patients reported overall high quality visits and 78% said their virtual care visits were with their regular provider. He's gonna come back to that. That is an important theme. Okay, so remember that 78%. Their virtual care visits were with their regular provider, their local healthcare provider, and over 75% said they would continue using telehealth for chronic disease management.

What happened between June, 2020 and where we find ourselves today? In short, we learned what a hybrid environment looks like. I would say it's more than that, but that's where we're gonna start. So some more numbers. . There was a leveling off of Telehealth nationally to 50% or less of what it was at the heights of the initial lockdown.

According to the Commonwealth Fund in April 20th, 2014 percent of outpatient visits were telehealth and that leveled off to 7% in August and has remained stable since. And the Fair Health Telehealth Tracker found a dipping claims from 7% in January of 2021 to 5.9% in February. Now he comes back to Kahneman's concept of system one thinking.

And he gives this example, I think it's a good example. A dermatologist that starts their visit online on a telehealth visit will more likely recommend a follow-up telehealth visit. But if they start with an office visit, they were are more likely and more inclined to provide them with a follow-up visit in the office.

And that's due to the heuristic patterns that are burned into the brain over 30 plus years of in-office care. So why is that happening? He goes on to say, when I talk to provider organizations, I hear common themes, dragging them back to an in-person. Dominant care model, themes such as filling beds and charging facility fees come up repeatedly, not to mention the threat of lower reimbursement for telehealth visits compared to in-person care.

And here's one of the main points he wants to make and I'm gonna come back to, which is . He says, I recently talked to a friend who works for one of the largest national payer organizations, which led to an important insight. From January through October of 2020, local providers, your local provider generated 96% of their telehealth claims, and only 4% came from the national providers.

Those are the Teladocs, the Amwell, and others. Compare that to 2019 when 54% of the claims were from national providers, and the trend is moving back in that direction. Okay, so that's where we're heading. We're regressing to the mean. What this says to me is that there is indeed a market for telehealth.

However, the choices we make in the next few months. We'll determine the landscape for telehealth in the US for at least a decade, providers must resist that strong magnetic force that draws us back to an in-person, brick and mortar world, and find the right balance of in-person and virtual care.

Healthcare systems must embrace value-based care rather than fee for service model that brings people into facilities. This is difficult after experiencing a period of significant financial loss. Not only is it difficult, it's counter to the business model. And anytime I, I see things like must or should I step back and say, should I really must?

I really, because in a fee for surface model, which is where we still live today, there's a tricky balance of moving too fast or moving too slow. And I'm gonna get into that, into the, so what he cites some wild cards that could influence the strong pullback. Two face-to-face care. One is the originating site rule, and he also cites when he talks to forward thinking providers, their biggest near term fear is the entry of large consumer tech companies into the care delivery market.

If they can turn that fear into a pivot away from a reliance on brick and mortar, that could accelerate telehealth adoption and it could accelerate telehealth adoption. The question is, can they find the business model to make it work? And he goes on to say, we need to come up with a logical, financially sound reason for providers to pivot long term.

Simply saying that telehealth is the right thing to do, or that patients demand it won't be good enough, even taking the most objective view. The future where providers are not engaged in telehealth is not a pretty picture. All right, so the payers also have choices. He goes on to talk about that. This is a really good keynote, really good article.

If you get a chance to read it. It's on his, uh, blog. He shared it and he goes, this brings me to patients and consumers. Now more than ever, you have a voice urge your elected representatives to pave regulatory path that enables telehealth. You can also influence your employers and health plans, so let them know you want more access to telehealth, and if you prefer it, make your doctor aware of it, right?

So doctors have it as a tool in their toolbox. Now let them know you want . A telehealth first kind of experience and he closes with, we've lived through a historical time. I've heard it said over and over that telehealth advanced 10 years in the first two months of the pandemic. Yet our work is far from done.

As providers, we need to confront our place-based past or risk being marginalized as brick and mortar resources. Payers need to develop payment policies that allow appropriate telehealth to flourish without encouraging over utilization. Alright, great. Keynote. . If you had a chance to read it, go ahead and do that.

I'm gonna give you my so what, as you know with these stories, I do a, so what? Which is, why does this matter? Why should you pay attention? But the national players and the payers are going to take the lead back from local healthcare providers. That's my personal opinion. They're just going to do it. And the reason is the financials of the situation.

Institutions that have the right financial incentives. We'll move faster and go further in a fee for service world. The health systems need the government money to make this work. The challenge, of course, is that this will erode a portion of their business over time, as the national players and new entrants continue to figure out the financial model or wait for that government money, which may or may not come.

It's a catch 22, which all creative destruction presents to incumbents in a market. To do digital video downloads, Netflix had to let go of the revenue model of sending videos through the mail. It was a new model, and it would take years for the one model to completely replace the revenue of the old model.

Of course, the trick is you can't do too early either. If you trade your current revenue before the market is ready to make the switch, you end up sucking cash outta your business. This is why the companies in the Fortune 500 turn over so quickly now, the market shifts are coming quicker and the transition is tricky, and few incumbents are able to create a culture that embraces the shifts and even creates them before their competitors are able to think of them.

The imperative is to build the capabilities, try business models, and insert telehealth into existing business models where it makes sense. Rapid experimentation and creativity are key. Be a student and a fast follower of the systems that find models that work. The entire industry is doing this experiment at the same time.

Keep your ear to the ground. Watch the news stories, see what's working in different markets. Make phone calls. Talk to your peers, figure out what they're doing, and become a fast follower. But in order to be a fast follower, you have to have the technology components in place before you figure out what you're gonna do.

That would be my plan anyway. That's what I would recommend. That's all for today. If you know of someone that might benefit from our channel, please forward them a note. They can subscribe on our website this week,, or wherever you listen to podcast Apple, Google Overcast, Spotify, Stitcher, you get the picture.

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