Positioning Telehealth for the Future: ‘Rear-View Mirror’ Lessons From COVID-19

By Peter Antall, MD

“We have the technology.” It’s a catchphrase from “The Six Million Dollar Man,” a TV show that filled children of the 1970s with the hope that they would one day live in a world where bionic humans weren’t just the stuff of science fiction. And while bionic implants are still an emerging but competitive market, we’re entering a time when the digital health advancements many of us once dreamed of, like virtual care, are transforming healthcare as we know it.

Now, those advancements are not only critical to our country’s defense against the coronavirus pandemic—both the current wave and the subsequent waves—but they’re also allowing us to reimagine how all healthcare is delivered.

During the pandemic, the spotlight has turned to telehealth and its power to deliver healthcare while maintaining social distancing. But as the World Health Organization warns of a second peak of coronavirus cases in the United States and a second wave of COVID-19 later this year, healthcare leaders must consider: How do we apply the rear-view mirror lessons from the first wave of the pandemic to our virtual response to consumers’ healthcare needs during the second wave? Further, as many providers adopted telehealth for the first time during the COVID-19 outbreak, they experienced how telehealth could benefit their practice even outside of a pandemic.

Here are three key insights gained during the initial trajectory of COVID-19 around incorporating telehealth as a first response.

1. Strengthen the infrastructure for telehealth. As we saw during the first wave of the coronavirus, even health systems that had invested in telehealth found they needed to dramatically ramp up their capabilities to meet swelling demand. Forrester Research projects that virtual visits will reach 1 billion in the United States this year, with 900 million resulting from COVID-19 alone. “This is going to become medicine, moving forward,” one health system leader shared with me recently. “The pandemic has pushed virtual care ahead 10 years.”

For example, at Augusta University (AU) Health System in Georgia, the organization had a relatively new home-based telehealth program when COVID-19 hit. Health system leaders quickly realized that this program would play a big role in their response to the pandemic; however, the ability to rapidly scale would be a challenge. They also found, like many other organizations, that the process of shifting most of their ambulatory care visits to an all-digital format was challenging.

Once the coronavirus began to spread, AU Health quickly bolstered its telehealth capabilities, training 400 providers on virtual COVID-19 screenings and collaborating with the Georgia Department of Health and the Georgia National Guard to open testing sites. From March 10–20, AU Health performed 1,500 virtual COVID-19 screenings; by April 20, it had conducted 3,500 virtual screenings. Those who qualified for testing based on a virtual screening were directed to an emergency department (ED) testing center established by AU Health.

Today, AU Health is expanding its telehealth footprint and creating virtual services in the ambulatory space, such as postoperative visits and geriatric care. So far, 22% of ambulatory visits have been converted to telehealth, primarily in areas such as behavioral health, neurology, family medicine, and pediatrics. The system’s goal is to convert 50% of ambulatory visits to telehealth.

The onus isn’t just on providers to support a more robust telehealth response. For the U.S. healthcare system to fully leverage telehealth throughout the coronavirus pandemic, stakeholders such as government, health plans, and health systems must partner to:

• Ensure equitable access to broadband technologies for patients
• Limit regulatory barriers to telehealth adoption, such as licensure portability and reimbursement reform
• Incentivize programs that encourage innovation, particularly for vulnerable populations in skilled nursing and long-term care facilities

2. Position telehealth as the “great load balancer” in healthcare. Using telehealth to leverage clinicians from areas that are less affected by the coronavirus can replenish vital healthcare services in areas that are overwhelmed. This puts trained resources where they are most needed, saving lives while shielding those who have not been infected. It’s an approach that also helps to prevent harm, such as when local workers become overtaxed in keeping up with demands for care. Our own Amwell Medical group ensures we can provide this assistance by obtaining multiple state licenses for our providers. This notion was also extremely helpful during the initial COVID-19 wave. For instance, the New York medical license reciprocity allowed us to project our entire national network of providers to help the New York City outbreak.

Another example is Ochsner Health in Louisiana, which enables providers from outside their system to “Uber into the telehealth app.” More than 2,400 providers—both within and outside the health system—are trained to deliver virtual care through Ochsner Health’s telehealth platform. Currently, about 230 on-demand urgent care visits take place each day, with an average wait time of just eight minutes. The organization far surpassed its goal of 6,000 telehealth visits in 2020, with more than 80,000 virtual visits conducted since March alone.

Even within a state, any provider who is duly licensed can provide telehealth services throughout that state. This is useful for specialty consults, on-call coverage, and projecting care to rural regions. But, as mentioned above, national licensure or a national compact allows for much greater load-balancing potential. The Federation of State Medical Boards’ Interstate Medical Licensure Compact has helped some, but it is fraught with challenges and only available in some states. The coronavirus pandemic has demonstrated what can be achieved when state licensure barriers are removed; hopefully the future will involve more licensure portability.

3. Establish the right incentives for virtual care. The use of telehealth to replace in-person, routine care ensures continuity in care without exposing individuals to other illnesses—including the coronavirus—in the waiting areas of physician practices or EDs. Leading health plans are already offering telehealth to their members, but with caveats, and the offerings are disproportionately in states with reimbursement mandates. In the federal space, reimbursement for telehealth is still spotty—permissible in Medicare Advantage (MA) but hamstrung in fee-for-service (FFS) Medicare by the site restriction. Medicaid coverage for telehealth exists, though it varies dramatically by state. But expanding access to telehealth will require commercial payers and the federal government to incentivize providers and patients to use virtual care, and to offer payment parity for in-person and virtual services. It also necessitates regulatory flexibility, including greater flexibility around modality and model.

Prior to COVID-19, CMS took steps to increase access to telehealth for seniors by allowing MA plans to make telehealth a core benefit. After the arrival of the pandemic, the U.S. Department of Health and Human Services also took steps that resulted in a waiving of the Medicare site restriction for FFS Medicare. This has increased utilization and, importantly, encouraged providers to adopt telehealth for their entire patient panels.

The technology to combat the pandemic is here

The use of telehealth to transform our response to the coronavirus pandemic isn’t some futuristic idea. Telehealth was already establishing itself as a standard point of care prior to COVID-19. But during the pandemic, telehealth has become a necessity—and a vital part of most systems’ strategies. Telehealth has played a key role in triage and gatekeeping overloaded EDs. It’s allowed providers to care for their patients while their offices are closed or restricted, and it has given patients much-needed access to care. In short, telehealth has saved lives and helped keep our healthcare system going. As we move forward, telehealth will simply be a part of how routine healthcare is delivered.

Peter Antall, MD, is chief medical officer for Amwell, a telemedicine provider.