Trends in Telehealth

The HealthTech Build event on telehealth was hosted in the beautiful new Well-B innovation space in the Prudential Mall in Back Bay, part of Blue Cross Blue Shield of Massachusetts.  As part of the event, Well-B offered extended viewing hours for their very relevant exhibit on the Connected Home.

In the midst of a circle of soft chairs and pillows (Well-B has really made this comfortable), we gathered a panel of experts who are working on the frontlines of telehealth technology.

Speakers:

Joris Van Dam, Head of Digital Therapeutics, Novartis

David Mou, MD, MBA, Co-founder & Chief Medical Officer, Valera Health

Kelly Kernan, Director, Market Insights, AmericanWell

Mary Rollman, Principal, KPMG (Moderator)

The discussion focused on how telehealth is still in its early days but is approaching an inflection point of adoption by patients and physicians.

The hope is that telehealth can solve some of the fundamental problems in healthcare delivery.  One can imagine that at some point in the near future, telehealth will become a pervasive part of care. It will be delivered as part of a new model of comprehensive team-based care with non-clinical coaches who maintain frequent contact with patients through multiple channels including video, text chat, voice calls, and in-person visits whenever necessary.  There is every reason to think that the costs will be dramatically lower while providing a higher standard of care.

The barriers to adoption include the lack of financial incentives for physicians, conservative mindset of clinical staff and hospital administrators, state patchwork of regulatory restrictions and physician medical licensing, and slow movement toward value-based care and team-based care models with health coaches.

Here are some of our takeaways from the event.

• Clinical research
  • Telehealth has great potential to bring down the cost of clinical trials and make the research more effective. Less labor would be required for remote patients.  It allows the use of a large representative population instead of a smaller skewed population based on whoever can visit one of the clinical trial sites. 
• Adoption
  • Demand from customers is driving new specialized areas of service like acute care and behavioral health.
  • There is often patient bias against telehealth based on the perception that it’s a second rate product when compared to a clinic visits.  Valera has found that offering both in-person visits and telehealth increases the perceived value of telehealth as value-added. Even if the patient doesn’t want an in-person visit, they want to have the option.
  • AmericanWell has experience from the early days of telehealth.  On the hospital side, many earlier customers were large healthcare systems who had experimental budgets to invest in specific clinical scenarios like telestroke while today’s customers want enterprise platforms that involve an internal IT department and make the service broadly available across many clinical practices.  On the health plan side, earlier customers were checking a box for employer clients to offer a perk to employees, while today’s companies are more strategically exploring segments like managed medicare and small employer plans.
  • A less positive data point is that one of the largest insurance companies reportedly has  less than 1% adoption of telehealth. This shows it’s still early days, even if changing fast.
  • Valera has seen that behavioral health physician adoption is often especially slow.  Physicians are generally comfortable with the current system and don’t want to make a change to their workflow. A physician may show interest in telehealth and try it for a day but will never make the shift to full-time. Of course, any impact on salary is a major factor in these decisions.
  • Fewer older people want telehealth, but not a dramatically lower number than millenials. The older population might want different telehealth use cases such as writing prescriptions.  Old people are much more loyal to a PCP (8% would leave their pcp) than millenials (40% would leave).
  • Younger physicians are more likely to adopt telehealth as is true of other new technologies.  A parallel is the example of Iora health where founder Rushika Fernandopulle went to the Brigham and asked for physicians who wanted to try something new.  He got a lot of interest from good physicians who were focused on the mission instead of the paycheck. The same trend can also be seen in the C suite of health plans and hospitals. There is currently a change of guard to people in their 40s and 50s who are more receptive compared to the previous generation.
  • Some telehealth platforms are software only while others are full solutions that include staffing of telehealth physicians and other clinical care providers.
• Telehealth and collaborative care
  • One reason that health coaches make sense is they allow physicians to keep focused on more complex care.  New models for reimbursement are beginning to make this possible, including a CMS experiment that makes payments for physicians who refer patients.  
  • There is interest in task shifting by physicians so that only complicated cases rise to the top physician level.  For many chronic conditions, the provider will view mental health as a distraction from the primary disease measures they are working toward.  The physician is often happy to quickly hand off mental health care to someone else. At the same time, the patient can reach their objectives which often prioritize mental health over physical measurements like functional ability that are perceived by physicians to be a greater priority.
  • Collaborative care is proven by RCTs to provide better care and save money.  The patient connection is the most important thing and care should be optimized for human relationships.
  • The old model for psychiatry is 45 minute sessions because that is what the billing codes reimburse.  But testing has found that more frequent short interactions like texting are more effective, reduces stigma of visiting the office.
• Rural Care
  • A rural success example comes from Hawaii and was focused on behavioral health.  Telehealth can be good for isolated populations because it reduces stigma when everyone personally knows the local mental health provider.
  • Rural healthcare uptake has been less than predicted, perhaps due to rural patient expectations of traditional in-person doctor visits.  In addition, the rate of rural adoption might be counterbalanced by the urban population’s greater desire for on-demand convenience and high rates of technology adoption.
• Liability
  • There is a lot of discussion about the line for health coaches to prevent them from providing medical advice. Ultimately it’s important to have rigid protocols for escalation. The risk involved may be analogous to the case of Tesla automatic driving where the company has been punished for fatalities even though their systems have been shown safer than human drivers.  It’s common that new technologies are penalized more.
  • The liability for behavioral telehealth can be strange.  Some doctors will say they would rather not want to know if a patient is suicidal for liability reasons.  Valera’s founder is doing research at Harvard that uses movement data to estimate risks of suicide. Protocols can be more comfortable for physicians.
• Advice for founders
  • You are never selling to one customer and you need to understand the incentives of everyone.  It’s important to demonstrate enough value to change current behaviors. It’s not helpful if the non-clinical people say your system is amazing while doctors say they won’t use it.  Today most startups are showing up with some clinical research so a financial business case may be important.
  • Don’t assume that people always care about their health, sometimes behaviors are different to what you might think.
  • Engagement can be more important than exciting innovations like AI and machine learning.  An example is Livongo who have become a very successful company with only basic enabling technology that allows people to form a social bond.  Focus more on clinical process than new tech.
• Medicaid and severe mental illness
  • In the medicaid population, patient compliance is difficult.  For insurance companies, it often makes sense to buy the patient a smartphone and teach them how to connect with Wifi. Communications response time by providers can be important for compliance by this patient population.  If there is latency of over 2 days, the compliance decreases. On the other hand, patients with severe mental illnesses like schizophrenia are one of the most high compliance populations. This may be because they don’t want face to face interactions.
• Regulatory and reimbursement
  • Regulatory barriers are real.  Just last year, Texas became the last state who’s state board of health made telehealth permissible.  This is partly a legacy of physicians being defensive out of a fear that telehealth might steal patients.  Today the challenge is reimbursement. In 40 states aand DC there are parity laws for reimbursement so that health plans must cover telehealth.  However this rarely includes equal reimbursement. In 30 states, there are laws for Medicaid.
  • Within this landscape, it’s not surprising that physician adoption is low. This is slowly changing as CMS are adding a few codes for remote patient management and patient visit by telehealth.
  • One challenge is that many physicians are often not good billers and may miss opportunities to bill for services such as addiction counseling.
  • One of 8 ED visits is psychiatry but there are rarely enough physicians and the cost of a behavioral health telehealth visit is far cheaper than an ED visit.
  • Telehealth will become a tool for value based care, but value based care is not happening as fast as hoped.
• Other thoughts
  • In 10-15% of cases, they recommend a personal meeting instead of telehealth.  For example, this is advisable for the first visit of a bipolar person. But if the person can’t get care or doesn’t have insurance, Valera will provide care without payment in the interim.
  • Depression in MS is different than depression in cancer. Some psychiatrists will be better with different types of patients.
  • One interesting trend is the consumerism of healthcare.  Companies are trying to make telehealth as a digital front door so that patients can easily access services and interact.  This is culturally very challenging for hospital systems and providers who do not historically align themselves around the patient as customer.  Healthcare now has to catch up with what’s been standard in other industries.

Speaker biographies:

Joris Van Dam, Head of Digital Therapeutics, Novartis

Joris is a Digital Health intrapreneur with 15 years’ experience in Pharmaceutical Research & Development, focusing on the use of digital technologies to transform therapeutic innovation, patient engagement, and clinical trials operations. Joris currently leads the Digital Therapeutics initiative at Novartis Institutes for BioMedical Research, including its collaboration with Pear Therapeutics. Prior to that, Joris launched a number of digital health initiatives involving EHR integration, pharmacies, and mobile health applications in Africa and India. Joris holds a PhD in Artificial Intelligence from the University of Amsterdam.

Kelly Kernan, Director, Market Insights, AmericanWell

Kelly started her career in healthcare in policy, at the Medicare Payment Advisory Commission. From there, she went to California to help run the largest private pay for performance program in the country, at the Integrated Healthcare Association. Kelly has been at American Well for two and a half years, where she leads the Market Insights team – keeping the company up to date on the telehealth landscape and key trends affecting American Well customers. She has an MBA and an MPH from Dartmouth.

David Mou, MD, MBA, Co-founder & Chief Medical Officer, Valera Health

David is the co-founder and Chief Medical Officer of Valera Health, a venture-backed digital healthcare company that empowers healthcare organizations to manage chronic medical and mental health. David is a psychiatrist at Massachusetts General Hospital (MGH) where he conducts research on prediction of suicidal thoughts and behaviors and a Soros Fellow, a Horatio Alger National Scholar, and a Blavatnik Fellow at Harvard Business School. He graduated from Harvard College with an honors degree in neurobiology, and earned his MD MBA from Harvard Medical School and Harvard Business School. His writings have appeared in the New England Journal of Medicine.

Mary Rollman, Principal, KPMG (Moderator)

With more than twenty years of experience as both a practitioner and consultant Mary has experienced all aspects of today’s global business. Working across industries including: pharma, biotech, medical devices, consumer goods, consumer electronics, federal government, high tech, oil and gas, she brings a unique perspective to her clients. She has run day to day operations, led large transformation programs, designed and led leadership programs to grow talent and managed M&A due diligence efforts and post merger integrations. 

A big thanks goes to Well-B for hosting the event.  Also our appreciation goes to Rightpoint for sponsoring the event’s generous spread of food and drink.