Telemedicine helps you provide better patient care, lower no-shows, retain patients and also to generate additional reimbursement dollars. Here’s a primer on telehealth, the various options you have and the pros/cons of each. Hopefully this guide will help you decide whether your practice should invest in telehealth or not – especially as providers must now live both in a fee-for-service and fee-for-value world.
We have taken advantage of the latest technical advancements for teleretinal screenings, televisits for skilled nursing facilities, telvisits in ophthalmology, televisits in ergonomics – this primer has inputs from our direct experience as well.
Quick guide on telemedicine
Telemedicine itself is a complex and varied field – there are technologies such as e-visits which are encounters between a provider and a patient, remote patient monitoring, store-and-forward or asynchronous telemedicine which is an encounter that doesn’t take place in real-time but involves the review of electronic documentation followed by a recommendation for follow-up care.
The multitude of different means for care delivery creates the opportunity to customize solutions to meet a patients’ needs. In addition to meeting the patient’s needs, there is potential for telemedicine in all its variants to improve a provider’s satisfaction with their vocation.
As providers look at more fully transitioning to a value-based payment paradigm and begin examining different network models – be it joining a health system as a contracted or employed provider, forming a supergroup, affiliating with a multi-specialty group, or joining a looser group of connected providers in a physician-led clinically integrated network or independent practice association (IPA) – telemedicine provides an avenue to better profit from such a transition and to improve the patient’s care experience at the same time.
There are 3 modalities to understand:
- Evisits or televisits
- Remote patient monitoring
- Store and forward
E-Visits or televisits
When most people think of telemedicine, whether they know it or not, they are imagining e-visits. Simply put, e-visits – which are sometimes referred to as televisits – are usually audiovisual encounters that occur in real-time between a provider and patient that are both at separate locations.
There are a lot of platforms out there for such services and, indeed, many health plans and employers have partnered with specific vendors and contract physicians to provide e-visit services. Often, e-visits are used for lower intensity urgent care visits.
Benefit of televisits – Reduced emergency utilization
Such visits can be used – when appropriate – to reduce Emergency Department utilization. Additionally, they provide patients with a way of receiving some care without having to leave their home and at an affordable cost.
Benefit of televisits – Address specialist shortages
If one is uninsured or has a high-deductible, the cost for an e-visit is often around $45-55. There are also specialties providing these services. For example, telepsychiatry has grown and is continuing to grow and other specialties such as rheumatology have been experimenting with ways to leverage telemedicine to address their specialty’s shortage.
Benefit of televisits – Improved efficiencies for uncompensated encounters
Medical practices, specifically, can use e-visits in a few unique ways. If the practice is, for example, a surgical group where there are numerous uncompensated encounters post-op, if it is medically responsible, it may be more efficient for both the provider and the patient to receive some or all the post-op appointments via e-visits.
Such virtual visits can also be used by specialist providers to monitor new or changed medication regimens.
Both uses can allow a provider to more quickly see patients and, possibly, save a patient from having to drive or have a caregiver drive them into a practice that may -especially in rural areas – be a significant distance from their home and involve missing work.
Such a process will save the front desk staff check-in time and save the patient waiting room time; moreover, the provider will be able to see more patients since the logistics of having patients check-in and meeting with a medical assistant or nurse is removed.
Benefit of televisits – Reducing no-shows and improving office workflow
Primary care practices can also benefit from e-visits.
Providers have had success with using telemedicine for routine follow-up visits such as those for depression or ADHD medications. Some have also used them for hypertension follow-up to assess how a patient uses their home blood pressure cuff.
Visits that might lead to a loss of revenue because the patient is diverted to an urgent care after hours can be captured by the primary care practice which might provide uncompensated on-call care prior to diverting to an urgent care.
If a practice has a relatively high cancellation rate, e-visits can be used to augment a practice’s income as well. Pediatric practices, likewise, can increase patient satisfaction and encourage a stronger continuity of care by providing telemedicine.
For example, pediatric groups could provider e-visits early in the morning – the provider can even be at home – to assess children for parents who are concerned that they may be too sick for school.
Also, as with adult primary care, there already exists significant uncompensated care or care that is diverted to Emergency Rooms or Urgent Cares that can be converted back into income for the pediatric practice.
Remote Patient Monitoring
Remote monitoring is a completely different area of telemedicine that has had significant potential and, already, great results.
Remote monitoring or telemonitoring involves using technology such as tablets and specialized versions of blood pressure cuffs, spO2 monitors, glucometers, thermometers, and scales.
Typically, using Bluetooth, the devices are connected to the tablet and the patient’s data is relayed from the tablet to a monitoring tool or application used by physicians, nurses, or care managers.
Reminders from the care providers can be sent to the tablet, and the patient can report their medication adherence. If metrics deviate from expected norms, care providers can intervene earlier in the process and, hopefully, keep the patient in their home rather than have it exacerbate and lead to additional complications and hospital/ER utilization.
While, initially, the patient may seem inconvenienced by having to use these devices and interact with the tablet, once the habit is formed, the patient’s day-to-day life will be more convenient as they will likely experience fewer flare ups of their chronic condition, and they will, hopefully, spend less time in the hospital or at a doctor’s office.
For providers, as they are being pushed – willingly or not – into value-based arrangements or even population-based payments, additional tools are needed to manage the cost and increase the patient satisfaction for populations with costly and life-limiting disease such as CHF of COPD.
In elderly populations, cost and utilization linked to these two diseases is often significant. Remote patient monitoring, if implemented well, can provide higher quality care and lower costs as shown here for CHF and here for COPD although, to be fair, some studies have found little to no benefit, so it appears that there will still be a debate on the use of the technology.
Providers, especially those in value-based arrangements such as one of the Medicare ACO models (notably the NextGen ACO or the traditional Medicare Shared Savings Plan) can work with their partners to see where, for their population, remote patient monitoring can provide a benefit.
Unlike e-visits which can be implemented more-or-less population wide, remote patient monitoring will likely need to occur in a much more targeted manner to be effective.
Benefit of RPM – Reimbursements
CMS has already announced reimbursement policies and associated reimbursement codes for remote patient monitoring. According to mhealthintelligence, “The final rule for the 2020 Physician Fee Schedule gives hospitals and health systems more opportunities to use remote patient monitoring and paves the way for new telehealth and mHealth programs.”
The Centers for Medicare & Medicaid Services (CMS) updated their CPT codes and now, CPT code 99453 pays $19 on average, CPT code 99454 pays about $64, CPT code 99457 pays around $51 for non-facility and $32 for facility and CPT code 99091 pays about $58.
There is much more clarity on RPM reimbursements, CPT codes and a clear path to additional revenues in exchange for taking on this additional burden.
Benefit of RPM – Higher patient engagement
There are several studies like this one done by NIH that speaks volumes about the increased patient engagement due to remote patient monitoring. There’s another brilliant article written by becker’s hospital review here, that is based on the “nudge theory”. This is the same theory that we use in our patient contact center / medical call center as well. Nudging patients / reminding patients seems to keep them engaged to our customers.
Benefit of RPM – Higher patient care adherence, easier value based care
As we move towards value based care and value based payments, care adherence becomes even more important when it comes to achieving the triple aim. Care adherence and preventive care allow providers to be better equipped to reduce acute/episodic care and demonstrate higher value based care.
Simply put, higher care adherence = higher patient engagement = lower acute episodes = demonstration of higher value based care.\
Benefit of RPM – Higher patient satisfaction and reviews
This should have been expected but never was that guiding principle for adoption of remote patient monitoring. In general, it has been documented (see here) that 25% of survey respondents stated remote patient monitoring increased patient satisfaction.. Which inevitably leads to better patient reviews.
Store-and-Forward or asynchronous telemedicine is probably the most technologically straightforward; however, it is also the one least discussed.
It lacks the flashiness of real-time e-visits or the technological sophistication of remote patient monitoring.
The process for store-and-forward involves sending data – usually text, pictures, and x-ray/radiology images – to a provider for their review.
One of a few things will then occur.
- The receiving provider will furnish a recommended course of treatment to the patient if the transmission occurred directly from the consumer.
- If it was another provider that submitted the information, the receiving provider will amend or concur with the treatment plan or diagnostic thinking of the submitting provider or
- The receiving provider will state that the complexity is such that a visit is required.
Studies have found that with some specialties, store-and-forward technology has led to a decrease in wait times and eliminated the need to see specialists in person; thus, freeing up visits for those who have a medical need that cannot be resolved remotely.
While there are certainly challenges around its use – notably, it is hardly ever paid for by health plans, providers that are responsible for the entirety of a patient’s healthcare cost and utilization can, in a responsible way, reduce both under the right circumstances.
Specialties such as dermatology, ophthalmology, and infectious disease are some of the most straightforward to implement via store-and-forward.
An additional benefit is that store-and-forward telemedicine strengthens the patient’s relationship with their primary care provider by keeping patient within their practice.
Issues with telemedicine
It’s not all that rosy a picture. There are (were) several barriers to telemedicine. Some of them have been relaxed due to COVID, however, challenges still remain.
State laws are complex and reimbursements are varied across payers. Make sure that you understand your reimbursements well enough before you get started.
At a minimum, you need to understand the parity laws for that state, the limitations of locations in your state, the types of telemedicine allowed in that state, the covered services, who the eligible providers are (whether your specialty can even use / offer these services), whether you can e-prescribe or not, whether you need patient consent or not (there are specific rules around patient consent).
Still not a complete exam
Doctors in specific specialties still will not feel 100% comfortable with telemedicine or televisits. Take ophthalmology as an example – tele refractions have been around for a while now, but still do not have a great deal of traction; primarily because of questionable reliability.
While it can solve problems, it is used essentially as some form of triaging. E.g. a patient might complain of bilateral itching and can be sent antihistamine drops. However, this also depends on whether the patient and provider state allows e-prescribing for these scenarios or not.
Meanwhile, if a patient presents with flashes, floaters, vision loss – this may need immediate in person evaluation.
In ophthalmology, as an example, most anterior segment conditions can have some amount of telemedicine evaluation.
This is not a problem with telemedicine as a concept in general. It’s a problem with perception – telemedicine cannot be thought of as a replacement to a full, comprehensive exam. In many provider groups, there will certainly be cases that cannot be diagnosed via telemedicine. In such cases, triaging is important and that in itself contributes to the success story of telemedicine.
Should you take advantage of telemedicine?
Deciding to take the take the leap and implement one or more variants of telemedicine in a practice is a big decision to make.
There are costs incurred, training that must be undertaken, and there is likely also the concern that patients won’t respond well to it.
These are all valid and good concerns for a practice to have; their business is to provide high quality, efficiently delivered care to patients, and if it isn’t done to a certain degree of satisfactions, patients are apt to look elsewhere for their care.
The best advice is to look at the practice’s strategic goals for the next few years to see what telemedicine modality will make the most sense. Are you in primary care practice looking to fully embrace PCMH?
Perhaps then extending hours through e-visits might be a good test case. A dermatology practice may look at store-and-forward.
A cardiology practice that is part of an ACO may look at partnering with the ACO on a remote monitoring initiative.
As with any project – and especially an IT project – there will be hurdles and frustrations; nevertheless, telemedicine has thus shown promise to increase efficiency and lower some costs in healthcare, and its consideration ought to be part of any practice’s strategic planning discussions.
#1 Example telehealth solution – occupational therapy
Here’s how we helped an Ergonomist and Occupational Therapist working in the field of injury prevention for hi-tech, insurance and healthcare enterprises.
Much like any service based business, our client understood that the only way to grow revenues was to add more staff / increase headcount. The more headcount they added, the more the overheads – in other words, profit margins kept getting smaller. Increased headcount also led to higher revenue & cash flow requirements… all the problems that you know very well.
The basic idea was to do the following:
- Acquire – Generate more patient leads with a “foot in the door” offer, at a low cost of acquisition
- Convert – Provide tangible value to these new patients with this low priced offer. This is serviced with minimal effort from our client’s side.
- Nurture – Be in regular contact with these new patients, provide tangible value and aim for the larger business – being introduced to the companies these customers work for.
- Up-sell – Present these initial customers with a slightly higher priced service offering that isn’t a big ask from these new leads. For this, only two pictures were required from the customer. Again, this was also serviced with minimal effort from our client’s team.
How it was executed
Our customer launched a simple mobile app that allows their providers to achieve all of the above (telehealth doesn’t necessarily need to be a mobile app).
The mobile app presents 4 paths to help someone with aches/pains (patient)
- Self assessment – the patient is asked a series of questions to help them with their aches and pains
- Solutions for body discomfort – wherein the patient can click on various body parts to identify self care and ergonomic tips.
- Help videos – helps the patient make immediate changes to their posture with self help videos
- Ergonomic equipment recommendation – helps the patient choose from various products to ease their aches and pains.
Facebook was a perfect venue for advertising the app. Considering the segment that the app was going to help, this would have been a very large audience.
The app was advertised on Facebook with a small ad spend of $5/day (of course, proper audience creation, segmentation etc was done to identify the right kind of audience and show the app to only these users).
In fact, the audience was limited to California as well since it provided more than enough ROI.
Mobile app downloads were achieved at a very low cost per acquisition.
The “foot in the door” offer was for patients to immediately see value in an ergonomic consultation.
Approximately 80% of people that downloaded the app used both the self assessment.
Approximately 20% of these users also used the various solutions the app provides for body discomfort.
About 35% of these users that downloaded the app also signed up to hear more directly from the practice
About 20% of the users that answered various assessment questions, also signed up as a lead to hear more from the practice
To service this “foot in the door” offer, the practice owner and their team didn’t have to spend a single minute. These assessment questions and the solutions for various body discomfort were all canned responses.
In other words, the initial “foot in the door” offer was a raging success !
Nurture – Be in regular contact with these new patients.
All leads that were signing up to hear more from the practice are constantly nurtured via various methods.
Push notifications – there are several ways that the practice is staying in touch with their patients. Push notifications is one of them.
As an example, when a patient is seen using the app within the past hour (i.e. they are actually active), a push notification is sent to remind the patient to take a 2 min break and stretch every 30 mins of sitting at their desk. This has a dual purpose. First, for people that are really using the app, it keeps them engaged and helps them achieve their goals. On the other hand, if someone hasn’t opened the app in the last hour, it doesn’t bother them at all.
Does that mean that the practice is not going after these “inactive” patients? Nope !
Campaigns are set up and regular push notifications are sent to patients that have downloaded the app but are not using it actively. The practice also monitors the conversion rates of these mobile users.
For patients that have already provided their email address or phone number, they are nurtured via email/ SMS providing various occupational hazards and tips on how to avoid them.
Up-sell to existing patients
The idea was to present these initial customers with a slightly higher priced service offering that isn’t a big “ask” from these new patients.
Once we saw that people were interacting with the app and using the various self help and self assessment areas of the app, it was now time to up-sell these customers to a personalized recommendation. We called this “Ask an expert”.
Of course, for their regular practice, this would require an in-person visit from the patient or if this was being done at a contracted enterprise, the team would have to make in person visits to their offices.
Instead, this up-sell, again, required minimal inputs from both the patient and the practice team.
The patient was asked for a single picture from the side of them sitting at their desk (capturing the computer, keyboard and their feet). This allowed the practitioner to “virtually” see the patient and immediately recommend posture changes, recommend any changes to various equipment in use in addition to recommending any alternate desk/chair options.
This was a very easy up-sell as the patient had just undergone self diagnosis, already obtained a lot of tangible value from the get-go.
#2 Example telehealth solution – ophthalmology
As is well known, diabetic retinopathy is the leading cause of blindness in the USA (mostly for adults 20-74 yrs of age). About 30 million Americans and 414 million people worldwide have diabetic retinopathy. With early detection, vision loss is preventable in up to 95% of the cases.
AAO, NCA and NQF recommend annual retinal exams for diabetic patients – however, only 20-50% really comply. These are assumed to be due to various reasons including, but not limited to:
- Lack of patient awareness and education
- Lack of access to healthcare and even more so, specialists.
- Patient logistics are usually the biggest factor.
Even though retinal exams are to be included in NCQA HEDIS and CMS STAR ratings (and even for CMS ACO diabetes management), despite the fact that DRE compliance increases incentives under HEDIS/STAR ratings, compliance has been poor.
Fort Drum Regional Health planning organization had started a telemedicine based diabetic retinopathy screening program where 95 % of the target population live in a health profession shortage area (HPSA) across various sites (see here). In less than a year after launch, they reported pretty promising results here.
As reported numerous times, the main challenges of patient logistics are due to the current workflow (as below)
- A patient visits their PCP for a check up (not necessarily related to diabetic retinopathy)
- The PCP office knows that they are supposed to do yearly retinal exams (well, many PCP offices are not equipped with this clinical decision support system either).
- The PCP office refers the patient to a specialist office (ophthalmologist). They typically do so by handing the patient a note or a referral pad referral.
- The patient leaves the office – there’s no further follow up.
- A minority of those patients call the ophthalmologist offices (specialty – hence, they are already backed up)
- The patient faces barriers in setting up an appointment with the specialist office
- Finally, and when the patient does get an appointment with the specialist office, they may or may not show up.
- Even when the patient does actually show up for the visit, the encounter/visit notes may or may not be sent back to the PCP office.. Therefore leaving an open care loop.
An ophthalmology group in NYC that deals with a large diabetic population wanted to offer teleretinal screening services to their referring partners.
This not only assisted in medical marketing for them but at the same time extended patient compliance in addition to assisting the primary care providers to meet their yearly CDC screening goals.
How it was executed:
In this particular case, the PCP office was responsible for patient acquisition, identification for retinal screening cases and therefore the ophthalmology group depended on the PCP offices.
The PCP office would create the patient as a new screening case to be diagnosed. They would then upload their images (right and left eye) to the web portal. This would send the alert to the retinal specialists on staff at our ophthalmology group and the specialists would immediately diagnose the images.
More often than not, while the patient was still at the PCP office, the PCP would get a report back. The system would generate a report with all information and notes necessary for billing purposes as well.
For patients that were diagnosed with NPDR, the PCP office could immediately send an electronic referral to the ophthalmology group so the patient compliance was already expected to be higher.
While WelchAllyn and retinalscreenings offer a slew of retina specialists that grade images, this does not help individual ophthalmology practices generate new patient business. Using those existing services is like listing themselves on ZocDoc – you cannot predict the amount of business you can generate, because every retina specialist is already on those networks.
Since the patient referral was generated immediately and the patient got an appointment before leaving the PCP office, the problem of patients forgetting to follow up with the specialist office was entirely eradicated.
That was it – the ophthalmology group was able to serve their referring partners above and beyond what they expected, many more diabetic retinopathy cases were determined as well.
#3 Example telehealth solution – skilled nursing facility
Skilled nursing facilities face a severe shortage of workers. As it is there is a documented shortage of primary care physicians and the gap keeps getting wider.
On top of it, SNFs have been known to have a shortage of direct care workers. Add to this, the primary care shortage – makes matters even worse.
The fact that a majority of baby boomers are above 65 and will soon be entering into the purview of skilled nursing facilities, this acute shortage needs to be addressed.
One way to deal with this is to provide primary care providers on call. This is exactly what one telemedicine company wanted to do – they had a roster of USA licensed physicians that were ready to provide on-call services.
This is not a new business model per se, as primary care providers have been provided on an on-call basis for a while. However, in this particular case, the telemedicine company wanted to provide video and voice calling facilities to the skilled nursing facilities.
The basic idea was that when the SNFs would face a volume of patients without having enough primary care providers on site, they would immediately book an appointment with these on-call doctors. Each provider would have VPN access to the EMR of the skilled nursing facility hence would have the ability to look at patient records as well as update with diagnosis and treatment/care plans.
The idea was executed quite simply – the nurse would create appointments on available providers’ calendar. The provider being on call, would always have their calendar up to date. At the time of the call, the provider would read the nurse’s note for the upcoming patient video call, login to the SNF’s EMR, read the patient chart and thereafter, start the video call. While on a video call with the patient, the provider would take as many notes as needed and as part of the after-call-work (ACW), they would update the patient’s record on the SNF EMR to reflect these notes.
At all times, these recordings needed to be available for audit and security reasons, stored on a HIPAA secure infrastructure.
That’s about as simple as it is.
There are several ways you can take advantage of telehealth – whether it is store and forward, e-visit or remote patient monitoring.. that’s truly a business decision for you to make.
Stay tuned for medical billing updates on telemedicine.