Payer, Provider, Patient, and Professional Society: A Crash Course on Clinical Appropriateness

July 11, 2023

ID10118

To CiteDCA Citation Guide

00:00Anyway, thank you so much to all the
00:02panelists and the guests returning.
00:04It's a great pleasure to introduce Panel 4,
00:07which is going to talk about payer, provider,
00:09patient and professional Society of crash
00:12course on clinical appropriateness and I
00:14can't think of anybody more appropriate.
00:17To lead this session, then my good
00:20friend and colleague Judd Hollander.
00:22Judd is a Senior Vice President of Healthcare
00:25Delivery Innovation at Jefferson Health.
00:27He's also Professor of Emergency Medicine,
00:29really just a real visionary in the
00:32field of digital health, virtual care,
00:35connected care and built out the
00:37Jeff Connect telemedicine program.
00:39The urgent care program has been
00:42developing courses and certifications
00:44and really building infrastructure.
00:47To train a new generation of clinicians and
00:51providers in the delivery of virtual care.
00:54And I think this concept of
00:56clinical appropriateness,
00:57how we define it, how we implement it,
01:00how it meshes with our payers,
01:03how we come to build it into our training
01:06programs and certification programs,
01:08how our patients come to understand it,
01:10super important.
01:11So with that, Judd, I'll turn it over to you.
01:14Thanks, Lee. What, what?
01:16What a great introduction.
01:17Let let's go to the next three
01:19slides where I will comment probably
01:21the most visionary thing I've
01:23done in 2022 is select these three
01:25panelists who know much more about
01:27this topic than me and I'm going to
01:29let them introduce themselves and
01:31then we're going to do it a little
01:33different than the prior panels.
01:35So you know we'll we'll speak one at
01:38a time but the the people listening
01:41should feel free to interrupt and the
01:43panelists should interrupt each other.
01:45We, you know we we got an ER bent.
01:47Two of the panelists are ER docs with
01:50me and we used to you know no rules
01:52and a little bit of a free for all.
01:54So rather than just have one of us speak,
01:57we we got going to encourage
01:59the other two to interrupt.
02:01And we're actually going to encourage
02:03the people who are tending to put
02:05the questions in the chat and
02:06then I will interrupt.
02:08So we could engage in some
02:09really good dialogue.
02:10But I think I'll let each of the
02:12panelists quickly introduce themselves
02:13and then we'll get into the talks.
02:15Nick, please go ahead.
02:16Thanks, John.
02:17Honored to be part of great symposium.
02:20I'm the former Chief Digital
02:22Officer of Prisma Health,
02:23been with that health system for 19 years.
02:25Actually last Friday,
02:26November 4th was my last day there.
02:29As I move into new adventures as a
02:32strategic advisor to multiple companies.
02:34So great to be here, Ogden.
02:39Thanks, Chad, for having me.
02:39Thanks all for having me here.
02:42I'm an emergency physician on faculty.
02:43Yeah. I do a lot of work actually
02:45on quality and payment policy.
02:46And so it's exciting to
02:47engage in this conversation.
02:49OK And Lulu, also
02:52happy to be here, Emergency physician
02:54and director of Telehealth Education
02:56at Georgetown, good to be here.
02:58Okay. And what were we going in this order
03:00was Nick going 1st and Argin second.
03:02Was that the way we planned it, Okay,
03:03Nick shaking, you said yet, so.
03:05So we're going to do this and I
03:07think you know Nick's going to lay,
03:09I don't want to say the groundwork
03:10because we've had a whole day of hearing
03:13different parts of digital health,
03:14but but give you a perspective on how
03:16we can feed this into quality and
03:19clinical appropriateness And then Argin's
03:21background is phenomenal in this space.
03:24In terms of measure payment and pay
03:26for performance and and understanding
03:28that better than you know,
03:30certainly I do and probably many of you do.
03:32And we think understanding how it works
03:34in the real world is important for us to
03:36frame how it should be in telemedicine.
03:38And then Lulu's going to speak more
03:40towards the training side and because
03:42I just like to make the analogy
03:44for those of you who have had the
03:46wonderful life changing experience of.
03:48Going to a hospital and going
03:50up on a new EMR,
03:51you know when you go to work
03:53someplace where everybody knows
03:55the electronic medical record,
03:57they can show you on the fly when
03:59you're working your clinical shift.
04:01But when you go up on epic and the person
04:03on the right doesn't know how to do it,
04:04and the person on the left doesn't
04:06know how to do it and you all got
04:07to figure it out the same day,
04:09you need training and telemedicine is
04:11like that because before COVID existed,
04:14the older people didn't know how to do it,
04:16the mid career people didn't know
04:18how to do it and the younger people
04:19didn't know how to do it.
04:21So when you were going to learn how to do it?
04:23You need training and Lulu is going
04:24to speak to that as a leader in
04:26that area to tie this all together.
04:28But Nick, I'm going to turn it over to you.
04:30And remember, use the chat, use the Q&amp;A.
04:33Feel free to interrupt.
04:34And panelists feel free to interrupt as well.
04:38Great. Thanks, Judd. I'm gonna
04:39send me your control the slides
04:42just say next slide and
04:43it's controlled centrally.
04:44Perfect. So as we dive
04:46into our discussion day,
04:47I like to start off talking about the
04:49common perceived differences between
04:51traditional and digital health.
04:53As a take away from the next few slides,
04:55I hope we can walk away reimagine
04:57how we view digital health in the
04:59traditional care delivery system.
05:01Like other non healthcare verticals,
05:04digital solutions can be an enabler that
05:07can carve out instead of a separate carve
05:10out and preconsumed preconceived nuisance.
05:12You know since the high tech deck a
05:15lot of providers obviously when they
05:17think about new digital solutions.
05:19They're get worried because it may
05:21disrupt their workflows and cause
05:23more disruption in their work day.
05:24But really digital solutions
05:26have transformed how we bank,
05:27how we travel,
05:28how we watch movies and so many
05:30other services that we used
05:32in healthcare every day.
05:33So you know, healthcare shouldn't
05:35be any different than that.
05:36Judd,
05:37go ahead and go to the next slide please.
05:39So when you think about traditional
05:41and digital healthcare, you know,
05:43I I've been an internal medicine
05:45physician for almost 2 decades now
05:46and I've seen both sides of this,
05:48especially during COVID.
05:49And so most people think of
05:52traditional as fee for service.
05:53You know, they're focusing on those
05:55patients that come in the office.
05:56It's focused as traditionally
05:58to the baby boomer populations,
06:00those established patients,
06:02those folks that you've built the
06:04rapport over many, many years.
06:07It's also, if you think about it.
06:08More of a reactive,
06:10right.
06:10You're seeing chronic disease follow up,
06:11you've seen people when they're
06:13acutely sick and and you're not
06:15really seeing what's happening
06:16in between office visits and it's
06:18still very hard to get into most
06:20practices regards to access.
06:21It's also very tight tech light
06:23especially on the patient's side.
06:25Other than most likely they use some
06:27portals for their EHR data access,
06:30they're not really engaging in other
06:32things such as wearables and getting
06:34that real time access to data.
06:36Also long wait times,
06:38as we mentioned before,
06:39it's usually one way care.
06:41They need to be seen you try to
06:42go to see them.
06:43It's not more on demand care and
06:45it's it also limit a health system,
06:48you know prison health,
06:48the largest health system,
06:49South Carolina.
06:50And the only way we can expand our
06:52catchment area is to build new practices,
06:54more primary care practices,
06:57more multispecialty practices etcetera.
06:59But if you really infuse digital right,
07:01you can actually help you take
07:03care of a larger population.
07:04And so you think about more
07:06movement towards value,
07:07more towards population health,
07:09easier access, consumerism,
07:11those are things that really resonate
07:13when you think about digital,
07:15but they can coexist.
07:18Next slide.
07:19So we think about how we see patients.
07:22So before the EHR and even up to recently,
07:25we usually follow the the,
07:27the column above right,
07:29the horizontal that you see there.
07:31Now you see someone in the office,
07:33you,
07:33you change some diabetic medications,
07:35they're either doing well,
07:36you set up some Wellness
07:38things and they go off.
07:39You have no idea other than
07:40if they engage with you,
07:42what's happening with those patients.
07:44You don't know if their sugars
07:45are being well controlled,
07:46their blood pressure is well controlled,
07:47you don't know if they run
07:49out of medicines real time.
07:51And and so you're really kind of
07:53waiting for them to communicate
07:54with you and sometimes.
07:56They get sick before they can
07:57communicate with you and they end
07:59up in the emergency room or and if
08:01they get sick enough to get admitted
08:03to the hospital with digital.
08:04Think of it as a tool that enables
08:07you to take care of people real
08:09time and have that even sometimes
08:11astronous data that's coming in that
08:13gives you feedback on the patient.
08:15How their blood pressure doing,
08:16how their Sugar's doing.
08:17And then using automation to help
08:19escalate people to the right Ave.
08:20of care,
08:21the ability to know someone's getting
08:23sick before they know they're getting sick.
08:25Is what keeps people out of the
08:27hospital and allows for that
08:29more proactive care management.
08:30And so again,
08:31being able to take care of people
08:33at home before they get sick and
08:34even if they're about to get sick do
08:36hospital home and other types of activities.
08:38So this really is a merger of the two.
08:41The next slide Judd demonstrates,
08:44I know there's a lot of data on here,
08:46but bear with me for a SEC.
08:48So when you think about these
08:50two traditional versus digital
08:53forms of healthcare delivery.
08:55They really need to be merged.
08:56We need to stop thinking of
08:58them as two different things.
09:00They really need to be an enabler to
09:02enhance the traditional care delivery system.
09:05We're not going to up and healthcare
09:08delivery as we know it right now just to
09:10go 100% digital and and and we don't,
09:13we shouldn't expect it to be 100% digital
09:15now as our population has changed.
09:18You know with the millennials
09:19outnumbering the baby boomer population,
09:21they expect care to be delivered
09:23in a different way.
09:24They want more on demand care,
09:25but they also will still need
09:27the services of traditional areas
09:29such as being able to go get labs
09:31or ancillary services, imaging,
09:33go see a pharmacy,
09:34go to go to an ER if they need to.
09:37So how do you marry the two By using data,
09:40patient preference, that's CRM information,
09:43EHR data,
09:44social determinant data to then
09:46escalate patients to the right Ave.
09:48of care based on their preference
09:49and their need at the time.
09:51So if you think about it,
09:52setting up virtual primary care,
09:54seeing someone that's net new to
09:56your system or even established,
09:58but then no one based on your
09:59zip code to say, hey,
10:00there's a clinic right near you.
10:02I'm going to order some labs.
10:03I'm going to have you go get them there.
10:05And once I get those results,
10:06I'm going to call you back
10:07just like you would
10:08if you're actually seeing
10:09someone in the office.
10:10So think of it as a blending of the
10:12two orals in this conceptual diagram.
10:14Next slide. And lastly,
10:17I want you also to think about
10:19is not just ambulatory care,
10:22think of it about digital
10:23transformation across all care venues,
10:25the entire continuum,
10:26it's not just about at home care.
10:29It's also thinking about how
10:30do we enhance acute care,
10:32post acute care that remote
10:34patient monitoring in between and
10:36and so that your whole system is
10:38cohesive in this digital strategy.
10:40What I've seen as a digital
10:42officer for the last four years
10:43is that most people think about 1
10:45area where they focus ambulatory,
10:47potentially primary care,
10:48maybe potentially Pediatrics
10:50within primary care and then
10:52within schools within that area.
10:54But then you haven't really
10:55changed that whole ecosystem.
10:57So what happens in that situation is a
11:00patient can go from a very easy access,
11:02easy to see a provider to then going
11:05into something that's archaic to
11:06them and and so you really need to
11:09transform your digital experience.
11:11With your traditional altogether,
11:12not just focusing on one side and
11:15there's so many different components to
11:16this and and as the questions come up,
11:19I'm happy to go into it.
11:20But think of it at this at the
11:2240,000 foot level is infusing
11:24digital into traditional care,
11:26health,
11:26health,
11:26delivery and and making it simple
11:28and it's just one way of delivering
11:30healthcare and that's what you
11:31do throughout your health system.
11:34So Nick, I, I, I,
11:35I resisted the urge to interrupt you,
11:37although I was going to anyway at this point.
11:40And I got a question because one we've
11:42talked a lot about you know, hybrid care.
11:44We've talked a bit today about you,
11:47you know how digital care and
11:49regular care should you, you know,
11:51not just replicate the visit
11:53that we do in person digitally.
11:55But what I what I haven't heard a
11:57lot of talk about is no care. Right.
11:59There's a whole bunch of perfectly healthy
12:01people out there that that don't need
12:02to go for a regular doctor's checkup.
12:04Or do they?
12:05You're an internist and there's
12:06a whole bunch of healthy people
12:08out there in their mid 30s that,
12:10you know,
12:10why do they even need to go to the doctor?
12:12They need digital care.
12:14They need in person care.
12:15Or are they just perfectly fine with no care?
12:19Right. Well, I think this is comes into
12:20the whole concept of Wellness, right.
12:22So I'm not really too concerned about my
12:2518 to 40 year old demographic to you know,
12:28most of them are healthy and
12:29hopefully doing right things.
12:30But there's still an opportunity to
12:32influence that population from smoking,
12:34exercising, eating, right, etcetera.
12:36So those things don't catch
12:38up to him later on.
12:39So that no care is more to me,
12:41asynchronous care where you have an
12:43automated chat bot who's pushing you along.
12:46You see a lot of this happening
12:48already in behavioral health
12:49where a lot of people are doing
12:50asynchronous cognitive behavioral
12:52therapy and and helping themselves.
12:55And such an important part
12:56of Wellness and burnout.
12:58So 100% agree.
12:59I think that care is something
13:01that everybody needs.
13:03The question is what the level is.
13:05And and and that to the point,
13:06if you're at Defcon one
13:08meaning you're healthy,
13:09everything is good,
13:09things are moving along,
13:11but you're what you you're also
13:13getting ready you know for future events,
13:15searches, Wellness exams.
13:16I also want to make sure that you stay
13:19healthy by exercising eating right,
13:21etcetera,
13:21which then helps your insurance and
13:23your premiums and your longevity.
13:26Good. Thanks. Any other questions
13:28for for Nick before we move on?
13:30We'll come back to group
13:32questions later at the end.
13:34All right, Adjun, take us away.
13:35Take us into the real world
13:37and how we determine what's
13:38appropriate and what's quality.
13:40Thanks, Jeff.
13:42So I know everybody here has probably
13:44seen this New Yorker piece around the
13:45promise in Paris of virtual care.
13:47There's a whole section on it that
13:48I know is going to lead into the
13:51next panel actually around parody.
13:52And I will sort of say one thing that
13:54I think is a little provocative here,
13:56which is that the pursuit of parody
13:59is often at the cost of innovation.
14:02And what that means is that as there
14:04is more and more effort made to say,
14:06get payment parity for telehealth
14:09or virtual care services,
14:11you start essentially restricting the
14:13care model to the rules of today's game.
14:16And there's a lot of status quo,
14:18there's a lot of rules,
14:19there's a lot of things already
14:21baked into how we bill and how we
14:23pay for a variety of office based
14:26in person healthcare services.
14:28And what can end up happening is the
14:30pursuit of that parity essentially takes
14:32away what makes virtual care so innovative.
14:34And so I asked this question,
14:35It's like,
14:36is telehealth parity the goal?
14:37I could probably should have
14:38made the side of it more specific
14:40to say is telehealth quality.
14:41The parity, the goal.
14:42And the reason I say that is
14:44we are embarking on,
14:45you know,
14:45what has started with the
14:46Affordable Care Act.
14:47In many ways we are now at another inflection
14:49point of value based care delivery.
14:51The consensus definition people
14:52use for value based care is that
14:55value equals quality over cost.
14:56If you get cost parity by
14:58getting payment parity,
14:59then we're going to judge quality over
15:01that same cost and we're going to
15:04essentially create a value equation
15:05for virtual care and telehealth.
15:07It starts getting hindered by all
15:08the problems that quality and value
15:10measurements had for the past decade.
15:11And so I think to be more disruptive
15:13and to be truly innovative.
15:15And for all the wonderful ideas I've
15:16heard being part of this conference today,
15:18it's really going to be thinking
15:19about how you find a third way out.
15:20How does telehealth really transform care?
15:23How does virtual care create a
15:25different kind of care delivery so that
15:27it's not the same rules of quality?
15:29Next slide.
15:31And this is a point actually I should
15:33say that Bob Branson brought up.
15:34I can Click to the next animation.
15:37So this is actually a graphic from Phillips.
15:39I don't think they knew that they
15:40were doing it when they made it.
15:41But what I like about it is that the
15:43bottom blue row in their graphic
15:45there describes the traditional
15:46way in which quality measurement
15:48and quality is quality measures in
15:50healthcare have historically been
15:52created and that is by settings.
15:54And what it instead tells us the
15:55story where at least Phillips view,
15:56and I think folks in part of this
15:59world in this meeting today also
16:01view is that telehealth is this
16:03really transformative tool that can
16:04go across all of these settings.
16:06The problem is historically been
16:08in quality measures that for
16:09example in CMS is as the
16:10largest pair in the country,
16:12largest developer of quality measures,
16:14largest pusher of both quality measures
16:16and value based care models has quality
16:18measures specific to each of these worlds.
16:20You can have, you know they have
16:2210 measures that make up the core
16:24set for skilled nursing facilities.
16:25Those have nothing to do with the
16:27separate set of measures that exist
16:28for longterm acute care facilities.
16:30Almost nothing to do with physician
16:31level measures that live in a
16:33lot of these new registries.
16:34And so the world of quality measurement
16:36as it currently exists has never
16:38achieved its goals of pushing
16:40broader healthcare quality forward
16:41or improving health and outcomes,
16:43because it's lived in all these separate
16:45little silos of quality measurement.
16:47And if telehealth were to do the same thing,
16:48telehealth and virtual care were to say,
16:50well, we should just, you know,
16:51add another box to the bottom of that line
16:53that says virtual care after specialist home,
16:56we need virtual care quality measures.
16:58I've seen that happen time and
17:00again with almost any new specialty
17:02that it comes into medicine,
17:04with almost any new sort of care
17:05model that comes into medicine.
17:06The first default is we need
17:08quality measure parity,
17:09we need some quality measures for us.
17:11Other people are developing quality measures,
17:12not by us.
17:13And what you end up with is
17:15this cottage industry.
17:17Of segmented quality measures that
17:19don't really allow the settings
17:21to work across themselves and
17:23for healthcare to move forward.
17:25So I can
17:26interruption #1.
17:27So this is very location specific, right?
17:30And and do should we take care
17:32of people differently if they're
17:33on the third floor or the 5th
17:35floor or is it really should it
17:37be focused around whether they
17:39have diabetes or heart failure or
17:41maybe diabetes with heart failure.
17:43Yeah. So this comes up in the
17:45quality measure world all the time.
17:46We take heart failure patients.
17:47And if you qualify for an inpatient
17:50admission for your heart failure versus
17:52an observation stay versus an Ed visit,
17:55we essentially evaluate the quality
17:56and what a good outcome is wildly
17:59differently between those things,
18:00we segment between those things.
18:02But for the patient,
18:03that's all the same.
18:04Heart, right.
18:05And so I think that this is a place
18:07where telehealth actually has this
18:09opportunity where if we think of virtual
18:12care as a population based tool,
18:14if you think of measuring the quality
18:16of virtual care for a population of
18:18people with diabetes or with heart
18:20failure as opposed to how good was
18:22their telehealth care in the emergency
18:24department for heart failure,
18:26we actually advance this and make
18:28much bigger strides. Next slide.
18:32This comes from the AM A and you know,
18:34they started to do some early work
18:36on creating frameworks for thinking
18:37about how we measure value in digital
18:39care and value in telehealth.
18:41The things that I like from this graphic
18:43that I think are worth pointing out is
18:44that when they think about the domains
18:46of healthcare quality and this was,
18:48you know, an inside baseball conversation,
18:50largely people from the virtual Care
18:52World that were constructed the document.
18:54The domains they come up with are
18:56very similar to their original
18:57ILM domains of quality,
18:58very similar to the domains of quality
19:00using the CMS quality strategy,
19:01clinical outcomes, quality and safety,
19:03access to care, patient and family,
19:05caregiver experience,
19:06clinical expertise and then
19:08financial and operational impact.
19:09I personally think that one of the
19:11challenges that exist right now if
19:12you were to do a scan of telehealth
19:14or virtual care quality measures,
19:16is that because there's been sort
19:17of a growth of some simple measures
19:19or early measures that are specific
19:21to virtual care themselves.
19:23They've been heavily focused on patient
19:24and family and caregiver experience
19:26and some stuff on clinical experience.
19:28And that's not to say that we can't make
19:30a much better experience for patients
19:32when they engage with virtual care.
19:33And it's not to say that clinicians
19:35may have a much better experience
19:37providing virtual care, but I.
19:39I think with the mistake that gets
19:41made with done with that is that it
19:42doesn't achieve the point of quality
19:44and value based care and quality
19:46measurement which is to advance health
19:48outcomes improve well-being and to do
19:50that for the whole person not just
19:52sort of within the silo of a single
19:54touch point or a single episode of
19:56care that might occur next slide.
20:00This is a side that does not come
20:02from the virtual care model is at all
20:04but I think it's one that if you're.
20:05Part of where sort of Healthcare
20:07is going you need to be aware of.
20:09It actually comes out of CMS&amp;HHS
20:11and it comes from sort of the
20:13post Affordable Care Act.
20:14Free COVID time is what I call that
20:17time period and what it describes
20:18is what the hope was for what value
20:20based care alternative payment
20:22models would do in healthcare.
20:24Category one is a world in which
20:26all payment is just fee for service.
20:28And sadly,
20:29while it would look great
20:30that in the future state,
20:31there's very little fee for service
20:34payment in most organizations.
20:36Even in most organizations that
20:38have robust virtual care programs,
20:41A/C O's developed a bunch of
20:43things deployed outwards.
20:44The highest numbers you'll see is maybe
20:4630 to 40% of their payments that have
20:49moved to category two and category 3.
20:51Where most of the world in
20:53healthcare today is,
20:54is for many things in category one,
20:56because we don't really know what quality
20:58and value means for a lot of specialties,
21:00a lot of procedures,
21:01a lot of different things we
21:03do in care settings.
21:04They're sort of category two is
21:06done as sort of an afterthought.
21:08What that means is you get paid
21:09fee for service, but you say,
21:11but if I meet some quality
21:12target at the end of the year,
21:13give me a little bit of a bonus
21:15or take a little bit of a penalty
21:17and that's largely where we live
21:19in American healthcare today.
21:20There are glimmers of hope.
21:21The glimmers of hope are largely
21:22people who are in category three.
21:24That's things like affordable,
21:26sorry ACO's things along those lines
21:28that a lot of the CMMI payment models
21:31that try to start moving towards capitation,
21:34they start moving towards delivery
21:36organizations taking financial risks
21:38over the population of payment and then
21:40very little lives of category 4 those.
21:43Largely category 4 today in my mind
21:44happens in those rare instances
21:46where you've got a vertically
21:48integrated healthcare system,
21:49a health plan and a delivery
21:50organization that live under the
21:52same umbrella and those are both
21:54geographically sparse as well as even
21:55within those places fairly sparse.
21:57And So what that means is where's telehealth,
21:59the telehealth payment going to fall within
22:01this if you fight for payment parity,
22:03that's like asking for I just want the
22:05same category one as something else.
22:07And I think that that's going to
22:08be short stripped to me where the
22:10opportunity for virtual care is.
22:11Because it can flip the cost
22:13part of the value equation.
22:15If we can deliver high quality care,
22:16better outcomes,
22:17better health at wildly different
22:19cost via the virtual care model,
22:22it is perfect as a tool to help
22:24organizations get from category
22:252:00 to 3:00 and 3:00 to 4:00.
22:27And so that's where I see it being
22:29as a tool that advances payment
22:31reform as opposed to a tool that
22:33needs payment reform next side.
22:37These are sort of the last
22:37thing I'll close with,
22:38which is that these are some
22:39of the emerging areas that are
22:40happening in quality measurement.
22:41If you listen to what's coming
22:42out of CMS today about what they
22:43see in the quality measures that
22:45they're trying to invest in,
22:46develop in and where they're trying to
22:48push measures and where there's gaps.
22:49One is in HealthEquity.
22:50There was a wonderful discussion
22:52earlier today around the digital divide.
22:54And I think understanding how measurement
22:57can ensure that virtual care closes
22:59gaps as opposed to increases gaps in
23:02access to care will be important.
23:04There's a lot of focus on
23:05provider focused measures around
23:06burnout and physician experience.
23:08These are not end all be all,
23:09but there's a place that is
23:11essentially a desert.
23:12We have no measurement in this
23:13space at all and we know that it's
23:15essentially the healthcare delivery.
23:16And then there's a lot of measures
23:18being developed around usability
23:19of electronic health records and
23:21digital health technologies.
23:22I think that will touch the virtual
23:23care space that'll largely live
23:25within organizations.
23:26It won't be in the pay for
23:28performance space and
23:28so. That's my hopefully quick
23:30whirlwind of what's going on.
23:32So I think now we know how the
23:34world is going forward and the
23:36payment models are going to change.
23:37Arjun just described that for you.
23:39And and so lulu's going to tell
23:41us how are we going to get there.
23:43So we know how to deliver care
23:45when those payment models change
23:47and we could do more population
23:49health and more value based care.
23:51So Lulu, take it away.
23:54All right, so that is the question, right?
23:57How do we train clinicians to
23:59provide quality telehealth care?
24:01And it it depends.
24:02It depends on a few things.
24:04First, you'll want to define
24:07your desired outcome, right?
24:08If your desired outcome from
24:10the training is to teach someone
24:11the mechanics of telehealth,
24:13so how do you do a video visit?
24:15That's a pretty defined skill set,
24:17and it doesn't take that long
24:19for someone to pick that up.
24:21The more elusive outcome is teaching
24:23the concept of how do I take
24:26telehealth and use it as a tool to
24:28improve my patient's care experience.
24:30So that's number one.
24:32And the second question before jumping
24:34in is how are we defining quality care,
24:36right.
24:36So Nick and Arjun just touched on this,
24:38but healthcare traditionally
24:40very episodic discrete episodes.
24:43And so as a result,
24:44some of our quality metrics risk
24:46anchoring on these individual encounters.
24:49So in virtual care,
24:50that would translate to did this visit
24:53result in the right diagnosis or how
24:55much revenue was generated from this visit?
24:58And those are the wrong questions.
25:00To really assess whether a telehealth
25:03encounter fulfills these domains of quality,
25:05we have to step back and see where does
25:08that encounter fit in the bigger picture?
25:10How does virtual care augment?
25:13Those traditional episodes of care and
25:14then bridge the gaps between them.
25:16So once we have answers to
25:18these two questions,
25:19then we can work backwards and determine
25:21the right way to train our clinicians.
25:23Next slide.
25:26All right. So here we've defined
25:28the outcomes in the metrics.
25:30Now we can parse out what's the
25:32clinician's role and then we'll
25:33break that down into teachable steps.
25:35So for the remainder here,
25:36I'll use video visits as an example.
25:39I think we're all pretty familiar
25:40with that concept in telehealth.
25:42So next, first you'll want to assess the
25:46clinician's baseline fluency with telehealth.
25:48In the last few years, everyone's gotten
25:50a bit of a sprinkling of telehealth.
25:52But we shouldn't assume that
25:54exposure equals confidence, right?
25:56So assessing the baseline includes
25:58things like general proficiency
26:00with the computer and webcam,
26:02familiarity with the video platform,
26:05knowing what note type to choose for
26:06telehealth, encounter, etcetera, right?
26:08So establish the basics next.
26:12You'll want your clinician to
26:13check the technical boxes,
26:14so these are it almost seems
26:16too simple to even state,
26:17but these are such quick and
26:20easily modifiable ways to deliver
26:22a quality telehealth experience,
26:24and so that's ensuring adequate
26:26setup of lighting and broadband and
26:28a quiet space to work from. Next.
26:32All right, so when training clinicians.
26:34You want to provide regular feedback
26:36to allow for course correction.
26:39And especially important,
26:40as Judd mentioned,
26:41when we're all for the most part
26:43learning this at the same time,
26:45that course correction is really key.
26:47So when I'm working in the
26:48emergency department,
26:49I'm working alongside colleagues.
26:50We run cases by each other.
26:52It's a very collegial way to
26:54benchmark my practice patents.
26:56And it's a lot harder to achieve
26:58that with virtual encounters,
26:59but arguably more important,
27:00because when it comes to a lot of telehealth,
27:03there isn't really a standard
27:05of care out there yet.
27:06So I do want to know under which
27:09circumstances my colleagues are sending a
27:11patient in for in in person evaluation,
27:14if they see a patient with cough,
27:16how many of them are getting
27:17sent in for an outpatient X-ray.
27:19And this transparency of comparison is
27:22how we how we develop best practices.
27:26Next you want to establish super
27:30users within the service lines and
27:33encourage peer-to-peer teaching so
27:35those relationships already exist
27:36out there within departments,
27:38within groups that have worked together.
27:40So use that network to your
27:42advantage and encourage both more
27:45personalized teaching and as a result
27:47better learning and retention.
27:49So in fact one node.
27:51Tell them to go on and infect a
27:53dozen more and that'll be way more
27:55effective than any one-size-fits-all
27:56teaching that you can try to apply.
27:59Next,
28:01you want to encourage your clinicians to
28:04lean into the advantages of telehealth.
28:07As mentioned several Times Now,
28:09we're not trying to take in person care
28:11and replicate it virtually, right?
28:12We're using a little bit of technology,
28:14but we're trying to really improve
28:17the traffic light coordination
28:18dance that is patient care.
28:20As Arjun mentioned,
28:21telehealth has an innate advantage when
28:23it comes to a few quality metrics.
28:25And so these are the metrics we should
28:27be delivering on as much as possible,
28:29right? These are timeliness,
28:31patient comfort,
28:32lowering barriers to access.
28:35Telehealth has some advantages.
28:36These are some of them.
28:38We should really lean into that.
28:40The flip side of this is.
28:42You got to be honest about your limitations.
28:44So to borrow an example from one
28:46of my mentors, Ethan Booker,
28:47if you imagine you have a patient
28:49who calls in to on demand your
28:51on demand platform overnight.
28:53They've got chest pain. But yeah,
28:55he's pretty sure it's just heartburn.
28:56He really doesn't want to wait
28:58in the Ed for 12 hours.
28:59If you ultimately prefer this
29:01patient into in person care,
29:03is that a failure of telehealth?
29:06I'd argue no, right?
29:07It's an appropriate use of telehealth.
29:10As a stepping stone in this
29:11patient's care pathway,
29:12which is exactly how it should
29:14be intended to be used.
29:16All right, And then next last one.
29:18Here you want to emphasize the
29:19value of hands on practice.
29:21So virtual care is like any other skill.
29:23You get better at it with practice.
29:26You can do this with simulations
29:28or standardized patients.
29:30Some some aspects that are
29:31specific to virtual care you
29:33want to practice troubleshooting,
29:35audio and video connectivity issues.
29:38Anticipating that a number of your
29:40patients are going to run into those?
29:42Be creative with the tools
29:43that you have at your disposal.
29:45Ask your patient to pull out
29:47their home pull socks,
29:48or if you're using Zoom as your platform,
29:50you can screen share to explain
29:53particularly complicated concepts.
29:55Understand that there are
29:56some benefits there.
29:57And then most importantly with
30:00experience also knows also comes knowing
30:03when telehealth isn't the answer,
30:04right?
30:05So when we're training a surgeon
30:07to provide quality care,
30:09the best lesson is to know when not
30:11to cut and similarly goes for telehealth.
30:14So the bottom line to all of this
30:15is that we can't really think of
30:18delivering or teaching quality
30:20telehealth as a technical skill to be taught.
30:22There are technical components,
30:23but really we need to be thinking about
30:26it as restructuring our framework,
30:28our mental framework of how we deliver care.
30:31All right.
30:32That's all I got back to you, John.
30:34All right. So thank, thanks.
30:35So I really have a question for everybody.
30:38It to me, it seems kind kind of
30:40obvious that if you got to invent a
30:43healthcare system from the beginning,
30:46would you build what we have right now?
30:49And I would.
30:50Bet that there's not a single human
30:51being in healthcare who would answer,
30:53they would do that.
30:55So I I think summarizing what we heard here,
30:59telemedicine is 1 component
31:00of a care delivery system.
31:02And too many of us even today have talked
31:05about telemedicine like it's a thing.
31:08It's not a thing.
31:09It's like the cardiologist on the
31:11third floor isn't different than
31:13the cardiologist on the 5th floor.
31:15It's the ologist that's the
31:16thing that's important,
31:18not the modality that they get.
31:20There, we need to quit.
31:22And I think Arjun said this nicely,
31:24we need to quit segmenting things.
31:25I'm going to steal that word
31:27and use it more often.
31:28It's not telemedicine versus
31:30inpatient care in person care.
31:32We have to stop thinking that way.
31:34You saw a great slide that look like
31:37a Doppler effect that Nick showed you
31:39where we could provide better holistic
31:41care if we integrate these things together.
31:44And we need to do as Lulu said,
31:46what's best in any specific situation,
31:48finding someone on telemedicine.
31:50And sending them to the ER,
31:52it's not a fail, it's a good thing.
31:54We identified someone that
31:55needs to be in the ER.
31:57To me, the medicines, the medicine.
31:59So if you're looking at
32:01pay for performance yet,
32:02yet you know metrics or quality metrics,
32:05diabetic having not getting renal,
32:08failure, not having a stroke,
32:10that's an outcome we should desire.
32:12And again, condition specific,
32:14not location specific,
32:15but there are some tricks.
32:17You need to know how to work the toys.
32:20I I mean you needed to learn how to use
32:22a stethoscope and an otoscope and an
32:24ultrasound machine and other things.
32:26So this is just another one of
32:28the tools we can use to take care
32:30of patients And and then I do
32:32think we get lost way too much in
32:34comparing it to in person care and
32:37and that's been a recurrent theme.
32:39But,
32:39and we all think and there
32:41is a digital divide,
32:42I'm not taking that away,
32:44but there are multiple studies now that
32:47show telemedicine can actually improve
32:49access and reduce some inequities
32:51despite the fact some people may
32:53not have access to the technology.
32:55Because those people happen to be the
32:57same people that don't have a car or
32:59a ride or a way to get to the doctor.
33:02And so really we're going to end
33:04up with office visits and home
33:06care and digital technologies.
33:08Combining.
33:09So we get the best of both and
33:12I think that's all way forward.
33:14Where we are going to fail is
33:16if we keep comparing a new thing
33:19we do to an old thing we do.
33:21So I'll give you a really
33:24easy example if you
33:25come in to get sutures removed.
33:28Some nurse takes your temperature
33:30and all your vital signs.
33:32If you are perfectly healthy, that's a waste.
33:35When I look, you don't need that.
33:37That's just like an inefficient thing.
33:39That nurse would be better using
33:41their time to be with somewhere else.
33:43So I think that as we learn how to do
33:45things on telemedicine and we can't
33:48listen to everybody's heart and lungs,
33:50let's not try and go back and listen
33:52to everybody's heart and lungs.
33:54Let's try and learn.
33:56In person, what can we cut out
33:58of the visit because it's low
34:00yield and not efficient and and
34:02I think we'll do better that way.
34:04So that's kind of my summary of it.
34:07But you know,
34:07I'd I'd love for other people to give their
34:09thoughts and throw out some questions.
34:11We got really smart panelists
34:13that I put together.
34:14So pick their brains,
34:15please.
34:24That was awesome. Judd.
34:26That was really a provocative I I
34:29guess let me just throw a question out.
34:31To Arjun, which is I think you alluded
34:34to the fact that you know most of
34:37our pay for quality is in is a sort
34:39of a back of the envelope reaction
34:41to a fee for service delivery model.
34:44And that it's beside process measures,
34:47it's actually really hard to construct
34:50meaningful quality equations.
34:52So if you were going to pick
34:54some areas or you were going to,
34:56you know you made you head of CMMI for a day.
34:59And you could actually launch some some
35:02demonstration pilots in specific areas.
35:04Are there some places that you'd
35:05start with where you think that that
35:07telehealth slash virtual hybrid care
35:10could really show substantial value?
35:13Like what, what, where would you start?
35:15Yeah, I mean, Full disclosure because
35:16I'm working on this one right now,
35:17but like one model people may be aware of
35:20is CMMI has a model called E T3 emergency
35:23triage transport and treatment model.
35:25And what this allows is you call 911,
35:28that's a current model everybody's
35:30used to ambulance comes to your house.
35:33If that ambulance service provider
35:35is participating in the model,
35:36they can now provide you with
35:38telemedicine services at home and avoid
35:41a transport to the emergency department.
35:43That's a really innovative way
35:45of thinking about using a little
35:47bit of what we have in in person,
35:49bricks and mortar care,
35:50combining it with virtual care
35:51to something that can really,
35:53really increase value because now
35:55I might be able to deliver the
35:57same quality outcome without the
35:58cost that cause attributed with a
36:00bricks and mortar hospital.
36:02The catch on this is interesting and this
36:03is where I sort of I I feel like I've broken
36:05the rules that I just put in the talk,
36:06which is that.
36:07The way CMS implements this
36:08though is that they're nervous,
36:10right?
36:10Everybody's nervous to sort of
36:11just upend the payment system
36:13overnight and so it's gradual.
36:14And so you basically get paid the
36:16same amount you would get paid
36:18to do the transport as you would
36:20get paid to not do the transport
36:22and do and use telemedicine.
36:23Where is this going?
36:24Where could this be in the future world?
36:26A future world was imagine if an
36:28ambulance service provider took a
36:29payment for a population and says.
36:31We will take care of all transport
36:33necessary in this geography.
36:35One tool that we have that allows us
36:37to maximize value in delivering those
36:39transport services is virtual care.
36:42And we've got telemedicine partners
36:43and now they're really thinking
36:45about regionalizing care.
36:46They're really thinking about which
36:47patients can get telemedicine care,
36:49which patients need on the ground
36:51movement between different places.
36:53And so that's a way how we that's
36:54how we sort of gradually get there.
36:56But I think it's those types of
36:57ways in which there's a lot of
36:59alignment in terms of where patients.
37:01Already want to go how they already
37:03want to get care and we can do sort
37:05of care in a completely different way
37:06than we've thought about doing it before.
37:09Yeah. I mean, it's interesting
37:11when you think about that model,
37:12there's a reality where instead of sending
37:15a full ambulance truck and paramedics.
37:18I send a lower skilled paramedic
37:20on a scooter to your house with
37:22with a telemedicine first approach
37:24and only if you are determined to
37:27actually need oxygen or a diuretic or
37:29morphine or whatever do I actually
37:31dispatch the ambulance that you
37:32could dramatically increase,
37:34respond, improve response times
37:35if you went with that strategy.
37:38You know they do that in
37:40the Netherlands actually.
37:41Somebody literally goes on
37:42an ambulance to the house.
37:44And the requirements to get a
37:46full ambulance rig out there.
37:48I, I, I have a a friend that lives there.
37:50Mom fell down the steps,
37:527580 years old, busted a shoulder.
37:54The scooter showed up,
37:55said she could get a ride,
37:57take the bus.
37:58Yet you know it's just not expectations
38:00of everybody transports you and
38:02you know what she did and she had
38:04a broken shoulder and she was fine.
38:06I'm not saying that's the
38:08system we should use,
38:09but but I do think that.
38:11We have to be the big people to
38:13make the hard decisions or somebody
38:15else is going to make it for us.
38:17And and if we don't figure
38:19out how to cut expenses,
38:20someone's just going to take
38:22another 5% of off everything
38:23we get for everything else.
38:25And we're going to have an
38:27entirely dysfunctional system with
38:28miserable people working in it,
38:33unlike what we have today.
38:37Looks like Bart has his hand up.
38:40If there's time. Thanks Lee.
38:44I, I, I've enjoyed
38:45I've enjoyed the the
38:46the entire entire day so far
38:49question to panel 4 panelists from 4:00
38:54what what we're clearly
38:56talking about is, is is taking what
39:01we perceive as the next incremental
39:04rather giant far reaching step.
39:07It totally makes sense. To us,
39:12but what we're witnessing is
39:13that the entire
39:16domain of healthcare, hybrid healthcare
39:20including digital Healthcare is
39:22evolving still quite rapidly.
39:25In your estimation, any of the panelists
39:27are we ever likely to see
39:30a large incremental jump in
39:32payments and coverage? While our
39:36system is rapidly evolving or
39:38are we more likely to see small
39:41incremental adjustments as
39:43the whole system reaches more,
39:47you know, a status status
39:51quo or or a stable, a stable model?
39:58Nick, you want to take that first?
40:00Yeah, sure. I I think there's a lot
40:02of things that need to be in place.
40:04I think what I'm seeing and I've gone
40:05to our local state government and
40:07talked to a large panel about this,
40:09there's already conversations about
40:11what's going to happen after the public
40:13health emergency on reimbursement
40:14from the commercial payers. You know,
40:16CMS has sense of final rules on RPMCCM,
40:19but really we don't know what's
40:21going to happen for chronic disease
40:23management for those routine visits
40:25and acute visits moving forward.
40:27You know with the by administration
40:29is going to continue supporting this
40:30at the till the end of the year.
40:32But one of you know a lot of folks
40:35are lobbying and there's a lot of
40:37support on the hill to continue support
40:40because it's shown a significant
40:43reduction in cost over the the COVID
40:46period for especially ambulatory care.
40:48You know but the skeptic of me feels
40:51that you know it's going to #1 take
40:54health systems a long time to change.
40:56Because you have to change the governance
40:58process in order to make that.
40:59You have to change and uproot
41:00everything throughout acute 2.
41:01Ambulatory to the payment model
41:03depends on how much of A, you know,
41:06eruption that's going to be.
41:08Is it going to?
41:09Support the services or or they're
41:10not And so we got to keep the lights
41:12on for the health system and as
41:14you know every health system has a
41:16negative operating margin at this
41:18point And and so we definitely
41:19don't want to drive cost out,
41:21I mean a revenue out,
41:23we want to drive the cost out and and
41:25so and then the third part is which is
41:27also something that's being discussed
41:29which may slow things down irregardless
41:31of how enthusiastic health systems are,
41:34how how great the technology is.
41:37And the buy in is is the the medical
41:39legal factors that play a part in this.
41:41You know is it like the examples
41:43around ET3 and potential chest pain
41:45and and and a person falling down
41:48the stairs with a shoulder injury.
41:50You know there's a there's a worry and
41:53you know if something goes wrong of
41:56malpractice and being sued still in
41:58America which is more profound here
42:00due to lack of tort reform in this
42:02country compared to the rest of the world.
42:04So I think a lot of things in the
42:06stars have to align in order for
42:08it to meet more dramatic change.
42:10Also on the technology side that we need
42:11to have more consolidation of tools.
42:13We still have a lot of point solutions
42:15that don't have a cohesive solution
42:17where you have more enhanced visits and
42:20you can do a physical exam if you need to.
42:22You could do at home lab testing,
42:23a point of care testing you do at
42:26home imaging and all those things
42:27need to be kind of enhanced and the
42:30cost that needs to be kept down.
42:32And we can't keep adding to
42:33the overall IT expenditure
42:34of health system.
42:35So I think it's going to be
42:37incremental short answer but I'm
42:38hoping that if we can get all
42:40these various components which
42:42are all in flight and everyone's
42:44trying to support them that
42:46we hopefully by 20-30 we'll be
42:48having a different conversation.
42:50So. So I I have a little cynical
42:52response to to the question but
42:54and and you know me well enough.
42:56That have you ever met a payer who paid
42:58for something before they were forced to?
43:00And have you met a ever met a
43:02health system executive who cut
43:04out something that made high
43:05margins before they were forced to?
43:07So we're kind of in a really
43:09difficult position, but the thing
43:11I haven't heard said a lot today,
43:13which is one of the things that
43:15that I look at is when you do
43:18own the payer and the provider,
43:20telemedicine's a winning solution, right.
43:22So we know in overall cost.
43:26I think everybody that owns the
43:28whole kit and caboodle is all in on
43:31telemedicine and and connected care.
43:33So we have our answer.
43:34Our problem is our incentives aren't
43:37aligned and and so the question is
43:39how do we get aligned incentives
43:40when everybody doesn't feel like
43:42they could give up any piece of
43:45the pie at the current time.
43:47Judd, I don't think you could have
43:49done a better job of teeing up
43:51Panel 5 than what you just said.
43:54And so let me pause here for a moment
43:56because we're at the top of the of the time.
43:59And thank you, Judd and the panelists.
44:01That was a terrific and really
44:03provocative conversation.