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Four Questions Telehealth Companies Must Answer To Ensure Long Term Growth

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With Covid-19 driving the urgency and necessity for its adoption by both patients and providers, telehealth has gone from marginal use in limited settings to become a fixture in the U.S. healthcare delivery system. Virtually all available data and evidence - from surveys of consumer adoption and preference to provider attitudes to investor confidence and capital in new virtual-first care models - suggests that telehealth is here to stay, and likely to play an ever-expanding role in healthcare delivery. 

What is less clear, however, is how the payer and policymaker will view telehealth as the Covid-19 pandemic subsides. Because while consumers may prefer telehealth and value access to virtual care for an increasing portion of their healthcare needs, it is still payers and policymakers who act as gatekeepers to designing access to healthcare services in the vast majority of cases.

Here are four questions that payers and policymakers are considering as they try to assess the role that telehealth should play. Answers to these are likely to lead to decisions around what services can be covered, under what conditions, from what settings, by whom, for whom, and at what rate. 


1. Does Telehealth Provide Quality Healthcare That Delivers Outcomes As Good Or Better Than In-Person Care?

This is one of the biggest questions that policymakers — not to mention patients, providers, and payers — have, and for good reason: there is little data and few high quality studies to shed light on the question. While “telemedicine” has been around for a few decades, modalities like video- and text-based telemedicine are still relatively young. And the jury is still out in many experts' minds whether it can adequately and safely deliver positive health outcomes that are, at the least, on par with traditional, in-person care.

For instance, some experts have noted that, while there is evidence that telemedicine can produce equal quality care in some circumstances, direct-to-consumer telemedicine delivery can create quality gaps with regard to antibiotic prescribing. 

Then there’s the issue of primary care, which, if done right, can deliver quality care while reducing downstream costs. How does telemedicine, which oftentimes doesn’t mandate care continuity (in that patients don’t have to see the same provider over time), ensure care continuity and better long-term outcomes?

“Quality is embedded in every part of the care we deliver. It’s table stakes,” said Hims & Hers Chief Medical Officer Dr. Pat Carroll in a recent interview. “We gather quality data daily through our EHR and track the care we provide on a five-point scale, evaluating whether providers are following evidence-based guidelines. Ultimately, we have to show we can meet the standard demonstrated by in-person care, and I’d stand Hims & Hers’ care quality up against anyone else.”

Dr. Carroll added that Hims & Hers has a score associated with every provider in its network, and will flag a provider for retraining if their score dips below a certain threshold. 

There are also companies offering a virtual-first primary care model, like the one employed by PlushCare. Rather than focusing on using its technology to handle one-off healthcare issues,  PlushCare is focused on relationship building between patients and doctors throughout the care journey to provide continuity of care in a way that emphasizes quality. The company also connects patients to doctors from the top 50 medical institutions in the country, thereby establishing a quality-focused foundation of care. 

There are some telemedicine providers like well-funded, video-based Doctor On Demand, which do allow for return visits to the same provider. 

“Doctor On Demand has a multi-pronged approach for ensuring clinical quality, including credentialing and accreditation, continuous professional development, and ongoing accountability,” said Latoya Thomas, Doctor On Demand director of policy and government affairs. “We also utilize several evidence-based resources to determine the appropriate clinical quality metrics to evaluate, and our clinical leadership reviews individual provider quality metrics on a monthly basis.”

The company also provides interesting outcomes data that indicate its revisit rates are comparable with in-office visits. 

“We know that there is a correlation between diabetes and high cholesterol which can put one at greater risk of heart disease and stroke. We’re able to show measurable results for chronic conditions, including a 24.5 percent reduction in A1C levels for 58.3 percent of critically high risk patients with diabetes, an 18.3 percent reduction in total cholesterol for patients with high cholesterol, and improved systolic blood pressure in 46 percent of patients with hypertension,” Thomas added.

That’s solid data, and it’s something that all telehealth companies should be collecting and investing in — the more quality measurement and analysis at work, the better. That means investing in platform technology that aggregates data; investing in quality-scoring frameworks; and investing in peer-reviewed quality-measurement studies that demonstrate that they are delivering quality care and tracking patient outcomes over time. 

Even earlier-stage telemedicine vendors should be tracking and reporting on patient outcomes, as the ones that do will be heavily rewarded in the eyes of every “P” in the industry: providers, payers, patients, policymakers, and the press. As the industry takes quality measurement more seriously, the data will help convince policymakers that the industry is ready for expanded, supportive legislation.


2. Does Allowing For Telehealth Actually Expand Access To Care, Especially For Underserved Communities?

It’s a common argument in telehealth circles: increasing telemedicine options can help reach communities that often experience barriers accessing care (e.g. healthcare deserts). On paper, that seems to ring true, especially for rural populations where provider options are seriously limited. However, broadband access in those communities remains a problem, which can limit telemedicine’s reach, adoption and impact.

As for minority communities of color, the problems are much more complicated, including a mix of cost, language/cultural, trust, and logistical challenges. Recent research and other evidence indicates significantly lower levels of telemedicine usage among Black and Hispanic patients, particularly those over age 65, as compared with white patients. While speaking about Rock Health’s Digital Health Consumer Adoption Report 2020, chief operating officer Megan Zweig shared that while “telemedicine use does vary across groups— it’s important to acknowledge the remaining access barriers that have yielded higher adoption among higher income, more highly educated, and urban consumers.” 

PlushCare CEO Ryan McQuaid noted that part of PlushCare’s vision is to bring high quality, low cost care to all patients, regardless of insurance or income status. So while PlushCare accepts insurance, 40% of their members do not use insurance, and 12% are from the lowest income zip codes in geographies they serve.

Hims & Hers has been proactive on this front by recognizing some of these hurdles and engaging with partners to find solutions. The company recently became a founding member of the Telehealth Equity Coalition, which also includes the National Health IT Collaborative, American Telehealth Association (ATA) and multiple other organizations. 

“We [Telehealth Equity Coalition] are a group of academics, nonprofits and industry experts coming together to address a critical issue facing our nation. We are working alongside researchers to unearth barriers to accessing telehealth and identify where telehealth could be an asset. We are starting with listening to what communities need and understanding their priorities, then we are asking questions that research could help us answer,” said Hims & Hers’ Mims. “For example, in areas that lack public transit, would telehealth be a good solution for primary care or managing chronic conditions? Could we work together to advocate for public policy that increases access to telehealth?”

The company also says that its cash-pay model, which doesn’t accept insurance, can be an attractive solution for people who either cannot afford insurance or have deductibles so high that it makes coverage irrelevant. For primary care, the company charges $39 per visit, which can be lower than an insurance copay.


3. Does Increased Adoption of Telehealth Raise Risk of Overutilization? 

While not an issue for cash-pay direct-to-consumer (DTC) telehealth vendors, the risk of over utilization is a common argument that telehealth critics have and continue to voice. Overutilization is of particular concern to payers that are footing the bills, and who have sought permission to use utilization management tools for better activity tracking. 

That said, many telemedicine vendors feel that there is an incredible need for more care regardless, especially when it comes to filling in critical gaps and driving patient engagement with their health.

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“I heard the same worries about retail pharmacy clinics,” said Dr. Carroll, who previously served as Chief Medical Officer at Walgreens. “What’s the actual fear? I think this country can do better to provide more access to care rather than less access.”

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When asked, Doctor On Demand referenced a study the company recently had published in the Journal of Medical Internet Research:

“Using Doctor On Demand data, researchers found higher relative increases for behavioral health and chronic illness visits from March through April 2020 as compared to the previous year. These findings suggest that, spurred by Covid-19, telemedicine is providing crucial longitudinal care for chronic health conditions, as well as helping to address gaps in access to in-person care worsened by the pandemic,” noted Doctor On Demand’s Thomas in an emailed statement.

Overutilization concerns will likely stay centerstage in telemedicine’s quest for more favorable policy frameworks. Even though questions around quality are arguably the most important, overutilization is the most powerful. As is so often the case in healthcare technology adoption and policy decision-making, it largely boils down to money. Especially with Medicare and Medicaid costs rising as Baby Boomers age, it’s incumbent on the industry to prove it delivers quality care at lower costs. 


4. Does Telehealth Open the Door to Fraud and Abuse? 

Related to the overutilization charge from critics, policymakers also have concerns about the prospect of fraud and abuse. Indeed, in its recently published Report To The Congress: Medicare Payment Policy, the Medicare Payment Advisory Committee (MedPAC) noted that “Expanding telehealth services also raises program integrity concerns. Telehealth companies have been involved in several large fraud cases, resulting in several billions of dollars in losses for Medicare.” 

The concern isn’t necessarily about the technology itself or delivery modality, but about the potential power it gives to fraud-friendly providers, and the ability it enables to scale fraudulent schemes. 

In the early days of the pandemic when the Trump Administration was rapidly lifting telemedicine’s restrictions and granting waivers in emergency response, administration officials were already raising some alarms in press briefings, as Kaiser Health News quoted from a briefing:

“There are unscrupulous providers out there, and they have much greater reach with telehealth,” said Mike Cohen, an operations officer with the Health and Human Services Inspector General’s Office, which investigates healthcare fraud. “Just a few can do a whole lot of damage.”

In many cases, the concern is that seniors can be more easily taken advantage of, and payers like Medicare may have difficulty differentiating improper bills from those submitted by a legitimate telehealth operation. In September 2019, the Justice Department charged 35 people in connection with a $2.1 billion telemedicine fraud scheme, one of the largest of its kind to date.

The trouble for the industry is that a few unscrupulous providers can spoil the opportunity for everybody. However, given that fraud and abuse issues occur throughout the healthcare industry, if the telehealth industry can make strides to answer some of the other questions and companies make efforts to increase transparency around their operations, it should bring trust and confidence to payers and policymakers alike.


Moving From Flexibilities to Permanence in a Post-Pandemic World 

Vaccines and spring is officially here, and we can start to see the end of the long Covid-19 winter. Telehealth helped millions of people find and access care during the past year. Payers granted exceptions and waivers to facilitate access to virtual care, and now face members and beneficiaries who have a strong preference for maintaining that access. 

Companies like Hims & Hers, PlushCare, and Doctor On Demand are most likely right: if done right, telehealth can improve healthcare access, reduce costs and deliver high quality care. The challenge for them will be to continue collecting, measuring and analying data that answers the types of questions above that payers and policymakers have. 

But with the business savvy these companies have shown, consumer sentiment tailwinds at their back, and more private capital pouring in to innovate further and meet new consumer needs, it’s an exciting and promising moment for telehealth.

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