When I started in this business in the mid-’90s, the idea that we could deliver high-quality care with the patient and clinician in different places was viewed, almost universally, with great suspicion. Those of us who embraced that vision put lots of effort into research that showed how virtual care delivery was of similar or sometimes better quality than in-person care. We used whatever bully pulpit we could to educate audiences that telehealth existed and could deliver high quality care. In the mid-’00s, we focused on economic sustainability and integration into clinical workflow. The ‘10s birthed the era of large-scale and consumer-focused telehealth businesses and the concept of virtual urgent care. As of August 2019, 0.19% of healthcare insurance claims were telehealth claims.
The pandemic was like a crack of thunder and a bolt of lightning in the middle of the night. Everyone gained experience with telehealth, and most of it went well. As of February 2021, 5.4% of healthcare insurance claims were telehealth-related, which has remained steady month by month. That is a 24-fold jump from the summer of 2019. Is that a victory?
I will return to that question, but first let’s address the fact that the conversation around telehealth has changed dramatically. It is an integral part of healthcare delivery now. The question is no longer “Does it work?” but rather we’re now asking, what are the optimal scenarios for telehealth and the right mix in the care delivery landscape?
In the ‘90s, I used to say there would come a time when we dropped the “tele” and it would just be “medicine.” I also said that I would not need to evangelize anymore and could perhaps find some other ax to grind. Thirty years later, although the content of my stump speech has changed, I’ve not had the temptation to declare victory and move on. In my view, we’ve not reached the point where we can confidently drop “tele” and assume that virtual care will find its equilibrium in the greater scheme of care delivery.
Returning to that 24-fold increase in telehealth claims I mentioned earlier, it’s important to note that 68% of that is attributed to behavioral health claims. There is no question that behavioral health was the big winner of the great telehealth experiment of 2020, and that is a beautiful thing for patients who need those services. The flip side is that most of the rest of what we’re calling telehealth is virtual urgent care, which, as noted above, really took off in the five years before the pandemic.
There is still plenty to evangelize to reach the goal of optimally integrating virtual care into the care delivery mix. Here are some things we can focus on to get us there more quickly.
- Take it seriously and act professionally. Something about the internet leads us to an informality, and that does the telehealth community no good. The goal of all practitioners should be that any telehealth encounter is as essential, high-quality, and serious as an in-person visit. There has been some erosion of trust around telehealth; we must get it back to move to the next level.
- Convince payers that it is a genuine service with real value. All the arm-wrestling around reimbursement levels, decreased payment for telehealth, and incremental extensions of favorable regulatory policy sends a message to providers and patients that telehealth is a second-class citizen. This does no one any good. It is not intellectually honest. It is time for telehealth to sit at the grownup’s table and be treated like an honest service.
- Proactively identify which clinical scenarios are appropriate for telehealth. This one is on the provider side of the industry. We’ve been disappointingly timid and passive about this; my guess is because we thought that pandemic telehealth was a flash in the pan, so why waste the time and effort? Once again, it is here and not going away. If we don’t develop triage algorithms that guide schedulers and our software systems, we deserve to be threatened with lower reimbursement, as we will be adding redundancy with all those patients who show up for a telehealth visit but really need office-based care (and vice versa).
- Encourage, invest in, and work with technologies that naturally enrich the data coming from the patient. One of the reasons telehealth isn’t gaining faster momentum today is that there’s only so much information a clinician can glean from a video call (or an asynchronous message exchange). In many cases, the office visit is a more data-rich environment. It is unfair to compare what a clinician can learn from an in-person history and exam versus a video call. But the future is bright. Think about the power home lab testing can add to that clinician’s data set. Think about the power of wearables and devices such as Tytocare’s solutions (I have no financial relationship with them). If I can take a medical history via a video call and add physical exam findings using a tool like Tytocare and home lab test results (think a home strep test, for instance), that significantly expands what I can do with that core technology of videoconferencing.
I don’t know what the right mix of telehealth and in-person care is – or when I will feel that we can take the “tele” out and put our feet up and declare victory, but it is not in 2023.
This is my roadmap for a telehealth evangelist for the next few years. What’s missing?