In this Jan. 14, 2019 photo, Caitlin Powers sits in her apartment in New York, and has a telehealth ... [+]
The Centers for Medicare and Medicaid Services’ (CMS) decision to eliminate the bureaucratic barriers that kept beneficiaries from using telehealth was, as I described at the time, a silver lining of the Covid-19 crisis. In addition to keeping people needing nonemergent care from overwhelming already overburdened frontline providers, it gave people a chance to finally experience what it’s like to conveniently receive care from the comfort and safety of their home.
As expected, healthcare consumers are in favor of this tool. Indeed, this genie’s out of the bottle, and it’s unlikely going back. In a recent survey of 2,000 U.S. adults, 65% said they liked using telehealth because of its convenience, and because of that, 51% that they’d continue using it after Covid-19.
However, it’s become quite clear that there are other barriers keeping telehealth from becoming a more mainstream part of the care continuum. Despite consumers’ appreciation for the technology, utilization, according to a report by the Commonwealth Fund, appears to have been declining since April. Why has everything to do with underlying business dynamics, and points to what must change before we can expect telehealth to stay.
The fee-for-service payment model doesn’t support the use of telehealth as a cost-effective tool integrated into the continuum of care. Temporary exceptions for Covid-19 aside, telehealth has historically been reimbursed at far lower rates than in-person visits. Providers have viewed it as an add-on service. And that’s a problem for commercial payers, who don’t see value in paying for an extra encounter.
Most providers seem to view telehealth as a quick fix rather than a lasting solution. They recognize that telehealth serves an important purpose right now, for patients and for themselves — under healthcare’s current business model, having a greater volume of telehealth visits is better than having no visits at all. Providers are pressing to return to more lucrative face-to-face visits.
Not surprisingly, commercial payers generally aren’t making increased payments for telehealth permanent. They’re concerned about how much value telehealth visits will provide post-pandemic, whether they allow providers to do the appropriate level of screening, whether a beneficiary’s full medical history will be taken into account, and ultimately whether telehealth will simply mean additional costs.
Under global or capitated payments with accountability for outcomes, the story would be different. With incentives to keep patients healthy, telehealth would play an important role in care. But few providers have been well-positioned or willing to move to new payment models that seem to have more financial risk. However, the revenue loss that providers have seen in the Covid-19 crisis has demonstrated that their risk in the fee-for-service model is bottomless.
There’s also the issue of payers’ and providers’ storied relationship with one another. Payers don’t trust providers, as they have historically “upcoded” and “upcharged” them for services/procedures. And providers rarely enjoy working with payers, feeling as though they mostly say “no” and too often demand prior authorizations and mountains of other paperwork that can consume nearly half their day.
All of these reservations likely explain the recent dip in telehealth use, and they all tie back to the fact that healthcare’s business model is not market-based. If it were – meaning there were transparency in cost and quality and accountability via payments tied to outcomes that matter – each of these issues would be addressed. The problem is that right now, payers and providers can’t conceptualize this because this business model is nothing like the one they’ve experienced for the last several decades.
Value and the patient/consumer are at the center of a market-based business model – not volume and transactions as in fee-for-service. As such, the focus for providers is on delivering the highest-quality outcomes at the lowest total cost of care, and telehealth, with best practices in place, represents a step in that direction. There are long-term benefits to keeping patients at home, rather than sending them into waiting rooms or ERs. Hospitals were never meant to be destinations of choice. To keep patients healthy and keep costs under control (even before Covid-19, but especially now), we’ll do best by helping patients stay out of medical facilities.
A market-based model not only unlocks telehealth’s demonstrable value to payers, providers and patients, it also creates an environment in which payers’ and providers’ frustrations with one another can be easily resolved. The transparency it provides allows payers to see upfront what providers charge, reducing the number of negotiation-based interactions both parties may have to have. Capitated and bundled payments reduce the number of papers providers have to fill out, leaving more time and energy for them to do what we need the most: keep people healthy.
In sum, the need for telehealth is clear, and that prompts the question, “Will telehealth become a permanent part of our future?” The answer is, yes it will, but not until payers’ and providers’ goals are aligned with a market-based model.
