Home telehealth’s big promise for population health
By John Rossheim | February 6, 2020
For example, when Centura Health of Colorado and Kansas augmented its home health program with call-center-based registered nurses, there was a 62% decrease in 30-day hospital readmissions related to congestive heart failure, chronic obstructive pulmonary failure, and diabetes, according to a Commonwealth Fund report. Emergency department visits, nurse home visits, and overall costs also dropped sharply.
There are still many challenges to widespread adoption of telehealth, such as tech glitches, legal and regulatory concerns, and the cost of investment and training. Insurance companies are slow to adapt, making reimbursement complicated. Still, the successful results some telehealth programs have seen are encouraging.
Telehealth can improve doctor-patient relationships
Some clinicians have worried that their clinical conversations would suffer when their faces and voices were converted to bits and bytes, but most say it hasn’t worked out that way. Virtual healthcare offers patients faster and more efficient access to providers, who, in turn, are able to make the most of their time with each patient. Better access translates to more consistent, ongoing care.
The ease of scheduling, conducting virtual visits, and monitoring vitals from afar can be quite appealing for patients, especially those with ongoing conditions. “There’s a huge quality impact for homebound, chronically ill patients, and an opportunity to increase access to various populations and parts of the country,” says Bryan Arkwright, vice president of innovation at SCP Health and an adjunct faculty member at the Wake Forest University School of Law.
In some circumstances, it’s actually safer to schedule a quick virtual visit if a patient suspects they have something contagious; this can be especially important for staffers and other patients who might be immunocompromised.
Telehealth primary care can also reduce expensive and often avoidable emergency room or urgent care visits that are giving doctors and hospitals a run for their money. “I sometimes do virtual visits on weekends to keep patients out of urgent cares and ERs, so that they don’t have to explain their whole history to a doc who’s new to them,” says Dr. Reale.
The elements of remote monitoring
Telemonitoring the vital signs of patients in home care is a trend still in pioneering stages, and right now the options are limited to stats like blood pressure, respiration rate, blood sugar, body temperature, and weight.
CareMore Health System uses remote monitoring for congestive heart failure, hypertension, and diabetes patients, especially after hospital discharge. “If these patients do need intervention — a change in medication, an extra visit — alerts are sent to us,” says Sachin H. Jain, M.D., president and CEO of the multistate provider.
Since 2017, DaVita, a network of kidney dialysis centers which has 24,000 home dialysis patients, has used remote monitoring with dialysis patients at high risk, often because they’re unable to manage at home without frequent check-ins.
DaVita monitors home patients’ blood pressure, weight, and temperature with Bluetooth-connected devices, and asks patients to complete a health questionnaire each day. Nurses and physicians can be joined by dieticians, social workers, and family members in a video check-in with the patient.
Each practice must also make decisions about which staffers are appropriate to offer telehealth services. Advanced practice providers such as nurse practitioners and physician assistants may be able to see patients in video visits and, for many low-acuity cases, create a treatment plan. A practice can give many of its doctors the option to see patients in dedicated time slots; alternatively, one or two physicians may specialize as virtualists.
Costs, reimbursement, and regulation
Primary care practices and specialty care providers must contend with the up-front costs of telehealth home care, such as staff training and specialized video-conferencing software. “It’s definitely an investment right now, partly because the patient population hasn’t caught up with it,” says Baker. “We’re not at the break-even [point].”
The challenges of telehealth ROI are substantial. Some 83% of providers said they plan to invest in virtual care, according to a 2017 survey cited in an Advisory Board report. But only 21% of providers report a highly successful return on their telehealth investment.
One surprising benefit for providers is that periodic virtual check-ins and remote monitoring of chronically ill patients can provide a very predictable revenue stream, Arkwright says. Arkwright does caution that “though the ROI for a home-based chronic program can be very strong, it can be a heavy lift.” On the flip side, a telehealth program for people with diabetes could cut their average annual emergency department visits from five to one or none.
The 50-state patchwork of policy, law, and regulation governing delivery and reimbursement for telehealth services is a final stumbling block. Each state’s Medicaid program has its own rules on telehealth reimbursement. And multistate private payers may treat telehealth claims very differently according to where they are filed, Arkwright says.
However, telehealth initiatives are beginning to see progress on reimbursement. Starting in 2020, changes to federal law will enable Medicare enrollees to obtain additional telehealth benefits via more providers in more parts of the country, both urban and rural.
With its promise to deliver faster care and more effective home monitoring at lower cost, telehealth is on track to be more widely adopted in the 2020s. Whether telehealth will become pervasive enough to help solve healthcare’s value crisis remains an open question.
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