May 29, 2020: This is a special episode consisting of sections from our panel on funding and the future of telehealth featuring insights on the topic from CHIME representatives, Mari Savickis and Andrew Tomlinson, and three healthcare CIOs, Stephanie Lahr, Praveen Chopra, and Albert Oriol — you can watch the full video on YouTube. The conversation revolves around the current massive experiment in telehealth resulting from the COVID-19 pandemic. Following its successes, there’s a need for lawmakers to understand telehealth’s value. Mari and Andrew explore the mechanisms behind healthcare legislation before noting how digital literacy and internet access challenges telehealth’s effectiveness. Stephanie provides her perspective that telehealth is here to stay, even if funding won’t support it. Albert talks about how the use of telehealth will be restricted to how financially viable services while Praveen notes the cases in which telehealth can serve as a good business model. Bill closes the robust discussion with some rapid-fire questions for the group. By giving a platform to five experts, this episode provides ample context on the state of telehealth. Listen to it to find out if telehealth really is the future of healthcare.
Key Points From This Episode:
LiveStream: Funding the Future of Telehealth
Episode 258: Transcript - May 29, 2020
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[0:00:04.5] BR: Welcome to a recap of This Week in Health IT Live. My name is Bill Russell, healthcare CIO coach and creator of This Week in Health IT, a set of podcasts, videos, and collaboration events dedicated to developing the next generation of health IT leaders.
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[0:01:13.0] BR: We have a great panel of participants for today’s shows. We have a view from DC and we have a view from the chair. That is the CIO’s chair. We have Mari Savickis and Andrew Tomlinson are here from CHIME as our representatives in the capital on all things health IT and we have three clinicians on the ground, Stephanie Lahr, CIO, CMIO of Monument Health, Praveen Chopra, CIO for George Washington University and Hospital, and Albert Oriol, the CIO for Rady Children’s in San Diego. Good morning everyone and welcome to the show.
Mari, we’ll start with you. You know, the reason telehealth didn’t take off prior to this was funding and then the second reason it didn’t take off was culture. Well, we seem to have plowed through this culture because we, quite frankly, we just had the world’s largest telehealth experiment that we could possibly have. So a lot of patients and a lot of clinicians have been introduced to telehealth and the response has been relatively good. Now, it just comes back to the funding and with so much positive feedback, what needs to happen at this point in DC in order for them to see the value, understand the value, and to appropriate the right funds in the right areas to fund telehealth’s future?
[0:02:42.9] MS: First off Bill, thanks so much for having us and for having our members because I have a saying that in Washington, hearts and minds are one, one story at a time and so it’s really important to get the messaging out regarding this and the success stories. I thought I would start with a little bit of level setting in terms of how we actually got here and what we can expect for the future. A lot of folks have used this analogy, I don’t really necessarily like the analogy that much but you can’t put the toothpaste back in the tube. But unfortunately, you can and I am an optimist so I think that there is a lot of room ahead for us to make some impactful changes in Washington regarding this but it’s not going to be a fit to complete.
The first thing I’ll say is I’ll give credit to the lawmakers for acting swiftly, they definitely acted quickly and there was a perfect, nothing’s ever perfect — so it began on March sixth with the first installment of funding which happened in the first stimulus package. And then in the third package, as the Care’s Act, there were a lot of flexibilities that were are actually codified temporarily. So again, just for under the pandemic. There was also some money for the FCC which I’ll let Andrew get into in a moment. But what I wanted to share with folks is that the reason this is possible is for two reasons. There is the Stafford Act, a national emergency was declared so that has to happen, and then also, HHS announced a Public Health Emergency. Two conditions have to be met in order for these waivers to move forward. Essentially, that is what has happened. The waiver, the Public Health Emergency waiver is up for renewal every 90 days. It was last renewed on April 26th. It is up for renewal again on July 25th. If I had a message for anyone who is listening who wants to see these flexibilities continued is; reach out to your lawmakers because, at the end of the day, this is going to be a very much a congressional play. There are some limited tweaks that we could potentially see from the administration but right now. I think that’s what we’re looking at and there have been dozens of bills that have been introduced and we could talk about a little bit about some of those. But maybe before we get too far into that, I want to hand it off to Andrew to talk about some great interest from the Federal Communications Commission.
[0:05:09.2] AT: Yeah, I think one of the big pieces that Mari has touched on is, it’s not just about being able to have access to the telemedicine services themselves — whether that’s the software side services or patient being able to access it through their providers but it’s about being able to make sure that people even have the broadband and internet access necessary to be able to utilize these services to their full extent. Some of the regulations and the policies within, the Centers for Medicaid and Medicare Services in HHS rely on the use of both audio and video technology to be able to deliver these telemedicine services, not everybody has broadband to be able to do that, not everybody, you know, when you start talking about the access to the internet, it’s not even just the ability to have a two-way video communication and trying out people that can’t stream a YouTube video.
The Federal Communication’s Commission, as part of the Care’s Act, received funding through the COVID-19 Telehealth Program to help providers stand up their telehealth services on the inside. But they also have a Connected Care Pilot Program which is going to be continuing on and at some point in the summer — we’ll be fully opened up — it’s just going to help to give people access to high-speed internet within their provider communities. That’s a huge piece of this conversation that needs to continue as well — that it’s about having good internet access as well as having access to being able to bill and reimburse and the provider’s side requirements to make sure that telemedicine is something that can continue into the future.
[0:06:36.1] BR: Yeah, Stephanie, we’ll start with you, I’d like to hear from the providers of, if the funding goes away in July, how will your health system think about telehealth? How will they either continue it, how will the pair it back, where will the continue to apply it? I realize it’s a tough question and it’s —
[0:06:57.2] SL: — Well yeah, it’s actually an easy question for me right now because our peak is July. That’s where we’re forecasting our peak. It’s going to be later in the summer, you know, potentially late, maybe it’s moving back to late June but it’s probably July and so if it’s not safe to bring patients in. We’re not going to bring them in and we’ll have to find ways to deliver care. I think we’ll be forced to continue to do some telemedicine whether or not we’re able to get some of the reimbursement for it. I hope we don’t end up in that position because again, while other areas in the country may have already peaked and are looking at reopening, we are not.
[0:07:40.9] BR: That’s an interesting point. I’m going to change the question on you but that’s a great point. I’m going to change the question by saying, post-pandemic, right? I’ll just say that because we don’t know what the data is. Post-pandemic, if all of a sudden, all the allowances that have been made go away, how will you guys think about telehealth? Will we snap back to where we were?
[0:08:05.8] SL: Well, I mean, we had a plan for how that was going to be incorporated into specialties, again, we can still do things like bring a patient to a clinic that’s 10 miles from their home instead of a hundred miles from their home and do a telemedicine visit in a specialty situation. We’ll go back to the construct of the plan that we were ready to roll out based on the limitations we had at that time and hope that we can continue to evolve the conversation and learn and generate data to help support it.
[0:08:37.2] BR: Albert, how about you guys in San Diego?
[0:08:39.7] AO: I would say, we would be pretty much along the lines of Stephanie’s comments. I mean, the reality is, whether we like it or not, if we cannot generate a margin, there’s no mission, right? That’s just a fact of life. There have been instances for instance, where telemedicine has allowed us to do things like do cochlear implants for patients who in, the past were not good candidates, because they could not drive daily the two hours each way to provide their kids the therapy necessary to train that implant, right? To allow them to hear exactly and we don’t see us pulling back on things like that. But certainly, for areas where this has become basically a matter of efficiency or satisfaction, if the dollars aren’t there, it just doesn’t make business sense to continue to provide a service at a loss that we can’t afford, right?
We would hope that those changes are something that has proven — and this as you mentioned, this is large experiment that shows that they work — I think our providers and our patients are showing us now that things are getting back to normal. What are the things that would be sustainable in that way because the quality is not compromised and because the service is good? And what were the things I need to get back to an on-site, face-to-face type of an encounter because while telemedicine might have allowed us to get over the hump, it just wasn’t optimal. I think there is an opportunity here to trust in our providers who I think have shown across — not just at Rady Children’s or in San Diego but across the country — they’re shown their commitment to our communities to do the right thing and to kind of let us figure out how things turn out to be and not remove those regulatory opportunities that have been put in place. So that we can finish through. There’s plenty of studies that have been started over the last eight weeks that are collecting tremendous amounts of data, that is going to show not just the immediate satisfaction or effectiveness but long-term impact of this way of practicing medicine and I think until we have that data making changes would be premature. I think we should sustain the changes that have been enabled and let this, if you will, experiment, run its course before we pull anything back.
[0:12:20.7] BR: Fantastic. Praveen, same kind of question for you. I mean, you have San Diego, we have North Dakota, we have DC. What would the impact be like in a major metro like DC, where you’re really seeing people, you have the haves and have nots equally represented in DC. What would happen if telehealth funding would be pulled back?
[0:12:51.3] PC: I think we actually started with that thing to feature about telehealth and we have a group here and I think we pretty much believe, we could be optimistic, we know, I don’t think it’s going to go back to the way it is. I think there are a lot of these activities out there. The question is, how do we shape the changes in the policy as it relates to how we provide care and how do we get paid. I think Mari, we had a lot of conversations, I think that’s how we have to focus on. I agree with Albert and Stephanie. I think we have to make it a sustainable business model. We talked about, where does the funding come from? There are three areas we think the funding is going to come from. The easiest of all that is payment parity. How can we maintain the payment parity? In some confined areas, I don’t think it is going to stay the way it is, if you couple that with policy and licensure issues and places of service. You put the technology, HEPA, and privacy consultant, which has been relaxed a little bit. I think they will regress as they should but wonder if you can maintain payment parity and also not only at Medicare and Medicaid level but also at other provider levels. That to us is important and I think if that doesn’t happen, I think it would be very difficult to sustain it.
Number two is grants, there is an FCC grant out there which is helping with telehealth and we apply for the grant. Number three is, we talk about this strategic bet. We’re talking with strategic bet here. Do we believe that a hybrid model, a telehealth is going to increase the capacity? We know that we have a lot of demand and we have a huge — a lot of wait time.
How do we increase, make it a 24 cross-server model? How can we expand the hours? And we are seeing that there are ways in which we can have a hybrid model of it by the improved access and make it easy. I think there’s a lot of factors in terms of patients not coming here, they’re not spending for parking and they’re not ‘tick-tocking’ the day out. And it provides a wireless social-economic benefit and we can partner with the CNDC here to fund that. It’s not only that but it is a good business model. If we can increase our visits by say 15%. 10% or 15% in the new model that would pay for itself. How do we do that? For example I know we did that at my previous board at Jefferson. We saw that if you look at a post-surgical visits. It is part of a global fee. So we pay one fee for the entire global fee. And we were able to get a post-surgical visit online. So gets and the physicians told us. He said, “You know what? Initially, I used to reserve an hour to meet with a patient after surgery and now I can do that entirely in 15 to 20 minutes.” I think that is going to be another way for us to think about how do we expand the capacity and you have to assume that there is a volume and demand out there.
And we believe that there is a demand out there and we want to think about how can we make it a strategic bet and create a business case to be able to keep on going in the new direction. And the other thing that we think about is there’s a value of the data and I think Stephanie, you said that, in my mind and I have your talk to a lot of politicians here and I am a newbie in terms of talking to politicians. A lot of you might have a lot more experience. But it is about, I think, winning hearts and minds with data. I think it really helps. And we are thinking about what is the value of data and also in doing a comparative study and what is the value from a research perspective and if we can do that — I think we would be able to shift the future of policy and payment in an effective way. We don’t know how this is going to look like but we were going to take an active role given the proximity with both the national and local policymakers.
[0:16:59.2] BR: All right, a couple of rapid-fire questions to close this and then Mari and Andrew, I want you to think about what we would tell or ask of CHIME members in order to build the story, right? The data and the story, think about that. That is what I am going to end up closing with but a couple of rapid-fire questions. If funding goes away with this, will consumers pay for it? Is there an appetite? They have experienced it, they like it, some like it. Is there a case where you are getting 20 bucks over here, you are getting 20 bucks over here and we sort of make up the gap? I ask what do you think, is that an opportunity?
[0:17:42.1] AT: I will go first. We are seeing, you know we see about 60% of our volume as Medical, which is the California Medicaid, I don’t think they have that luxury. So I think there are some consumers who have that luxury and they will pay for the convenience. I think a big portion of the population we serve, unfortunately, do not have that abilty.
[0:18:08.8] BR: And that’s Children’s Hospital. How about Stephanie or Praveen?
[0:18:14.6] SL: Yeah, I mean I think I would agree. We got a population of patients who have very limited financial resources and that is not probably something — I think that really lends itself more to something like an urgent care on demand. There can be the occasional dermatologic or something. I just want to see a dermatologist right and I can’t get into the specialist. But again, I think that further divides maybe the haves and the have nots when it comes to how we are able to provide care. And I’d like to see us not go in that direction that if it is something we think is good for patients, we should be doing it for all patients and make it work within the payer construct that we have and not create different avenues for patients with different financial means.
[0:19:05.8] PC: I would agree. I think this is not one-size-fits-all and what we are seeing is I think the consumer is more likely to pay for specialty. Access sooner than later than for private and urgent care. I have seen it. I think the business model is not there, the margins are not there and the consumer will not — they are not willing to pay for a primary care, urgent care kind of visit. However, we have seen, like for example, sight, that people are willing to pay. And for dermatology I think people are willing to pay and we are finding it out for a sub-specialty consult for direct-to-consumer model. I think there is a propensity to pay for a segment of consumers. The question is, can we create within an NR. I used to work in retail and we had a different value proposition for different segment groups. So I think the question that we have is social custom do we have is can we create a multi-modal path here? Where certain people who can pay will pay and the other people, then how do we work with our payers to make it affordable for them.
[0:20:16.3] BR: All right, second rapid-fire question, how important is it to keep the ability to practice Telemedicine across state lines and take those barriers down?
[0:20:27.8] AO: Huge.
[0:20:29.2] PC: Well it is absolutely critical. Absolutely critical for this.
[0:20:34.5] BR: Yeah and so, lots of states. Will this move us more rapidly away from fee-for-service and towards population health? And I say that from this perspective, you know Keiser does a million Telehealth visits a year. Well, the reason that we all know, the reason they do a million Telehealth visits a year is because they get paid to keep people healthy and keep them out of the hospital. So they are getting paid either way. Is that the way that this really transitions is that we really moved those models forward?
[0:21:12.8] AO: Well, I am an economist by background. So yes, I think life is about incentives, and if you align them correctly, you will get the outcomes you’re aiming for and if you don’t, you won’t.
[0:21:26.6] BR: Money talks, that’s what I am hearing you saying, Albert. Does anybody disagree with that? I mean when the alignment is there it really does work and I haven’t looked at Keiser’s numbers since March 1st but those are the numbers last year. It was some amazing number of Telehealth visits.
[0:21:48.3] PC: I think I agree with alignments to me. But alignment is, ever since I came into healthcare, alignment is the most complex thing to achieve. So to me, I think I am optimistic about it but I think a lot of things that have to be worked out for it to become the main catalyst to move away from people service.
[0:22:14.2] SL: Yeah, I mean I think one of the important things to remember about Keiser is they are the full ecosystem, right? They are paying themselves. They are the insurance company and they are the provider. It is a much different scenario, you can be part of an ACO or something like that. It is still not the same because it is still two buckets, you are just sharing the risk. And not every health system and every location is going to be in a position to really own the full ecosystem of being both the payer and the provider. And so I think that is a point of distinction that Keiser has been able to do a lot of great things and have had that great data actually for several years but that is a unique way to set it up and is not necessarily reproducible even in an ACO model when the alignment may be there.
[0:23:10.0] BR: Well, the last question for the three of you and then we will close with what we can do as CHIME members. And that is, is what is going on today crisis management, is that going to be the same environment? Here is the question, the question is, clinicians today cannot see patients face to face in a lot of cases, therefore they adopted Telehealth. Well, it is one thing to sit in front of your computer and do 20 Telehealth visits. It is another to do physical visits, Telehealth visit, physical visits, Telehealth visit, and whatever. And we implemented this, I implemented it incorrectly a number of years ago where we were looking at clinicians and saying, “Yeah you can do both, you know?” And we just know that that is a very hard model. Are we going to get pushback from them when there is that — when we go back to seeing physically and virtually?
[0:24:06.4] SL: Well I think your whole point, I think you just made the point yourself there, right? I mean if you set it up right that won’t happen. We have our places that are most successful are doing block scheduling. So the physician spends the entire morning sitting in their office doing Telemedicine visits while their colleagues are using the exam rooms and the nursing staff and then in the afternoon, they switch. So I think it is all about implementation.
[0:24:33.1] AO: Yeah I would add to that. You know in a number of specialties, we are seeing severe shortages, right? And I forget if it was Praveen or Stephanie who earlier said some of their specialties were scheduling people weeks and weeks out, right? And what we are seeing is telemedicine is allowing some of our more experienced physicians who are on the brink of retirement to rethink that retirement and say, “Well maybe I can continue to work for a few hours a week” or what have you in this mode.
In the telemedicine model, continue to do something I love and I am good at, I just don’t want to do this at the pace that I was doing it earlier and so in the same thing with young parents, etcetera. So I think this, if we do it right, it will not only enable us to continue to provide this service. It will continue, it will enable us to really generate a force multiplier in our clinical workforce, at least for a while. So I think there is plenty of opportunities. I am a glass half full kind of a guy and I think if we do this right, we will see multiple benefits.
[0:25:55.6] BR: Fantastic, yes Praveen?
[0:25:58.8] PC: Just adding to it, I think it is, and to be very frank, I think we heard a lot of feedback across specialties. They said, I knock on wood, “I think we need to keep on doing it but I am not sure how.” Because they are sharing the things that are working out really well, versus are the things that are not working out well and they are also researchers. So they are actually analyzing their own workflows and think about what is working and what is not working. And we kind of ended up with this slogan, it has to be what we are calling more like a physician and provider servant and professionally enabled. So we have a task group, which is basically called The Future of Telehealth and we are 50% of that group is physicians who volunteered here to drive this forward and I believe that there is a willingness and a readiness of engagement for us to make it better than it was three months ago.
[0:26:57.8] BR: Absolutely, Mari, Andrew, I want to leave you guys with the last word. What can the CHIME members do? How can we help to build the story around future funding of Telehealth?
[0:27:13.3] MS: Well, we are actually going to be launching a survey, which I am not always — I am always hesitant to clog our member’s inboxes more but, in this case, I think we again, we need some data and we need some stories. So we’ll probably be doing that in the next two weeks. So keep your eyes open for that. Contact us, we’re also happy if you are busy, you can ask your staff who have that expertise in Telehealth to contact us. So we want to start collecting that evidence base, so be in the lookout for that and I don’t know if Andrew wants to add anything else to that.
[0:27:51.9] AT: Yeah and I think when you talk about stories, you know Stephanie has talked about some of the challenges when it comes to virtual care and Albert and Praveen have talked about how it’s experienced in their areas. This is an opportunity of time for innovation when it comes to virtual care. So we need to hear the good and the bad, the great solutions that you have come up with, and the things that you have tried that didn’t work. It is really important for us to be able to understand the policy and how the policies need to be enacted because everything doesn’t fit everyone as Stephanie was mentioning and so it is really important to understand what works for who and what doesn’t work for those others.
[0:28:27.2] BR: Fantastic. You guys did not disappoint. You’re a fantastic panel. I love the back and forth. I tried to stump you a couple of times and I appreciate all of the answers.
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