Early Emerging Payor Themes

#TelemedNow Twitter Chat Wednesday, July 15 – 8 PM ET Introduction & Welcome: Ceci Connolly (@CeciConnolly) – Moderator Early Emerging Payor Themes

Q1 As the market adapts to new demand for #telehealth tools & devices, how do we get these into patient hands and then pay for their purchase/maintenance? Netflix model? Consumer OOP? Provider responsibility? A1 Notable Responses: Ceci Connolly (@CeciConnolly) My thought bubble: might be premature to say we know answer. Need to gather more data, let evidence guide us. It’s a vital question, and one hopefully @CMSinnovates can help answer. Andrew Watson (@arwmd) This is a great question, and the hidden cost is the cellular charge. This is what drives the expense. Even if we have recycled hardware, the access remains a barrier. We have seen this with our monitoring program. #telemedicine We need pop pooled data plans. Ryan K. Louie (@ryanlouie) How about do it the same way as with glucose monitors? If patients need to check their blood sugar, the device and supplies are all part of the package for total care. Same for #telemedicine and the accompanying tech and devices. Ami Bhatt (@AmiBhattMD) Agreed! We need workflows for #TelemedNow that mirror the well established workflows for inperson care. Michael Bagel (@MichaelBagel) Couldn't agree more @AmiBhattMD! Look at the success of #Telemedicine in Medicaid, individual market and commercial. Capitation allows for the opportunity for provider and plans to collaborate in their communities and improve health outcomes. Ami Bhatt (@Ami Bhatt) Population health models. Example: HTN patients with out of range BP in 6 months get a device with upload to EMR. Measure time to in-range measurements as value. Matt Sakumoto (@MattSakumoto) CPAP machine usage for OSA also a good model for device coverage and reimbursement Helen Burstin (@HelenBurstin) Start simple – use tools readily available in the home, like smart phones. Anything else will increase the price of entry and complexity. With frequent changes in insurance coverage and rising #uninsured with #COVID19, its hard to tie to insurance #TelemedNow. Connie Hwang (@hwangc01) I agree with @HelenBurstin instincts in starting with currently available smart phones. Maybe engage tech groups in further developing apps that actively gather biometric data (e.g., vitals, ECG, etc.) to support virtual visits. #TelemedNow Sam Lippolis (@samiamlip) Especially if video visits aren't even yet determined payment parity. For now RPM model using billing to insurance to offset cost of RPM program is a solid first step. Andrew Watson (@arwmd) And @samiamlip the big callenge with #RPM cost is how to bill for a call center. #TelemedNow. Salim Saiyed (@SalimCMIO) We need beyond “figuring out” capitation plans. We need universal coverage & parity! Jessica Spencer Castner (@DrCastner) For care of complex, chronic illness, or patients who require additional accommodation for set up that isn’t easily overcome with direct-to-patient mailing, integrate with nurse home health models as needed for initial visit. Jerry Penso (@jpenso) Patients should drive this, and providers will need to create such a rich, valuable experience that will drive loyalty and market share. Salim Saiyed (@SalimCMIO) Subscription models seem to be sustainable for longer term. Definitely need payors to adopt to some of these! Matt Sakumoto (@MattSakumoto) A lot more is on the provider plate now - "rooming," walking the patient through the app download or "connecting via device audio". I find it's seamless or goes horribly wrong! Adding a virtual MA helped a ton, but now that's another FTE in the mix #telemednow Q2 Should we Pay on Par for #telemedicine and traditional bricks & mortar facilities? A2 Notable Responses: Andrew Watson (@arwmd) Ceci this is one of the hardest questions I have seen. Payers - should be less cost. Providers - pay us on par. I don't know how to mediate this conversation. #TelemedNow Problem - HC providers are using a sunk cost business. Ceci Connolly (@CeciConnolly) I think we can find our way if the goal is high-quality, affordable coverage and care. Probably a glide path for a transition to value-based care w/ #telehealth a central tool Ceci Connolly (@CeciConnolly) This question is tricky because it can distract from what should be an industry-wide push for a value-based model. FFS is unsustainable, and as #COVID19 has proven, has not served us well. Jerry Penso (@jpenso) Tricky is right, as we don't want to lose the momentum we have gained. Connie Hwang (@hwangc01) Agree w/ @jpenso1 on need to sustain #TelemedNow usage momentum as we glide to long-term payment approach (FFS vs. value). @_ACHP plans see potential in continuing telehealth payment parity in near-term to collect data to inform FFS differences & transition to value contracts. Ami Bhatt (@AmiBhattMD) Payment for #Telemedicine services is more complex than does Video = In-person. We need a payment model which reflects the armamentarium of #telehealth services: devices, data storage, analysis and response and tie it to quality #TelemedNow Ami Bhatt (@AmiBhattMD) Yes. Recent @Aetna update says: Aetna reimburses all providers for #telemedicine at the same rate as in-person visits including behavioral services. Nice to see payors following suit, but permanence if far from guaranteed. Helen Burstin (@HelenBurstin) Tough question. It's not a zero sum game. Telehealth may need different staffing, but not necessarily less FTEs to do it well. Unlikely to reduce staff, so not clear why payment would be less, at least in near term. Matt Sakumoto (@MattSakumoto) And in the short term, MORE staff is needed to troubleshoot/tech support the patients AND providers #TelemedNow Ceci Connolly (@CeciConnolly) Would you say maybe fewer specialists, fewer MDs, more nurse practitioners, physician assistants, pharmacists? Team-based model and less brick & mortar expenses, fewer extraneous tests drive down cost #TelemedNow Salim Saiyed (@SalimCMIO) For the initial 1-2 year term we need #parity for #telemednow as most #physicians #healthcare systems are needing to make significant #technology and #human resources into it. After that tome perhaps negotiate with top performers. Sam Lippolis (@samiamlip) In status quo of F4S pay on pay until telemed adoption is at least 30% of practice consistently across the country. Lots of cost to get things going, working well. Perception from payers 'telehealth is easy & saves money'. But #TelemedNow is much more than a Dr. & an app. Andrew Watson (@arwmd) The argument is that there is less bricks / mortar, ergo less op-ex but we simply can't turn off clinics or pay rent 1/2 time. this is a tough one. Matt Sakumoto (@MattSakumoto) So many systems, providers, and patients are just getting on the learning curve, a year *minimum* of pay parity is needed to see any meaningful change. Ami Bhatt (@AmiBhattMD) If we allow the government and private payors to consider RPM, virtual synchronous and asynchronous all as separate charges, we will always be underpaid, and #TelemedNow will not flourish. Jennifer Co-Vu (@DrJenniferCo_Vu) We also need pt buy-in to make this happen. I’ve seen tweets of pts already complaining of similar copays for telemedicine vs B&M — if pt thinks they are getting subpar care w #Telemedicine vs in-person. We need to change culture from pt standpoint as well. Ginny Whitman (@GinWhitman) Great point! Need to ensure patients feel the value not just with visit but with bonuses like not having to drive to dr office, wait for 30m, talk for 10m then go home Eve Bloomgarten (@evebmd) patients love not waiting for hours in waiting room, taking days off of work , or wasting entire day driving 1-2 hours to office. Irma (@IrmaRaste) Not to mention, in-person visits carry risk to limb (car accidents) and now, even risk to life due to #Covid_19 #pandemic. Just like generally in #medicine, risk-to-reward equation is important. So it’s good to have the option of #telemedicine! Andrew Watson (@arwmd) Yes, the risk of travel can't be emphasized enough. Especially if you are sick and have to drive hours after d/c to home.... Ami Bhatt (@AmiBhattMD) Some chronic dz patients find the sounds & smells of the hospital bring back tough memories. An argument for #hospital practices in particular to embrace #telemedicine. An anxious patient is not in the ideal state of engagement to partner optimally in their care! Connie Hwang (hwangc01) According to @Altarum, Americans spend more time traveling & waiting for health appointments than for any other service, including getting driver’s licenses at motor vehicles agencies. $89 billion a year in lost time! Ceci Connolly (@CeciConnolly) Great point. Pleased to say our nonprofit, community health plans have waived #telehealth copays during #COVID crisis and potentially longer. Chad Ellimoottil (@chadellimoottil) Yes, absolutely. If payments are reduced, telemedicine use will drop. Payments should be the same for >12 months. Can re-evaluate later. Payers will see that they save money from reduced in-clinic services even if they pay the same for the E&M visit. Ryan K. Louie (@ryanlouie) Great question. I wonder if this is similar to what's happening in education and conferences - if it's moved online, do people expect some type of "discount"? Q3 #COVID19 has led to spikes in anxiety & depression & virtual care is a convenient, no-risk way to provide support many need, which is why plans like @HealthPartners are bulking up #mentalhealth capabilities via #telehealth. A3 Notable Responses: Tricia Brooks (@TBrooks_ACHP) I have heard one statistic of over 50% reduction in no-shows for behavioral health visits via #telehealth during COVID-19. #TelemedNow. That is a bright spot! Andrew Watson (@arwmd) When I stop and think about it, #TelemedNow. It is remarkable how healthcare turned and used #telemedicine overnight and all of these different platforms and new workflows and there are FEW if any reports of HIPAA problems, patients being hurt, …. All things considered…. Ami Bhatt (@AmiBhattMD) Provider #burnout was such an issue, only worsened by #Covid19 ... but what if the flexibility for clinicians imparted by #telemedicine continued? Would we see happier colleagues w/ control over their schedules? I think yes! Sam Lippolis (@samiamlip)This is my mantra!! Provider burnout can be helped by #telemednow Work from home, flex time. Providers don't have to be in clinic 9-5. COVID has shown flexibility for providers is feasible while giving great clinical care. Andrew Watson (@arwmd) So true. #TelemedNow Clinics from home, telerounding….. Matt Sakumoto (@MattSakumoto) I have enjoyed the lack of commute time, too. A small part of me worries about work-creep similar to "In Basket Management" from home, but it's up to us to set appropriate boundaries to avoid #BurnOut. Helen Burstin (@HelenBurstin) Hope virtual care can help alleviate #burnout too. But as practices reopen, clinicians will need help integrating telehealth into overall workflow or they will be even more stressed trying to switch between virtual and IRL visits. We need to share best practices #TelemedNow Jasminka Crinley (crinley_md) Patients first: absolutely! Always! Telemed benefits: yes! Ami Bhatt (@AmiBhattMD) Yes! I will share a best practice now ... try to keep video visits blocked together. If there is down time in an in-person clinic, use it to review asynchronous data. After 7 years of #telemedicine practice, don't recreate this wheel! Jasminka Criley (@criley_md) It is a constant quest for some kind of balance isn't it: taking care of yourself (by setting boundaries) vs risk of disappointing others or falling behind on tasks ... Jessica Spencer Castner (@DrCastner) Bright spot: more thorough & systematic adoption of telehealth innovations to improve ED efficiency & follow-up. Sharing “Innovations in Emergency Nursing: Transforming Emergency Care Through a Novel Nurse-Driven ED Telehealth Express Care Service” Jerry Penso (@jpenso) Dermatology, post-surgery, and annual wellness visits. Aditi Joshi (@draditijoshi) increased understanding by patients and clinicians of its utility. the ability to triage/evaluate/treat certain conditions. shortfalls it is still not accessible for those without the connectivity and devices - some of who may be most vulnerable to this virus. Jessica Spencer Castner (@DrCastner) Shortfall: full potential for disaster telenursing role has been underfunded, underresearched, & under-leveraged compared to the population need for this care & potential health benefit. Sharing “Telenursing in Incidents & Disasters: A Systematic Review” Helen Burstin (@HelenBurstin) Huge opportunity in MH, BH & SUD From @APAPsychiatric @ SaulLevinMD: Bright spot – patients keep their appointments: 32% of psychiatrists said ALL of their patients showed for their appointments, up from 9% before the emergency Katie Bates (@katiebatesdnp) example for HF specifically, % of patients on optimal GDMT, use of acute care services/readmissions, no show rate, patient satisfaction. All can indicate ability of telemed to facilitate med titration, assessment of decompensation, adherence to f/u schedules. Lisa Levitt (@llevitt800) WOW love this data point! I had seen older data of #telemednow reducing no show rate, and this update is wonderful to hear!! Great news across entire Quadruple Aim. Partying facePre-COVID I was starting to question how much care actually was getting delivered in our expensive system Jennifer Co-Vu (@DrJenniferCo_Vu) The implementation of #telemedicine program for peds Single Ventricle & Transplant pts got fastracked during #COVID. Bec of fear of exposure, we had Hundred points symbol parent buy-in: now we can do this to limit upcoming winter season viral infxn in this population.

Q4 How do we measure quality with #telehealth? Who would be in the best position to measure in-person visit outcomes v. virtual visit outcomes? A4 Notable Responses: Ryan K. Louie (@ryanlouie) For #mentalhealth, maybe a metric such as a lower rate of "loss-to-followup" Andrew Watson (@arwmd) This is were RPM does the heavy lifting IMO Jorge Rodriguez (@translatedmed) Applying a quality, safety, and equity framework to telemedicine is key. I like @KarthikSivasha3 piece: Andrew Watson (@arwmd) here is a good start here. HCAHPS and CAHPS and HEDIS are the backbone of value/ qualtiy. Salim Saiyed (@SalimCMIO) #primarycare quality metrics via #telemednow , Medicare #annual visits, #urgentcare , #COVID tests ordered, there are so many ways to track Helen Burstin (@HelenBurstin) While expanded access is a given, we need to assess patient & provider experience with telehealth. The holy grail will be improved outcomes - fewer ED visits, hospitalizations, chronic illness complications, better function, fewer days missed work/school #TelemedNow Rashmi Mullur (@rashim2008) Diabetes—#Telehealth has already shown benefit for glycemic outcomes. Now, with this high risk group, compare A1c to continuous glucose monitoring #CGM data—which has also grown in use 2/2 pandemic

Ceci Connolly (@CeciConnolly) Ok funny but gonna answer own question. Entire quality measurement system needs to be rebuilt for 21st century #healthcare: preferably with focus on FINAL OUTCOMES. Ceci Connolly (@CeciConnolly) Find opportunities where it’s easy to build in useful measurements. Meanwhile, continue to focus on reducing burden of collecting quality data by building automated, interoperable system w/ strong data sharing. Ceci Connolly (@CeciConnolly) That will allow us to shift measures toward a smarter system focused on meaningful health outcomes and support the shift to value-based care. Ceci Connolly (@CeciConnolly) Inside baseball here for all you DC policy nerds but one big step: establishing a Technical Expert Panel at @CMSGov to help guide discussion on quality measures in #telehealth. Lisa Levitt (@llevitt800) Certainly - this type of CMS tech expert panel sure is needed if it does not yet exist. Thanks for the alert and tagging more healthcare influencers. Ami Bhatt (@AmiBhattMD) By the end of 2021 we will all have so much virtual care data, that everyone needs to feel responsible for contributing to the literature and publishing. Different practices, local cultures, state regs, all relevant! Jennifer Co-Vu (@DrJenniferCo_Vu) One good outcome measure is: catching red flags by #telehealth that would otherwise be undetected (if longer wait for B&M visit vs more readily available #telehealth visit) thus preventing morbidity or even mortality. Ritu Thamman (@iamritu) Since “Our healthcare information is trapped.. in proprietary data models of electronic medical record & in our healthcare systems’ data warehouses -all strikingly clear in #Covid19 pandemic -Cleaning data is hard & we are in #quarantine

Q5 Providers and plans need risk adjustment to ensure patient data is being appropriately considered for risk and reimbursement. But what are reasonable guardrails?

A5 Notable Responses:

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