Perspectives

Once a vision for the future, virtual health is a reality of the present

Health Care Current | March 13, 2018

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes.

My Take

Once a vision for the future, virtual health is a reality of the present

By Steve Burrill, Vice Chairman, US Health Care Providers Leader, Deloitte LLP

I’ve just arrived home after spending an amazing few days in Las Vegas with more than 45,000 health IT professionals. In past years, some of the concepts I’ve heard at the annual Healthcare Information and Management Systems Society (HIMSS) conference have felt like they were set somewhere in the future, floating out on the horizon. But this year was different. At this year’s HIMSS18, it seemed as though the future had arrived—particularly when it comes to virtual health.

Virtual health stretches beyond the use of digital tools, or mobile devices that connect patients to physicians. It combines digital and telecommunication technologies to create a continuous connection between patients, physicians, and other caregivers. By combining technologies, health care stakeholders are able to more effectively coordinate patient care.

The idea of virtual health goes back decades. So why now? I think there are several reasons. First, technology has finally caught up with our vision for the future. Secondly, consumer expectations are higher, and demands for improved convenience and availability have increased. At the same time, many of the financial, behavioral, and policy barriers that have hindered adoption are starting to crumble.

As the health care sector transitions from a volume-based fee-for-service model to one that rewards value, virtual health could have a significant return on investment. For hospitals, physicians, and other caregivers, virtual health could enhance the ability to improve care, outcomes, convenience, and patient engagement while reducing costs.

Four reasons the time has arrived for virtual health

Based on the traffic at our exhibit booth—and questions asked during some of the sessions—there is clearly tremendous interest in this topic. Here are four reasons I think the time has come for virtual health:

  1. Improved technology: Internet speed and connectivity are light years beyond where they were a few years ago. In addition, most everyone seems to have a smartphone within arm's reach at all times (maybe not always a good thing!). Flip phones and dial-up have given way to smart devices (with exceptional camera lenses). Better technology has helped make telehealth more user-friendly and accessible for patients and providers. More than 90 percent of American adults use the internet,1 which means physicians have the ability to answer non-urgent questions from patients online. In addition, the vendor landscape has broadened significantly, and interoperability continues to improve. Patients, health systems, doctors, and health plans can connect with each other through a variety of devices.
  2. Evolving state laws: Over the past several years, some state laws have been modified to allow wider use of telehealth. Until recently, for example, some states did not allow providers to write prescriptions after a telehealth visit. Other laws required physicians to meet first with patients in person before telehealth visits were allowed. At least 34 states now have laws that require coverage for telehealth services.2
  3. More covered services: A growing number of state laws require commercial health plans and Medicaid to cover certain services through telehealth. Medicaid programs in 49 states and the District of Columbia now offer some telehealth coverage.3 A growing number of private health plans now pay for telehealth visits. As of 2016, 74 percent of large employer-sponsored plans had incorporated telehealth into their benefits (up from 48 percent in 2015).4
  4. Payment parity: Several states have enacted laws that require health plans to put payments for telehealth visits on par with face-to-face visits. At least 23 states and the District of Columbia now require full parity.5 Some states are exploring legislation that would let physicians use telehealth to meet with patients in other states. At least 18 states have enacted a compact streamlining licensing.6

We still have hurdles to overcome. Before the industry can fully benefit from virtual health, our care-delivery and payment models likely need to change (see Deloitte’s report, Realizing the potential of telehealth). This includes governance, workflow, training, and development. We also have to convince people to try it.

The vast majority of people (74 percent) say they are willing to try telehealth visits, according to the American Hospital Association.7 However, just over 20 percent have taken that first step and had a virtual visit. While most people are willing to try telehealth, it might not yet be offered by their physician. (While 26 percent of group practices offer a telehealth option, another 15 percent intend to start this year.)8 Or, patients might not be aware that it is available. In a 2016 Deloitte survey of health care consumers, most of the interest in telehealth was related to post-surgical care and chronic-disease monitoring.

Here are three areas where I think virtual health could improve the value of health care:

  • Outcomes: Virtual health led to a 15 percent reduction in length of patient stays, and improved the experience of chronically ill patients, and remote monitoring of patients once they leave the hospital can cut readmission rates.9 It is estimated that $7 billion a year (average of $126 per visit) would be saved if annual face-to-face doctor visits moved to virtual visits.10
  • Access: There are now about 200 telemedicine networks and 3,500 service sites in the US, according to the American Telemedicine Association. Adoption of virtual health could extend the reach of physicians and other care providers, and improve convenience for patients. Getting into a car and driving to see a doctor can be a burden for patients. Improving convenience and keeping patients out of waiting rooms can translate to a better patient experience.
  • Adherence: Virtual health can help improve medication adherence, health tracking, and patient accountability. It also can help patients better understand their treatment plans. Telehealth and remote monitoring can give physicians real-time insight into their patients’ health and medical data. For patients with chronic conditions, it can improve disease monitoring and alerts.

For virtual health to succeed, health systems should be thoughtful in how they integrate it. Many health care organizations have already implemented some type of virtual health. The organizations that can seamlessly integrate the technologies into their care delivery model—and create a fluid experience for patients whether care is virtual or in-person—can lead the way.

Based on several of the discussions I had at HIMSS—along with coffee break talk and elevator conversations—it is clear that virtual health is no longer just an idea. It is beginning to infiltrate hospitals and health systems, and patients, employers, and physicians are growing more comfortable with the idea. Virtual health, however, is in its infancy, and it is important that health systems have the right infrastructure and strategies in place as they move forward. To stay relevant, hospitals and health systems should prepare for this future, which seems to have already arrived.

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1 Pew Research Center, 2018
2 Health Data Management, 2017
3 Health Affairs, 2016
4 https://www.medscape.com/viewarticle/849971
5 Health Affairs, 2016
6 Interstate Medical Licensure Compact, 2018
7 https://www.aha.org/system/files/research/reports/tw/15jan-tw-telehealth.pdf
8 https://www.hhnmag.com/articles/8350-telehealth-adoption-to-double-by-2018
9 The Wall Street Journal, 2016
10 http://www.healthcareitnews.com/blog/virtual-visits-cutting-healthcare-costs

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In the news

Top HHS officials outline priorities for health care stakeholders

Interoperability, consumer choice, and transparency are instrumental to achieving the promise of value-based care (VBC), Department of Health and Human Services (HHS) Secretary Alex Azar told a group of hospital executives on March 5.

Speaking at the Federation of American Hospitals’ policy conference on March 5, Azar emphasized the following points:

  • Patients need access to technology that allows them to access their health records, and they have a right to control their own health information.
  • Price transparency can encourage competition while driving down costs.
  • Medicare and Medicaid must play a major role in the transition to VBC, and should lead the way for private payers.
  • Government regulations—including some reporting requirements and anti-fraud protections—can impede the implementation of VBC.

Azar said other priorities for HHS include addressing the opioid crisis and reducing high health insurance costs.

The following day, Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma echoed many of these ideas at the HIMSS18 Conference. Current health record systems and regulations are outdated, costly, and burdensome, she said. CMS is looking to change this through the following programs and initiatives:

  • Patients Over Paperwork would make EHR use easier for providers and improve the coordination of care between providers.
  • MyHealthEData would give patients access to and control over their records. Under this initiative, patients could link mobile health apps, wearables, and other health technology to their EHRs. Patients could also authorize researchers to access their health data. The White House Office of American Innovation will run MyHealthEData, with support from the Office of the National Coordinator for Health Information Technology at HHS. The Department of Veterans Affairs and National Institutes of Health will also be involved in the project.
  • Blue Button 2.0 is an application programming interface (API) that will allow Medicare beneficiaries to share their information more easily using the HL7 FHIR standard. This provides a secure connection and lets beneficiaries determine which organizations will receive their data. Blue Button 2.0 is the updated version of a system piloted by CMS and the Department of Veterans Affairs.

Related: US Food and Drug Administration (FDA) Commissioner Scott Gottlieb reiterated the need to cultivate innovation and competition—specifically, regarding biosimilars—in a speech on March 7. Gottlieb said:

  • The current payment scheme for biosimilar makers does not reduce drug prices for patients. This hinders competition.
  • FDA wants to expedite the development process for biosimilars, including by helping developers conduct more targeted trials. This way, it will cost less to bring the drugs to market.
  • Price transparency would encourage competition and market uptake, but payers must agree to be transparent.
  • FDA will take steps to educate providers and patients about the safety and value of biosimilars.

Idaho’s state-based health plans may run afoul of ACA rules

Idaho’s plan to allow insurers to sell health insurance that does not meet ACA requirements (such as essential health benefits, no lifetime or annual coverage limits, and the ban on medical underwriting) is illegal, according to a March 8 letter from CMS Administrator Seema Verma.

In January, Idaho Governor C.L. “Butch” Otter (R) issued an executive order directing the Department of Insurance to design low-cost, but non-ACA-compliant, individual market plans. An insurer selling such plans would have also needed to sell ACA compliant plans (see the January 16, 2018 Health Care Current). Verma said that, while she was sympathetic to Otter’s concerns about insurance affordability, CMS has a duty to uphold the law, and the agency would enforce the ACA’s provisions if the state would not. The letter cited ten ACA provisions that Idaho may have breached.

However, Verma stressed the administration’s commitment to giving states flexibility through Medicaid and State Innovation waivers. She also highlighted the recent proposed rule that would expand the availability of short-term, limited-duration health plans as an alternative option for Idaho to consider (see the February 27, 2018 Health Care Current).

CMS partially approves Arkansas’ Medicaid waiver request

On March 5, CMS approved Arkansas’ Medicaid waiver amendment request, which will add a work requirement for certain beneficiaries. The agency, however, deferred its decision on another part of their proposal that would have lowered the Medicaid eligibility limit (for the state’s expansion population) from 133 percent of the federal poverty level (FPL) to 100 percent.

Under the new rules, Arkansas will require most able-bodied adults (under age 50) to participate in “community engagement” activities in order to keep their coverage. These include working, searching for employment, job training, education, and community service. The new requirements are slated to go into effect this June.

In 2013, CMS approved Arkansas’ Section 1115 demonstration waiver that requires adults covered under the expansion to purchase subsidized health coverage through the state’s health insurance exchange. This is referred to as the “private option.”

States that have not expanded Medicaid have been watching to see whether CMS will allow states to claim enhanced matching funds for partial expansions (i.e. to an eligibility level less than 133 percent FPL, as called for in the ACA).

Related: On March 8, Utah’s Senate passed a bill that would expand the state’s Medicaid program to childless adults whose income is under 95 percent FPL, and to allow those with incomes over 100 percent FPL to purchase plans on the state exchange. The bill would require the state to submit a waiver request to CMS to impose work requirements on the newly eligible group. The bill would also allow the state to stop accepting new applications for expansion coverage if the program runs out of funding.

CMS announces grants to improve MACRA quality measures

Over the next three years, CMS will contribute up to $30 million toward improving Quality Payment Program measures based on input from providers and patients. In a March 2 statement, the agency said it intends to focus on:

  • Engaging with clinicians,
  • Minimizing regulatory burdens,
  • Developing policies around consumers,
  • Ensuring measures are aligned and comprehensive, and
  • Making data collection more efficient within the Quality Payment Program.

The agency says it also will take steps to fill outcome measurement gaps within certain specialty areas, such as oncology, palliative care, and emergency medicine. It will also focus on patient outcomes and experiences, the coordination of care, and service use, including overuse. (For more information about the Medicare Access and CHIP Reauthorization Act (MACRA), which established the Quality Payment Program, see our report “Rebuilding the foundation of health care under MACRA.”)

New CDC report reveals a worsening opioid crisis

The opioid crisis is getting worse, according to a new report from the Centers for Disease Control and Prevention (CDC). Suspected opioid overdoses in emergency departments (ED) increased across all genders, age groups, and regions from July 2016 to September 2017, according to the report. Overall ED visits increased 30 percent over the 14 month period.

Regional trends included:

  • Eight states reported opioid overdose increases of 25 percent or more
  • EDs in the Midwest region saw a 70 percent increase in opioid overdoses
  • Among cities and towns, large metropolitan areas saw the highest rate increase in opioid overdoses at 54 percent

CDC recommended several actions for health departments, providers, and emergency departments. These include increasing access to opioid use treatment, medication-assisted treatment (MAT), and provider education. Once controversial, MAT now has received recent support from the federal government. For example, FDA Commissioner Scott Gottlieb, M.D. announced forthcoming guidance for MAT, and HHS Secretary Alex Azar has said his agency will embrace it. The administration also has increased its focus on the opioid crisis in the recent weeks (see the March 6, 2018 Health Care Current).

Related: On March 8, the Senate Health, Education, Labor and Pensions (HELP) Committee held another hearing on addressing the opioid epidemic. This hearing, which focused on state leadership and innovative solutions, included testimony from governors Larry Hogan (R-Md.) and Kate Brown (D-Ore.). Hogan called for federal partners to stop the flow of illegal drugs, including fentanyl, and to provide resources needed to address the epidemic. Brown said she intends to declare addiction and substance abuse to be public health crises in Oregon. She urged lawmakers to treat substance abuse disorder as a disease.

ACA risk-adjustment formula is flawed, court rules

HHS relied on a flawed formula to redistribute funds among health plans, a US District Court in New Mexico ruled on Feb. 28. The ACA created a set of policies (commonly referred to as the “3 Rs”) to create a fair and stable individual insurance market: risk adjustment, reinsurance, and risk corridors. Under risk adjustment, plans with a greater share of healthy members pay into a pool; CMS then redistributes money to plans with a greater share of unhealthy members.

In a lawsuit filed in 2016, New Mexico Health Connections—one of 24 not-for-profit Consumer Operated and Oriented Plans (CO-OPs) created through the ACA—said the risk-adjustment formula was inaccurate. As a result, CO-OPs and other small carriers, paid too much into the program. In its suit, Health Connections said it was required to pay more than 20 percent of its 2014 premiums into the program. The court ruled that HHS’s risk-adjustment methodology “is arbitrary and capricious” because it relied on state-wide premium averages. The court rejected other claims made in the lawsuit.

Poll reveals disconnect between patients’ preferences and doctors’ perceptions

Older adults often disagree with their doctors about needed services, according to a new report from Michigan Medicine’s National Poll on Healthy Aging. One in four older adults said their own doctor often recommends medications, tests, or procedures that are not necessary; more than half of respondents had the impression that this is a common phenomenon. However, 50 percent of older adults have gotten such a test recommended by their doctor anyway, even though they did not think it was needed, and 40 percent of those who were prescribed a medication they did not think was necessary still filled the prescription.

The poll results suggest the need for better communication between patients and clinicians. Nearly 80 percent of patients who thought they needed a medication, test, or procedure said their doctor explained why it was unnecessary. Of those, 60 percent said they understood their doctor’s explanation, and 30 percent said they understood somewhat; 10 percent said they did not understand at all.

According to the report, overuse is common, even though only 14 percent of older adults said they thought more medical treatment is better. Medications, tests, and procedures that are unlikely to improve health outcomes are unnecessary and wasteful. They also have the potential to harm patients. Avoiding unnecessary health care services can reduce costs without worsening outcomes and improve the patient experience, the report concludes.

(Source: Preeti Malani, et al., “National Poll on Health Aging,” The University of Michigan, March 2018)

New report on Medicaid ACO adoption highlights challenges and early successes

A new report from the Center for Health Care Strategies, Inc. found that early adopters of Medicaid accountable care organizations (ACOs) had positive results, but found that building the programs was a significant task. Below are some key findings:

  • Colorado’s Regional Care Collaborative organizations report $77 million in net savings for the state’s Medicaid program.
  • Maine’s Accountable Communities report $4.56 million in net savings for the state’s Medicaid program.
  • Minnesota’s Integrated Health Partnerships report $213 million in savings over the life of the program.
  • Oregon’s Coordinated Care Organizations have demonstrated improvements on most cost and quality measures and have kept the state’s Medicaid program expenditures under the two percent annual growth target stipulated in their 1115 waiver agreement with CMS.
  • Vermont’s Medicaid Shared Savings Program reports $15.7 million in savings over the first two years of the program.

States have used both shared-savings models (ACO providers receive shared savings or bonuses based on hitting spending targets), and global budget models (ACOs receive capitated payments for enrollees). Many states implemented Medicaid ACOs in response to financial challenges. ACOs also measure quality and receive bonuses for hitting certain quality targets (for more information see the January 12, 2018 Center for Health Solutions blog and our report “Medicaid alternative payment models”).

Breaking Boundaries

Transportation and health care companies team up to overcome barriers to care

Access to transportation is often a critical barrier to receiving care, especially for patients who have chronic conditions and require regular appointments. A 2016 Community Transportation Association study found that 3.6 million Americans miss or delay medical care because of transportation issues. In response, ridesharing and transportation companies are partnering with health care organizations to change this situation.

Allscripts and Lyft recently partnered to launch a program that integrates the patient’s electronic health record (EHR) with Lyft’s proprietary application program interface (API). The new program incorporates non-emergency transportation services directly into physician workflows. This integration can help ensure patients make their medical appointments if they don’t have access to transportation. When a patient’s transportation needs show up in the EHR, the Lyft service automatically schedules transportation services. The care team is notified when the patient is picked up and is provided with an estimated times of arrival.

Transportation service company Uber recently launched Uber Health to help patients who have transportation needs. Uber Health allows clinicians to book rides for patients, caregivers, or other medical staff. Patients can also access Uber Health on their own apps, or they can call or text for the service. Health care organizations that use the program can also access a billing dashboard to make it easier to pay for the service. Health systems that are piloting the program say Uber Health has helped reduce appointment cancellations related to a lack of medical transportation.

Related: Deloitte’s recent report, New roads to the health care of tomorrow: How the future of mobility promises to change the US health care system, highlights how the emergence of connected, electric, and autonomous vehicles—combined with shifting attitudes toward mobility—are beginning to change the way people get around, and could have implications for how people access health care.

If ridesharing and car-sharing become more prevalent, vulnerable populations, such as the elderly and disabled, and patients who don’t have cars, may have greater access to health care. The paper takes the ridesharing trend further and discusses how it might be combined with autonomous vehicles and a connected vehicle infrastructure. This could extend the reach of health professionals by dispatching physicians, nurses, and others to remote care sites or patient homes. No longer designed around the driver’s needs, vehicle interiors can use other emergent technologies such as additive manufacturing, augmented reality, and virtual reality to create highly capable autonomous mobile care units. Such mobile care units could offer services that are now limited to hospitals, such as 3D printing a custom cast for a broken bone, running tests on vitals, or holding consultations with specialists.

Health systems that use transportation innovations to improve access to care have the potential to reduce no-shows, improve care coordination, and provide needed services. The patient experience is likely to improve as well, which could result in higher experience scores. Along with higher performance payments, health systems could also see their brand improve in the marketplace.

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