Does #telehealth drive overuse and over utilization?

#TelemedNow Twitter Chat Wednesday, May 5 – 8 PM ET Introduction & Welcome: Ami Bhatt (@AmiBhattMD) Does #telehealth drive overuse and over utilization?

Q1: What do we know about telehealth adoption and potential for overuse (e.g., visits, testing)?

A1 Notable Responses: Helen Burstin (@HelenBurstin) While many have raised concerns about potential overuse related to #telehealth…. Aditi Joshi (@draditijoshi) some studies show over utilization leading to increased costs in dtc for urgent care visits. Still a cost save if save in person care. #TelemedNow David Lui (@davidliumd) I've always wondered why we frame this adoption as "overuse"... when we make anything more accessible by being more convenient / more affordable, (Southwest Airlines, Smartphones) etc. we do see more utilization. why is that a bad thing? #TelemedNow Scott D Rippe (@ScottDRippe) Oversimplifying: industries don’t decide what “too much” looks like. Consumers do. Stakeholders then have to adapt – in this case, payers, providers, and unfortunately, policymakers. #TelemedNow #Telehealth David Lui (@davidliumd) sure as a payor perspective they should be worried - agree 100% #telehealth #TelemedNow but let's be honest - do we believe that the status quo of utilization was optimal? OR that there is still a big gap / need for care... what COVID exposed is that gap is large Helen Burstin (@HelenBurstin) Lots of conjecture for how #telehealth "could" result in overuse.... Ritu Thamman (@iamritu) Pre #covid19 @chadellimoottil found more downstream utilization from DTC URI visits( cases b/w 2016-2019) but in the Covid19 era #Telemednow utilization has protected pts & docs & led to less use in certain cohorts: overuse of ERs Andrew Watson (@arwmd) It’s a good point, and I think the term overuse eventually comes down to increased payment and increased net cost of care. What do others think ? Chad Ellimoottil (@chadellimoottil) 1. The idea that telemedicine leads to overuse Is conceptionally appealing, but there isn’t a lot of data to support it. Particularly if you align reimbursement for telemedicine with standard evaluation and management guidelines. Chad Ellimoottil (@chadellimoottil) 2. For instance, there is a concern that clinicians who use telemedicine will just start calling patients and billing for normal lab results. However, the follow up for results is already baked into the billing for the E&M. These bad behaviors could be easily tracked and audited David Lui (@davidliumd) and this issue isn't unique to #TelemedNow - also exists in office practices.. differences is the latter has active tools / audits... the former may need the same. Helen Burstin (@HelenBurstin) But actual evidence is very inconsistent: (down) testing (radiology, labs) (up) amb visits (e.g., after DTC respiratory visits) (down) ED visits (up) overuse antibiotics Aditi Joshi (@draditijoshi) Agree and also level of care in places that may be overburdened (EDs). If can ensure level of care appropriate, it won’t be ‘overused’. #TelemedNow Andrew Watson (@arwmd) You also bring up a good point Helen, how we define #Telemedicine. if you look at pathology and radiology and all of the traditional views, including ICU and stroke your, are those over utilized? I doubt it. Ritu Thamman (@iamritu) In cardiology also it’s underutilized “Clinician ordering of diagnostic testing and medications consistently decreased when comparing pre-COVID vs COVID-era and in-person vs remote visits” #TelemedNow Helen Burstin (@HelenBurstin) Good point @davisliumd. Right care at right time for right indication makes good sense. But do we know that it's "pent-up demand" or does ease of access lead to unnecessary care that could lead to unnecessary meds/follow-up visits? #TelemedNow Matt Sakumoto (@MattSakumoto) ABx use is more dependent on the physician than the method of Comm. Ability to counsel patient on appropriate antibiotics is a skillset applicable to in-person or virtual visits #TelemedNow Ami Bhatt (@AmiBhattMD) Overuse needs to be compared to other areas of overuse and see if this really drives up cost more than those. IMHO it doesn’t but it does provide more clinician patient communication. #TelemedNow Aditi Joshi (@draditijoshi) When I started practicing, because of lack of engagement there was higher stakes in patient satisfaction and discomfort in th practice which can lead to increased abx. Fixed with QA. Thankfully we are past this part. #TelemedNow John Lynn (@techguy) Healthcare is not something patients want to overuse. #TelemedNow Aditi Joshi (@draditijoshi) At doctor on demand we did free 72h callbacks for those not needing abx at first. They could callback if sx persisted for reassessment of abx need. Worked well. #telemednow Q2: What is the evidence for #telehealth and overuse/ inappropriate use of medications (e.g., antibiotics)? A2 Notable Responses: Aditi Joshi (@draditijoshi) there are a few studies in dtc companies outlining increased use and (peds) increased abx. However more stringent QA, abx stewardship and recent increased recognition of #telehealth has/will improve this #TelemedNow Davis Liu (@davisliumd) Again agree! It depends on metrics and physician leadership. Do HEDIS measures apply to #TelemedNow - abx use for bronchitis? sinusitis? Without putting systems / processes in place, we get a lot of variation in quality. Need to bring to #Telemedicine. Ritu Thamman (@iamritu) Once better triage is established based on outcome studies we will have a more definite answer. Til then, studies reflect both sides- here’s a RCT that shows ANbx use for URIs changes with education interventions #TelemedNow

Helen Burstin (@HelenBurstin) .@NCQA adapting many HEDIS measures to #telehealth. It's critical that we have same measures to assess telehealth v in-person care. Without evidence, easy to poke holes in #TelemedNow Sam Lippolis (@samiamlip) this has been a concern since the rise of DTC. I've seen companies focused to ensure it's not an issue. My statement is always - please compare to in-person prescribing rates to know if there's overprescribing Who has those studies.....? Judd Hollander (@JuddHollander) Agree. Its about the physician, not the method of care delivery. There are good docs and crappy docs in offices and on video. Luckily more are good. You dont blame the office building so dont blame the video. #TelemedNow Aditi Joshi (@draditijoshi) When I started practicing, because of lack of engagement there was higher stakes in patient satisfaction and discomfort in th practice which can lead to increased abx. Fixed with QA. Thankfully we are past this part. #TelemedNow Jancie Tufte (@Hassanah2017) Unfortunately not everyone I am involved with Diverticulitis research and other aspects of the condition, some Drs will always prescribe even if diverticulitis is uncomplicated @arwmd @stacy_hurt #telemedNow David Liu (@davisliumd) it's about process and systems. and is getting better! let's help nudge the right behavior - in person or #TelemedNow - Sam Lippolis (@samiamlip) We can't hold telehealth to a higher standard than in-person care #TelemedNow Judd Hollander (@JuddHollander) We published that telemed at Jefferson was just as good or more compliant w choosing wisely guidelines than in UC and ED w same docs. Davis Liu (@Davisliumd) of course Jefferson would do well with you and @draditijoshi with the leadership of @sklasko demonstrates importance of physician leadership, institutional structures / framework to ensure high quality care regardless of tools - #TelemedNow Chad Ellimoottil (@chadellimoottil) Then there is also this....we found patients were more satisified with their eVisits they were prescribed an antibiotic (90%) vs not (61%)

Judd Hollander (@JuddHollander) We believe its easier to pass on antibiotics in a 10 minute video visit than a 6 hour ER visit. Q3: Does the type of telehealth make a difference? DTC v telehealth with your care team? A3 Notable Responses: Komal Bajaj (@KomalBajajMD) It makes sense that telehealth with your care team might be more effective (and promote evidence-based action), but it depends so much on trust. Here's some strategies to build trust into telehealth via @HarvardBiz #TelemedNow Stacy Hurt (@stacy_hurt) #Telehealth is a tool used by a patient’s medical team to assist in care coordination & convenience. It is NOT to be used by a patient to replace the medical team-anyone doing this is disrespecting both clinicians & telehealth and needs to stop #TelemedNow Aditi Joshi (@draditijoshi) now that we have more clinicians doing it, we SHOULD do it with patient’s care teams. Initially you couldn’t get enough clinicians so relied on those who would. We/patient can now have the choice. DTC is still good for those w/out pcps tho. #TelemedNow Ritu Thamman (@iamritu) DTC V RPM engage different demographics & so the use cases are different - chronic disease management w RPM May improve outcomes; DTC wellness or HR monitoring may not or if trying to pick up early AFib will have low yield like @Apple heart study #TelemedNow

Janice Tufte (@Hassanah2017) video telehealth I expect could address some overuse with the ability to ‘see’ what the patient is calling about, though visits that do not require visual assistance audio only should be effective, especially if preferred #telemedNow Matt Sakumoto (@MattSakumoto) And we should strive to get a "PCP for everyone" so all patients are hooked into a care team with continuity #Telemednow @KFF #primarycare @primarycarechat Ritu Thamman (@iamritu) Also interesting that in mental health, most of the new #telehealth users were already engaged w their docs a sign that trust can be established via #TelemedNow… #TelemedNow

Q4: How can build evidence base to address telehealth appropriateness and utilization? A4 Notable Responses: Andrew Watson (@arwmd) Interop is critical so that the financing and scheduling systems can provide meaningful data. Aka payer UM #TelemedNow We need a central database. Much like @AmCollSurgeons #NSQIP. Ritu Thamman (@iamritu) It would be great to have in real time! Imagine with each click of the EHR we got smarter/learned something that could help our patients #TelemedNow Aditi Joshi (@draditijoshi) research on quality. Much of it being done specialty specific, applying differing practices to virtual. Some overlap so keeping abreast of similar c/o, practices, needs can go a long way. #TelemedNow Ritu Thamman (@iamritu) This is (key) for insurers esp. while RCTs take more time & $, observational data & micro randomized trials may provide quicker answers to which interventions like JITAIS work & in which situation #TelemedNow @JRGolbus@bnallamo Judd Hollander (@JuddHollander) No study is perfect. Payers will find problems with them all. #TelemedNow they just want to delay paying. ACHP (@_ACHP) Not sure its fair to paint all payers with the same brush on this. Our community-based plans understand the evidence, have backed payment parity in the short term and have championed preserving recent flexibilities. #TelemedNow Stacy Hurt (@stacy_hurt) Through patient reported outcomes from #telehealth use and continually asking #patients how we’re using it, when we’re using it, & for concrete examples/stories of why we need it #TelemedNow Davis Liu (@davisliumd) the people who want the evidence are the payors / self insured employers... will DTC patients care? Judd Hollander (@JuddHollander) They dont care about evidence. Thats just an excuse to not pay for care. They dont ask for evidence w new doctors or new buildings or new stethoscopes. Dont fall for that trick to enhance profits by not paying. Every day of delay is larger CEO bonus. John Lynn (@techguy) If someone isn't digging into the Medicare data on telehealth and things like utilization and how early intervention prevented later issues, then something is wrong. They have the data now. #TelemedNow Janice Tufte (@Hassanah2017) Next year @hdpaloozaI expect #telemedNow John Lynn (@techguy) We can't wait that long. #TelemedNow Helen Burstin (@HelenBurstin) I hear you @techguy. We need to examine impact of #telehealth meteoric rise during 2020, but we need to build data systems to look prospectively too #TelemedNow CME Information For #TelemedNow CME - the website to set up an account, register your cell and / or claim CME : If you registered your cell text the code to 412-312-4424 Tonight’s code for 1h of category 1 CME: COMING ON 5/6/2021

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