Payment and Coverage Parity for Virtual Care and In-Person Care: How Do We Get There?

July 11, 2023

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00:00And in person care, how do we get there?
00:02And I'm delighted again to have
00:04close friend and colleague Dr.
00:06Bart Demarshall, who is a professor
00:08of neurology and medical director of
00:10digital Health Research and the Center
00:12for Digital Health at Mayo Clinic and
00:15known Bart forever and and you know,
00:19a pioneer in Telestroke and really, I,
00:21I believe really put Mayo on the map.
00:23When it comes to digital care delivery,
00:26so Bart, thank you for stewarding
00:28this final session.
00:29And I hand the podium to you.
00:33Thank you, Lee. It's been a tremendous
00:35day and myself and my colleague,
00:39panelists Panel #5 are excited to contribute.
00:47Yeah. And the formatting,
00:49the formatting and the closing comments
00:52on Panel 4 do provide an excellent.
00:54Segue into our topic.
00:56So payment and coverage parity,
00:58virtual care in person care,
01:01how do we get there?
01:02I'm going to make some brief
01:04introductory remarks regarding
01:05our seven panelists that join me.
01:09We are all employees of Mayo Clinic,
01:13Mayo Clinic and Mayo Clinic
01:15College of Medicine and Science
01:17and I will introduce each.
01:20Now and then,
01:21we'll invite each of them to to take
01:25their turn making brief presentations.
01:29So we'll start with Sarah Meyer.
01:32She is a director of Payment
01:34and care delivery policy and
01:35assistant professor of health
01:37services research at Mayo Clinic.
01:42Our next speaker is Doctor Sarv Turkonda.
01:45He's an associate professor
01:47of plastic surgery.
01:48A former Medical Director at the Mayo Clinic
01:51Center for Connect Care and importantly,
01:53he's the the Chair of the Board of
01:56Directors of the Federation of State
01:59Medical Boards in establishing policy.
02:01Our fourth speaker is Ryan Williams.
02:05He's a lawyer and compliance officer
02:08for the Center for Digital Health
02:10and is involved in all policies
02:13related to regulation compliance.
02:16Our entire enterprise wide digital
02:19practice Make a note Learn is the
02:21Director of Revenue Strategy,
02:23Innovation and Government Program Strategy
02:25at Mayo Clinic Center for Digital Health.
02:29Jordan Coffey,
02:30my colleague at the Center for Digital
02:33Health in the Research and Outcomes
02:37unit and our last speaker is Doctor.
02:40Nandita Kera is an Associate
02:42Professor of Medicine.
02:43She's a consultant in Hematology,
02:45oncology and the Associate Chair of Digital
02:49Transformation and Practice Integration.
02:52In the next slide here are
02:54objectives for the final session.
02:57We're going to tackle this
03:00topic chronologically together.
03:01The composition of short presentations
03:04in the dialogue to follow will
03:06address where were we,
03:08so reviewing the pre pandemic state
03:10in the public health emergency.
03:12On virtual care coverage and its
03:15influence where we now today it's it's
03:19excuse me a top of mind for all of us
03:22as we anticipate the post public health
03:25emergency virtual care coverage scenario.
03:27So we'll hear where we now anticipate
03:30outcomes and implications.
03:32Where do we want to go to pick up
03:35on on discussion from the earlier
03:37panels if we had the opportunity to
03:40draft an ideal payment and coverage.
03:42Parity plan for hybrid virtual
03:44care and in person care,
03:45what would it look like and I'll
03:47seek all of our panelists inputs and
03:49their thoughts and and ultimately
03:50how do we get there?
03:51What role is there for developing
03:54or solidifying an evidence base
03:56to convince patients,
03:58clinicians and payers that there
04:00should be payment and coverage parity.
04:02So those are objectives.
04:04I will turn the presentation over to
04:08my colleague Sarah Meyer to begin.
04:10You're going to hear from each of us
04:13for three to 5 minutes and there will
04:15be room for some dialogue at the conclusion.
04:18Go ahead,
04:19Sarah.
04:19Thank you.
04:20Great. Thank you. Thank you so
04:22much for setting the stage for us.
04:24So I am going to start out at a high
04:26level by giving an overview on where
04:28we are in terms of the public health
04:30emergency timeline and and what we can
04:32expect actually in the upcoming week
04:34and then moving forward from there.
04:36So the most immediate key decisions
04:39points are the the most recent
04:41renewal of the PHE was October 13th.
04:44At the end of this week we are
04:46going to reach the yet again the
04:4960 day notice deadline,
04:50which is really key because the Biden
04:54administration has really been crystal
04:56clear about indicating that they will
04:59provide notice of a 60 day wind down if.
05:03And when, well obviously when the
05:05the public health emergency ends,
05:07so that comes at the end of the week.
05:09So we are already here at Mayo Clinic
05:12watching and waiting to see if we're
05:14going to receive that 60 day notice.
05:16If that 60 day notice does come
05:19through then the PHE will end in
05:22early mid January and if not, if,
05:24if it, if it does not come through
05:26then the expectation is that.
05:28Once again moving into early mid January,
05:31we would see another renewal
05:32at a 90 day increment.
05:34That's the time frame that's always
05:36required of the public health emergency.
05:39From January,
05:40the next renewal is April and then
05:42from there the next renewal is July.
05:44This of course is really a key feature of
05:48everything that we're talking about today
05:50because so many of the flexibilities.
05:53In terms of who can provide telehealth,
05:55where telehealth can be provided
05:57and how it's reimbursed are are
05:59mapped to the PHE right now.
06:01A really interesting side note
06:03related to all of this is the CBO
06:06right now in terms of projecting
06:08legislative costs around telehealth
06:10and everything else right now are
06:13using a July 2023 termination
06:16date in developing projections.
06:19Next slide please.
06:21Just a quick highlight of of key
06:23flexibilities requiring action
06:24and where the action is required.
06:26Some issues have to be handled on the Hill.
06:28Geographic and originating site
06:30requirements and eligible provider types
06:33are are all items that even no matter
06:35how much we go to CMS and ask for a change,
06:38CMS can't make the change unless the
06:40Hill provides CMS with the capability
06:42and authority to make those changes.
06:45Other key flexibilities requiring
06:47regulatory action are highlighted below.
06:50So specifically related to reimbursement
06:52for services provided with audio only
06:55technology and the the, the rates
06:57in general are really linked to CMS.
07:00Next slide please.
07:04Additional key point here in terms
07:06of the telehealth landscape on the
07:08hill and really what has already
07:09happened over the past year,
07:11what has happened up until now and
07:13what we can expect moving forward.
07:16So there in 2021 there were over 65
07:21bills introduced related to extending
07:25at various increments and in various
07:28spaces telehealth flexibilities.
07:29So this has been an issue that has
07:31received a significant amount of
07:33attention on the Hill and a significant
07:35amount of engagement around not just
07:38stakeholders but but legislators in
07:40terms of taking up the issue and
07:42recognizing its significance in 2022,
07:45in September, by September,
07:47we had 45 / 45 bills introduced
07:49and then moving to July,
07:51many of us are probably aware that
07:54HR4040 passed the House with very,
07:56very extensive bipartisan support.
07:59This includes A2 year extension
08:01through the end of 2024 covers
08:03many of the key issues that we've
08:06been speaking about today.
08:08This was never taken up in the Senate
08:11largely because there was not the
08:13the timing and kind of the political
08:16moment in time to to take up the issue.
08:18Next slide please.
08:21And then of course this maps to where
08:23are we today on the hill which is an
08:25interesting day to ask that question
08:27and what does that mean for us
08:28tomorrow and then the day is moving forward.
08:31So today obviously is midterm Election Day.
08:34There's really significant potential
08:35for impact on on the outcome
08:38from today in terms of what what
08:40we see happen moving forward.
08:42So key issue with telehealth is
08:44there is a very significant expense
08:47attached to extending telehealth for.
08:50One year, two years,
08:52any any increment of time,
08:54the CBO really costs it as
08:57a significant cost impact.
08:58So if we see Republicans take
09:01the House and maybe the Senate,
09:03we would see from from that space
09:06of a really potentially significant
09:08push to to push anything that has a
09:12cost to 2023 when we actually see the
09:15outcome of the elections today take effect.
09:18The flip side is that if we
09:20see an end of the the PHE,
09:22if we receive that notice this week
09:24and know that these flexibilities
09:26are going to expire,
09:27There's going to be significant
09:29pressure across Congress to take on
09:31the issue in terms of identifying
09:33whether there will be a Hill
09:35solution to some type of shortterm
09:37extension of the flexibility,
09:38whether it's for a year,
09:39two years or or something else.
09:42I will also note that the other
09:44key priority on the on the Hill
09:46that that is widely known is the
09:48federal government is funded through
09:50December 16th with the continuing
09:52resolution at which point it expires.
09:54So there's going to be a significant
09:56need either to pass another CR or
09:59omnibus package and that along with
10:01that will come an opportunity for
10:03telehealth to be taken up whether it
10:05is or isn't obviously not something
10:07I can really fully forecast.
10:09But we do,
10:10we will have a large number of
10:12other health policy initiatives in
10:14terms of reimbursement related to the
10:17physician fee schedule and various
10:19other hospital extender programs
10:22that are likely to be taken up in
10:25during the lame duck session, so.
10:27We will see some type of health
10:30policy activity coming in the next
10:33couple of months and we will all be
10:35looking to see what the outcome of
10:37today is and and what the outcome
10:39of the end of this week is in terms
10:41of the PHE to have a better line
10:43of sight into to what's to come
10:45in the upcoming weeks. Thank
10:46you so much for the comprehensive review
10:49on the on the capital, Dr. Triconda next.
10:53Thank you, Bart and thank you, Lee.
10:56You know, the subject of telehealth
10:58parity is obviously not new.
10:59And in the wake of the COVID-19
11:01pandemic telehealth use surge
11:03because of Medicare and private
11:05pairs easing payment restrictions,
11:07although currently there's bipartisan
11:09support from lawmakers for the continued
11:12use of telehealth following the pandemic,
11:14there's a lot of debate about
11:16implementation issues that still remain.
11:18And one of these is should telehealth
11:20continue to be reimbursed at the
11:22same rate as in person care.
11:24You know the issue of telehealth
11:25gained a lot of attention when CMS
11:28used its waiver authority to establish
11:30payment parity for in person video,
11:32in person video and audio only
11:35telehealth during the COVID-19 pandemic.
11:37Most commercial insurers follow suit.
11:40And if you look at this map,
11:42on your left are the states with
11:44payment parity laws prior to the
11:47pandemic States and Gray had no
11:49laws regarding payment parity.
11:51The states in purple supported
11:53payment parity within Medicaid
11:54and the states in blue or teal,
11:57however that looks on your screen
11:59had parity laws for all payers.
12:01On the right are the states
12:03with payment parity laws.
12:04During COVID,
12:05the number of states with payment parity
12:07for all payers increased from 9 to 21.
12:10During the pandemic, Medicaid payment
12:12parity increased from 5 to 14 states.
12:15Next slide please.
12:18This is the current map of payment parity
12:21of states with laws requiring insurers to
12:24implement payment parity as of August 2022.
12:27Now, this is a changing map.
12:30As you see, the dark blue states
12:33have implemented payment parity.
12:35The light blue states have
12:38caveats regarding payment parity.
12:40For example,
12:41Massachusetts restricts payment parity
12:43for mental health services only.
12:46Nebraska established payment parity
12:47for a certain mental health conditions
12:50and substance use disorders only.
12:52On the other hand,
12:53West Virginia implemented payment
12:55parity for established patients and
12:57patients in acute care facilities only.
12:59It's really unclear whether payment
13:01parity will continue and for what kinds
13:03of telehealth visits after the PHE.
13:05In fact, CMS has already indicated
13:07that Medicare will not cover audio,
13:09only telehealth for evaluation and
13:11management of visits after the PHE.
13:13And may decide to pay for tell
13:16of bills at a lower rate.
13:18Next slide, please.
13:21This is states with laws requiring
13:23coverage parity as of August 2022.
13:26Now coverage parity is less confusing.
13:28You can see by this map all but eight
13:31states have coverage parity laws.
13:32Only the ones in Gray have
13:35no coverage parity laws.
13:37We'll go to the next slide,
13:38please.
13:40So this is a map of states with
13:42permanent Interstate telemedicine laws.
13:43And I'm sorry there's a little
13:46bit all the color coding here,
13:47but I'll try to go through that
13:49pretty quickly here.
13:49Prior to the pandemic,
13:51telehealth use was largely limited,
13:54excuse me,
13:54and restrained by the ambiguous
13:56and often changing regulations
13:58regarding reimbursement and license,
14:00especially across state lines.
14:02State and federal legislation
14:04in the use of telehealth laws
14:07served as really Hendrason's.
14:09To fully realize the benefits of telehealth,
14:12particularly those laws that presented A
14:15patchwork of accepted and non eligible costs
14:18and services and became very complicated.
14:21It's really excuse me.
14:23Providers can deliver telehealth services
14:26across state lines depending on the rules
14:29set by the state and federal policies.
14:32As of September 2022 / 50% of the states had
14:37no permanent Interstate telemedicine laws.
14:4010 states. Those that are seen in
14:43light looks yellow on my screen but
14:45it was supposed to be light green.
14:47Have established A telemedicine
14:49license or a special permit.
14:51Seven states that are indicating
14:53orange here require some sort of
14:55registration process for telemedicine or
14:58implemented A waiver for telemedicine.
15:01My own state of Florida has
15:03$150.00 registration fee.
15:05Three states which are in dark blue here.
15:09Require licensure by endorsement
15:12or by reciprocity.
15:14The light blue states have either a
15:16pro bono policy or other way waivers.
15:182 states which are in purple which is
15:21Washington and Maine in this situation
15:24allow for only consultative services.
15:28Next slide and I think this is a
15:32very important issue as we move
15:34looking at advancing telehealth
15:35is the issue of licensure.
15:37You know Interstate compacts can
15:39simplify cross state telehealth.
15:41For specialists in participating states,
15:44The Interstate Medical Licensure
15:46Compact provides an expedited pathway
15:49to licensure and compact states.
15:51It preserves the state's rights to
15:53licensure but eases the burden of
15:56the licensure process for providers.
15:58It does have some restrictions though.
16:00To be eligible,
16:01A physician must meet 9 criteria and
16:04the first requirement for physicians.
16:06To participate in the compact is that
16:08they hold a full and unrestricted
16:10medical license in a compact state
16:13that can be that can be designated
16:15as their State of Principal license.
16:18The remaining 8 requirements is number one,
16:20They have to have graduated from
16:22an accredited medical school or a
16:24school listed in the International
16:26Medical Education Directory.
16:27They must have successfully completed
16:28a A/C GME or a OA accredited graduate
16:32education.
16:32Past each component of the USMLA
16:35or the complex exam hold a current
16:39specialty certification or time
16:41unlimited certification recognized
16:43by a BMS or a OABOS board.
16:46In addition,
16:47those physicians should not have
16:48a history of disciplinary action
16:50toward the medical license,
16:52not have any criminal history,
16:53criminal history,
16:54not have a history of controlled substance,
16:57actions toward the medical license,
16:59not currently be under investigation.
17:03Fortunately,
17:0380% of US physicians will meet
17:06all of these nine criteria for
17:09license through the compact.
17:11If you look at the map on
17:13your left which is the 2015,
17:15the Interstate Medical license
17:17compact had 15 participating states.
17:20Fast forward to August 2022 of this year,
17:23we have 37 states plus the District
17:25of Columbia and the territory of Guam
17:29that are participating in the compact.
17:31This really.
17:33Expedites the care across
17:35Interstate practice.
17:36And again,
17:37I I want to emphasize it does
17:39preserve the state's rights licensure
17:41and that's always been the hard
17:43part of a national
17:45licensure when the states
17:46want to preserve their
17:48ability to control licensing.
17:50Bart, I, that's my presentation.
17:52Thank you so much.
17:52I hope that was helpful.
17:54Thank you so much. Let's
17:56transition to Ryan Williams.
17:59Things far, I'll make my
18:00comments a little bit
18:04contained because I want to make sure
18:05that we have enough time to get to the
18:08landscape beyond and not just the recap,
18:09but just kind of put a glass on both what
18:12Sarve and Sarah have previously shared.
18:14While we still have the the PHE
18:16order still active or PHE declaration
18:18still active at the federal level,
18:21We know that it has been a
18:23really mixed picture,
18:23really dynamic picture continues to
18:25be a dynamic picture of the states
18:27many state level PHE did some.
18:29Operations have subsided interestingly,
18:31but it's kind of dovetailed with a
18:35bolstered impetus for commercial
18:37coverage for virtual care services
18:39and really a really awesome
18:41recognition of the value of virtual
18:43care services by commercial payers.
18:45And as we've talked a lot about today,
18:47you have to untangle a bit the
18:49different concepts of coverage parity,
18:51what services are covered within a
18:55particular plan and what mandates are.
18:57The focus of the laws around them and
19:00then distinct from reimbursement parity,
19:02what actually is paid for the
19:04services delivered.
19:05And as you can imagine,
19:07with all the maps that were previously shared
19:09just a moment ago with 50 different states,
19:11two different concepts,
19:12you're going to end up with a really
19:15colorful web of definitions that
19:18all need to be read in context of
19:20both the billing requirements and
19:21the state licensure requirements.
19:23If we can move to the next slide,
19:24I'll just make a couple more comments.
19:26I'm talking in the slide largely about
19:31legal requirements surrounding
19:32commercial plans, commercial coverage,
19:34although as I've mentioned a moment ago,
19:36many states might put additional
19:39coverage around this for state
19:41medical assistance plans as well.
19:43Most states do have a some statute
19:46on the books that governs defines
19:49telehealth for a reimbursement context.
19:52You will look at it positively
19:55that of those 44 with a statute
19:57that bothered to define telehealth,
20:0043 of those states will have
20:02some level of coverage parity
20:05included within that definition.
20:07That's definitely a positive thing,
20:09but some of them are going
20:10to define it differently.
20:11So you need to be cautious.
20:12Your mileage is going to
20:14vary that some of those.
20:16Coverage mandates will come with
20:18requirements surrounding the type of
20:20provider or the degree of which that
20:23cover the the type that yeah the type
20:27of provider or that kind of duration
20:30of that care about half of these states.
20:32So a significant reduction or
20:34significantly fewer of them will
20:36get to the degree or to the measure
20:39of reimbursement priority and
20:40some of them will include medical
20:42assistance or Medicaid plans and
20:44that and some of them will not.
20:46If you look at it as a modality RPMA,
20:49relative, relatively newer concept,
20:51although certainly with its own kind of
20:55ubiquitousness out of the COVID-19 pandemic,
20:58many states are beginning to fold
21:01RPM formally into those definitions,
21:03which guarantees some sort of coverage or
21:05some level of coverage for that service,
21:07usually within the medical
21:09assistance context.
21:09And I do see.
21:11Impetus for that growing as as state
21:14legislature legislative sessions have
21:16continued throughout the pandemic.
21:17Many more include some degree
21:19of store and forward care,
21:21although again reimbursement
21:23rates might vary around exactly
21:26what is required in there.
21:27If we can go to the next slide there,
21:29I'll just wrap up here.
21:30You haven't pulled out a couple of
21:33again stage setting things for where
21:35we are in the current landscape.
21:37Different statutes are more
21:38helpful than others.
21:39Just pulling out a couple of Miami
21:42state of Minnesota here gets pretty
21:45explicit in making sure that there
21:48is reimbursement at the same rate
21:49as the equivalent in person service.
21:51And again as I think as the
21:55prior panel highlighted well,
21:57there's still some.
21:58Room to negotiate.
21:59Exactly how do you measure
22:01quality at that point of that?
22:03It's one thing to guarantee payment,
22:05but it's not getting to everything.
22:08And then just to get to my last five here,
22:11we'll move forward for the Florida example.
22:14Other states are certainly less verbose
22:17or less are much more open language,
22:19don't get quite to the
22:22level of parity of language.
22:24This is not necessarily to say that there.
22:27Isn't that that there's a comment
22:31on the level of virtual care
22:33reimbursement happening in Florida.
22:34It's just leaving it open to the
22:36parties to handle contractually
22:37between the pair and the performer,
22:39but there just isn't a mandate tied to it.
22:42Certainly 2 contracting parties
22:43could have their own reimbursement
22:45methodology or quality measurement
22:47methodology within there,
22:48but it just is loose, looser.
22:50So there's no kind of state level
22:52mandate or oversight that goes with that.
22:54So again,
22:55your violence just kind of varies depending
22:57on the kind of construct of the statute.
23:00And I'll hand it over to my next speaker.
23:02So thank you, Ryan. Go ahead, Megan.
23:05Sure. So we've heard from my colleagues
23:07a lot about the specifics and details
23:09of payment and coverage parity.
23:10For the next few minutes,
23:11I'd like to think about this in the context
23:13of the larger healthcare landscape.
23:15The current healthcare system
23:17is not set up to support,
23:18compensate or incentivize
23:20digital care in all of its forms.
23:23Is our goal to replicate a system as
23:25complex as this and one that already lacks
23:28payment parity for existing services?
23:30Do we want true payment
23:32parity across specialties?
23:33Is virtual care less resource intensive
23:36or less expensive than in person visits?
23:38But then we reason that rational
23:40pricing is something that would help
23:42us to provide a payment consistent
23:43with the resources required,
23:45but rational pricing is something that
23:47our healthcare system has always lacked.
23:49With seemingly little insight
23:50into what the true cost to provide
23:52the service actually is,
23:54are we setting ourselves up to go
23:56down the same rabbit hole of additive
23:58costs to a broken system that does
24:00not support rational pricing and
24:02perpetuates this level of complexity?
24:06Consider when we add in the
24:08interwoven intricacies between
24:09licensing and credentialing,
24:11federal, state and local regulations,
24:13payment and coverage parity,
24:15the sheer list of service modalities.
24:17The vast number of waivers and pH.
24:19D exemptions and layer
24:20those onto this flow chart.
24:22This is unsustainable.
24:23There has to be some level of coalescence.
24:26So how do we get there?
24:27Next slide please.
24:30We have to think about this in
24:32ways that we haven't before.
24:34The current fee for service system
24:36and the underlying infrastructure
24:38and regulations are vastly limiting
24:40the enormity of transformation
24:41potential of digital healthcare.
24:43We know that costs are soaring beyond payer,
24:46employer and patient affordability.
24:47Providers are looking to bill
24:50for additional services that add
24:52revenue to pad their finances.
24:54From the ever increase in
24:55government payer mix,
24:56soaring labor market and material costs,
24:59and declining profit margins.
25:00Payers are looking to decrease their
25:03costs by improving the care provided.
25:05Patients are looking for increased
25:08access and affordability.
25:09How do we all win?
25:11Is payment parity the answer?
25:13Or could we challenge ourselves
25:15to consider a different approach?
25:17If the real issue is the current
25:19infrastructure of the fee for service system?
25:21Are we thinking too narrowly and
25:23missing the actual opportunity
25:25to leverage the advancement of
25:27technology and digital healthcare
25:28by keeping ourselves tethered to
25:31an outdated and broken system?
25:33Is this the final tipping point that
25:35could make a push for an entirely
25:37different payment and delivery system?
25:39Think about the ways in which we
25:41could connect, innovate care.
25:42All more seamlessly if we didn't have
25:45to bill for each and every service,
25:47if we found a different way,
25:48it could allow our healthcare system
25:50to catch up with the technological
25:52advances that modern medicine and
25:54our society at large have been
25:57enjoying for over the past 50 years.
25:59At a minimum,
26:00should payment parity be our
26:01intermediary step? Yes.
26:02But should it be our end goal?
26:05No.
26:09Megan, thank you for the presentation.
26:11I'm going to coming back to to many of
26:14you at the dialogue to seek your inputs.
26:17That's fantastic. Jordan Coffey,
26:19tell us about how research plays a role.
26:22Absolutely. Thank you so much,
26:23Doctor Demarshall.
26:24And as we consider everything that
26:26we've heard today regarding the state
26:28of telehealth and telemedicine services,
26:30you know I want to turn our
26:32attention a little bit.
26:33To how we might more proactively inform
26:36future conversations with policy makers,
26:38payers and it is a groups.
26:40Ultimately we know that objective
26:42evidence is key to informing these
26:44conversations with decision makers.
26:46However, we also recognize that
26:48conducting this type of work that
26:50leads to this type of rigorous
26:52high quality data takes time.
26:54So what do we do about that?
26:56So one of the things that one of
26:57the ways we're approaching that
26:59at Mayo Clinic is really trying to
27:01establish A5 year research agenda.
27:03And really the goal behind this is,
27:05is to ensure that we have a strong
27:06understanding of what are the
27:08challenges that we're facing,
27:09what are the headwinds that we're facing
27:11in industry and leaning into that.
27:13It's in order to focus our research efforts,
27:16efforts and our insights.
27:18In order to guide this,
27:19we've we've taken a modified Delphi
27:22approach to really understand what
27:23are the top themes that we could and
27:26should be focusing on and and my
27:28apologies to Doctor Hollander at Panel 4,
27:30but this is going to be a lot focused on.
27:32Really comparison and contrasting
27:34against the current state because
27:36we know that drives a lot of the
27:38the conversation.
27:39So we can go to the next slide
27:41here with that in mind.
27:43We we engaged over 40 digital
27:45health leaders across industries,
27:47payers,
27:48provide organization solution
27:49providers to identify you know
27:52really top concepts and themes which
27:55we might lead into based on those
27:59we affinitized and thematically
28:01coded and then reached.
28:02To an additional 120 individuals
28:05across the industry and ultimately
28:08this has helped us to identify
28:10really a prioritized understanding
28:11of of where we might,
28:14could and should focus some of our efforts.
28:16So within this identified primary themes
28:18with an emphasis on clinical appropriateness,
28:21parity,
28:22equity and access and economics
28:24with a moderate emphasis on themes
28:26relating to licensing,
28:28legal and compliance and patient engagement.
28:30And lesser emphasis on topics
28:33such as digital scalability,
28:35the potential for fragmentation
28:37in the healthcare system,
28:39team dynamics and and potential
28:40issues of waste, fraud and abuse.
28:43Next slide please.
28:45So where do we go from here
28:46based on on these findings?
28:47We're appalling teams of experts
28:49that are really help to define you
28:51know what are the key concepts and
28:52and key issues that we should start
28:54investigating down near and far
28:56and really using that to provide
28:58direction for studies that we're
29:00going to initiate proactively to help
29:02generating some of those insights and
29:04evidence to inform the conversation.
29:06However,
29:07before we embark on that journey,
29:08I really think it's critical we
29:10look at the current state.
29:11And so with that,
29:13I'll hand it over to Doctor
29:15Nandita Kera to help us reflect
29:16back on what we're seeing
29:17within the current literature.
29:20Thank you, Jordan. Next slide, please.
29:22So over the next couple minutes,
29:24I would like to share some data that is
29:27already out there to suggest that the
29:29telemedicine outcomes are quite comparable
29:31to in person care and I think that will
29:35help set the foundation for comparable
29:37reimbursements for this care modality.
29:40So this is a report from ARC from 2/20/19
29:42where they looked at 200 some studies from.
29:461996 to 2018 and basically they showed that
29:50telehealth consultations produced comparable
29:51outcomes or no difference from comparators
29:54whether it was in the ICU setting,
29:56Ed setting or outpatient care.
29:59Next please.
30:01More recently, with the pandemic
30:03expanding the use of telehealth,
30:05there have been some recent analysis,
30:07systematic reviews of literature also
30:09showing similar outcomes when telemedicine
30:12was used to replace or augment usual
30:14care and no differences in harm between
30:17the intervention and control groups.
30:19There was another review looking at
30:20more the primary care setting with some
30:22of the chronic diseases like diabetes,
30:24hypertension, hyperlipidemia.
30:26For studies from 2000 to 2018 and
30:29basically showed when looking at
30:31clinical outcomes for these patients
30:33that they were quite comparable
30:36or no significant differences to
30:38in person visits next please.
30:42So as we've heard the telemedicine
30:45is not just outpatient care,
30:47but it could also range from remote
30:49patient monitoring to hospital at
30:51home and so there have been these
30:53recent studies that have looked at.
30:55Various models of hospital at home
30:57care and basically showed comparable
31:00healthcare utilization in terms
31:01of length of stay or hospital
31:03readmission rates and overall better
31:05ratings of care from the patients,
31:07better patient satisfaction.
31:09There was a two site clinical trial
31:13of 172 patients comparing remote
31:15physician visits to inpatient.
31:17And again showed patient experience was
31:19quite similar and the overall adverse
31:21events and readmission rates were
31:23better with the remote physician visit.
31:26Next please.
31:27And finally when we talk about the.
31:30Outcomes,
31:31we are not looking just at
31:32heart clinical outcomes,
31:33we are also looking at some of the
31:35perceptions of the physicians and providers
31:37who are engaged in using telemedicine.
31:39And so this cross-sectional survey
31:42study reported on the data for that
31:45and basically what the the study
31:47showed was virtual visit was either
31:49better or was not very different from
31:52the in in person visits both from
31:55a patient and provider perspective.
31:57So I think.
31:58This is data that has set the stage
32:00and hopefully will continue to evolve
32:03and show that telemedicine can
32:05provide equal or sometimes superior
32:07outcomes and should be considered for
32:11that when considering reimbursement.
32:13That move to next.
32:15Thank you Doctor Kara.
32:16Doctor Chris Whitish,
32:17I fail to introduce you at the beginning.
32:20My apologies. Chris Whitish
32:21is a professor of medicine,
32:24he's an internist and he's a medical
32:26director at the Center for Digital Health.
32:28Leading all practice enablement, Chris,
32:32thanks, Mark. I take no offense
32:33and I'm happy to be here.
32:34So I just wanted to tell a bit about a
32:38couple projects we've been doing at Mayo
32:40within within digital health and these
32:42are very much kind of an operations.
32:44These are, I think I really should
32:46have titled my section kind of the
32:48hidden benefits of of telemedicine.
32:49So first of all, you know Mayo is really
32:51very much a destination practice.
32:52Patients are coming from far away.
32:55And many times are are planning
32:56their visit with us months ahead.
32:58So go ahead to the next slide.
33:03One of the things we've been doing
33:04is we've been doing video pre visits
33:06to do patient planning for patients
33:08that are coming several weeks ahead.
33:09The goal of this is to gather information
33:11about the patient's goals for the visit,
33:13potentially what they've had done
33:15previously and also to set some
33:17expectations with the patient.
33:18Go ahead to the next slide.
33:22In doing this, there were
33:24several really great outcomes.
33:26First of all, we had we're able to
33:27demonstrate that many of these patients
33:29have shorter itineraries because we were
33:31able to organize things ahead of time.
33:32Many times patients especially
33:33within the surgical practices to do
33:35the patient education beforehand.
33:37So when the patient got here,
33:38they immediately would have the surgery
33:40which would as many times have taken
33:43several visits previously the same
33:44time and travel for the patients
33:46they've many times had to take off work
33:49and and have expensive hotel stays.
33:51Our pediatric neurologists were thrilled
33:52because they had many of the materials
33:54they needed to adequately take care of
33:56the patient at the time of the first visit.
33:57Previously they were trying to piece
34:00that together and it was really kind
34:02of a fragmented visit procedure.
34:05Education could be done ahead of time.
34:07We also had a shorter time to
34:09first contact with the patient.
34:10You know the the especially
34:11in surgical practices,
34:12it's competitive out there.
34:13So getting a patient that we could
34:15benefit from and they could benefit
34:17from our care was important.
34:19And when we asked patients whether
34:20they liked you know meeting with
34:22us on video prior to their visit,
34:24they said they couldn't imagine
34:25it being done differently.
34:26They just sort of expected now next slide,
34:31the second project was on a
34:33physician flexibility project.
34:35As you as you know physician
34:37wellbeing is a is very much a concern.
34:40Currently, we do most of our video work
34:42is scattered out through the schedule.
34:43So you might see a couple in patients
34:46in person do some video work and
34:48then back and forth had the pandemic
34:50really demonstrated that people
34:52valued being able to work from home.
34:54So we did a pilot where we would do block
34:56scheduling of video work like within
34:591/2 day allowing people to work remotely.
35:01Next slide, this is ongoing,
35:05but we're majoring physician satisfaction,
35:07team satisfaction fill rates.
35:08And we're also learning about how
35:11we can adequately provide support to
35:13physicians remotely much like they have
35:15currently with their in person desks.
35:17So I'll turn it back over to Bart.
35:18Thank you.
35:20Fantastic. Chris. Thank you.
35:21So in the remaining 5 minutes,
35:23let me ask my colleague, panelists
35:30in in, in a world of options
35:33fee for service coverage.
35:34Payment, parity value based care payment,
35:37population based payment,
35:39capitated payment.
35:41If you were to, if you were to
35:43make a selection and or prediction
35:45for the future what what's what's
35:48best and and why making,
35:50can we start with you
35:53sure. So you know I think from the
35:56alternative payment perspective I
35:58think a lot of the CMMI programs
36:00that we're seeing are really still
36:02built on the fee for service chassis.
36:04So you know, if I had my way,
36:06it would certainly be more of a
36:08population health based payment or
36:09some sort of capitated payment.
36:11And I think it would allow us to
36:12have more of a prospective payment
36:13that we could then you know,
36:15budget and resource and align
36:16those resources and align those
36:18incentives accordingly.
36:20I'll stop and let my other
36:21colleagues speak too.
36:22Thanks, Megan. Chris, your thoughts?
36:27Oh goodness. You know, you know, I think.
36:31You know the deficiencies of
36:33this creates are so valuable
36:35especially for destination patients.
36:37You know, I think one of the huge
36:39benefits that we've seen is that
36:41you know patients come to us,
36:42we do a very complex workups,
36:45decision making and many times we need
36:47to be able to wrap up with the patient,
36:49but schedules don't align.
36:50So we could do that remotely down
36:52the road and even follow up on
36:54for several months afterwards.
36:55So I think that that's I think
36:57that's all part of a bundle that
36:58would provide benefit to the
36:59patient and have better outcomes.
37:01Thanks, Chris. Ryan,
37:02any any additional ideas? Sorry
37:08about that. I'm going to basically
37:11agree pretty readily with Megan.
37:12I think I favor some sort of alternative
37:15peanut model that is taking it further
37:18afield from the fee for service chassis.
37:20That was an elegant way to put it.
37:22I think as we look at one of the main
37:25barriers to expanding telehealth,
37:26there is a significant concern
37:29about the incremental cost.
37:31Which is a continual barrier for
37:33why this has been a difficult ball
37:36to carry forward across the line.
37:38So I think that would both respond to
37:42the both regulators concerns about the
37:45amount of money going into the system,
37:47but also meet patients better where
37:49they are and able to deliver their care
37:52conveniently while still making sure
37:54that they are there is some kind of
37:57global oversight of their care plan.
38:00Thanks, Ryan. Sorry, we've we've seen it
38:03all in in the past seven or eight years.
38:06But if you were to look ahead and plan
38:08ahead and in the leadership positions,
38:10you hold any additional insight or
38:13thoughts about the path forward. So
38:16Bart, I'm going to talk from a personal
38:19perspective because the Federation of State
38:20Medical Boards would not have any comment
38:23regarding payment models surrounding this.
38:25We're really about the
38:26regulation around telehealth,
38:27but from a personal perspective you know.
38:30What I don't want to see is the any
38:32stagnation around the growth of telehealth.
38:36And unfortunately we're
38:37trying to fight two things,
38:38right We we're trying to contain costs
38:41but also make sure that the providers that
38:44are engaged in telehealth want to be there.
38:47And and part of that is about payment.
38:51And yes, we we all believe that an
38:53alternative payment model would be better,
38:55but if you can't engage the providers.
38:58You know to engage in telehealth because of
39:01lower reimbursements telehealth won't grow.
39:03So it may require us and it may require us
39:06to go to a fee for service for a period of
39:10time and then cut back on the models payment.
39:13But what my what my fear is that when you
39:16start cutting back on payment models at
39:19this point telehealth is not going to grow.
39:22And that's what my fear is in the,
39:24in, in the future here.
39:26Hey, Bart, it's, it's Lee.
39:27I just want to interject one
39:29comment stimulated by these,
39:30these last few speakers and one of them is
39:34we've seen this in our equity work as well.
39:36When you bake differential payment into
39:38the payment system, you bake inequity
39:40into the into the healthcare system.
39:42So if you decide that you're not
39:44going to pay for audio only and we
39:46saw in previous session how reliant.
39:48The huge section of the population,
39:50particularly the Medicaid
39:51population is on audio only.
39:53You've now basically discouraged providers
39:56from offering that service and therefore
39:59those patients simply go without.
40:01As we know,
40:02there's there's unabsorbable need, right.
40:04So you can just fill your clinic
40:05right back up with people who
40:07can pay or pay out of pocket.
40:08And I think the 2nd observation
40:11is that as long as we're living
40:14three months to three months to
40:16three months with these waivers.
40:18We can't disinvest from our
40:20brick and mortar because we have
40:22to fire it right up again,
40:23you know like a burner.
40:25Once we know we have a permanent path,
40:28even if it's a lower rate,
40:29then we can start extracting value out
40:31of the lower cost of of providing tells.
40:33Right now we're providing both and it's
40:36really actually at an increased cost.
40:38I think the health systems it's a
40:40it's a revenue source for the for the
40:42zooms and the you know EH R's and the
40:44others of the world who are helping to.
40:46To to outfit this revolution but but
40:48I think we're really we don't have a
40:51framework yet to really extract value.
40:53So I agree some kind of payment
40:55ramp is needed and even if it's fee
40:58for ServiceNow with a five year
41:00ramp to value only at least it's
41:03a ramp and then you know that that
41:05you'll be able to provide it.
41:06So Bart let me turn it back to you.
41:08I didn't mean to interject there,
41:09but I just was so stimulated
41:11by these comments.
41:12You know, thank you.
41:13So thank you so much, Lee.
41:14I mean, as you,
41:15as you described that it reminded me of,
41:18it reminded me of standing
41:21in a jungle gym holding,
41:23holding an entire array of of
41:27thick ropes hanging from the
41:29ceiling and and and not being
41:31able actually to swing forward and
41:33grab a single rope ahead of us,
41:35still trying to,
41:36still trying to collect all
41:38that we have without advancing.
41:40It was a good, it was a good analogy.
41:42Our our panel has concluded.
41:44I want to thank all the panelists
41:46for for their input achieving our
41:50objectives maintaining the time and
41:52we'll turn it over to to you Lee.
41:56Thank you.
41:57Well,
41:57I, I, I you know once again every year
41:59I say I can't imagine the symposium
42:02getting better next year but it always
42:04does and so this was no exception.
42:05This was just really a fantastic
42:08and incredibly broad arena that we.
42:11That we that we covered today.
42:13And I want to just remind folks virtual
42:16care consensus.com is where you can
42:19find recordings of all the talks.
42:22We'll collect up any questions that
42:24came through the Q&amp;A channel and
42:26post answers there as well if we
42:28didn't get to answer them this time.
42:30And I want to thank all the panelists,
42:32thank all the participants who who
42:34stayed with us during the session
42:37and really look forward to.
42:39All of the great solutions that these
42:40panelists are going to implement in the year,
42:42in the year ahead.
42:43And in the immortal words of Bart's
42:46white board there, have a great day.
42:50Thanks everybody. Bye, bye.