Elevar (www.elevarco.com) recently interviewed our CEO, Justin Kahn, on the telehealth landscape and the future of medicine. See the original article here or read on below.
The Future of Telemedicine: Lessons from a Startup CEO
By Surabhi Reddy
Telemedicine services are widely expanding and growing across the country, propelled by the ubiquity of remote technology and frustrations over the typical healthcare process. Per a 2015 Rock Health survey, telemedicine was found to be popular in the 35-54 age demographic, to have high satisfaction rates, and to experience high levels of adoption.1 Considering the opportunity cost associated with traditional access to care (i.e. time, travel, etc.), telemedicine may represent the next great frontier in healthcare. Even the Centers for Medicare & Medicaid Services have expanded coverage for telehealth services to Medicare beneficiaries.2
Yet, with this expansion, numerous doubts have risen about the feasibility of telemedicine on a broad scale. How do we reimburse for telemedicine services? Can providers adapt to new telehealth technology? How will telemedicine affect the patient-doctor relationship? How can telemedicine be integrated into existing provider systems? What does the future of telemedicine look like – and does the hype live up to the reality? We spoke to Justin Kahn, Founder and CEO of TruClinic, a Salt Lake City-based startup with the mission of making telemedicine available for everyone, for insight on these matters. Working towards answering these questions will allow us to target development and research in telemedicine, with the eventual goal of optimizing this technology to best meet our healthcare needs.
Developing the Right Policy for Telemedicine
Reimbursement for telemedicine services is a muddled and contentious topic. According to Kahn, every type of payer (from Medicare and Medicaid to private payers) has different contracts and benefits for which they will cover. The passage of the ACA initiated a model for reimbursement of telemedicine services in Medicare and Medicaid. However, these reimbursements are largely limited to special circumstances and are often left to the discretion of individual states.3 Even now, five states bar the use of cell-phone video to facilitate telehealth.4 States can also govern telemedicine policies for private payers and providers – resulting in a lack of a standard procedure or business model across state lines. Currently, many providers are confident in the reimbursements they receive for in-person health services, but are unsure about how to implement and bill telemedicine services. Therefore, there may be hesitance to take advantage of this technology, which could exclude patient access to such services – creating a significant hindrance to potential expansion of telemedicine.
Reimbursement for telemedicine services is a muddled and contentious topic. The passage of the ACA initiated a model for reimbursement of telemedicine services in Medicare and Medicaid. However, these reimbursements are largely limited to special circumstances and are often left to the discretion of individual states.
For the roughly 55 million Medicare beneficiaries (that account for 20% of our national health expenditure), telemedicine options are rather limited.5,6 For the majority of beneficiaries, Medicare only reimburses for telehealth as a substitute for an in-person consultation, and patients must be located in a Health Professional Shortage area or rural census tract. Only Medicare beneficiaries in alternate payment programs, like chronic care management (CCM) or Comprehensive Primary Care Plus (CPC+) are eligible to receive telehealth at home and qualify for store-and-forward services. Providers must opt into the CCM or CPC+ track and meet the qualifications before they can be reimbursed for these telehealth services. Medicare beneficiaries, who account for a sizable chunk of our country’s patient population, stand to gain a lot from universal telemedicine eligibility. However, due to the laundry list of restrictions and limitations in their coverage, it is a hardly a viable option for them.
For Medicaid and private-payer insurance, the lack of a standardized, uniform reimbursement system makes it difficult for telemedicine to reach its full potential. Controversy exists between states on telemedicine parity laws, specifically whether to make reimbursement rates for telehealth services equal or similar to in-person services. If this parity does not exist, the reimbursement for telehealth will likely be a fraction of what it is for traditional services, effectively disincentivizing any provider from offering remote services. However, as Kahn mentions, many private payers are opposed to parity, as they prefer to negotiate their own rates and reimbursements.
Patients are concerned about privacy and security in telemedicine. Kahn emphasizes that “Healthcare information is the most sensitive information around.”
Differences in policies from state-to-state can make it difficult for private telemedicine companies and applications to expand. For example, in 2016, Washington’s Medicaid elected to provide limited reimbursement for store and forward delivered services, but Oklahoma’s Medicaid program ceased its store and forward reimbursement.7 Until we iron out the wrinkles in telemedicine policy (from reimbursement to parity to eligibility), we must temper our expectations of this technology as healthcare’s panacea. What we can do is offer providers and patients clarity on existing policies, as TruClinic does on its state reimbursement map. With this service, users can educate themselves about reimbursement policy based on their state of residence, insurance coverage, and type of service – a useful tool to obtain the right telemedicine for their healthcare needs.
Making it Work with Patients and Providers
Opponents of telemedicine cite the sanctity of the in-person, patient-provider relationship. How can a digital screen replace the therapeutic value of a face-to-face encounter, where feelings of trust and empathy develop?8 And while some doctors may be comfortable with technology and remote communication, many more are comfortable with the tried-and-true methods of the examination room in reaching a diagnosis. Moreover, patients are concerned about privacy and security in telemedicine. Kahn emphasizes that “Healthcare information is the most sensitive information around.” In a survey by Cisco, 39% of respondents reported that they did not trust websites to securely store their health data, and only 15% said they would be comfortable remotely divulging blood pressure or heart rate.9 Particularly when patients record and save medical information to submit to their provider at a later time, it becomes essential that this information is encrypted and securely sent to prevent a data security breach.
Opponents of telemedicine cite the sanctity of the in-person, patient-provider relationship. How can a digital screen replace the therapeutic value of a face-to-face encounter, where feelings of trust and empathy develop?
It is important to consider that one size does not fit all when it comes to telemedicine services. Patients and providers can have different comfort levels with different types of technology, depending on the device, platform, and/or medical service. If I tell a digitally-naïve patient to access his patient platform on an app that he/she must install on a computer in a public-library, there is a low likelihood of a successful telemedicine encounter. Fortunately, many of the solutions to problems in telemedicine for patients and providers can be addressed by technological developments. Telemedicine stations consisting of a videoconferencing interface with built-in technology like digital otoscopes and vital sign monitors allow providers to gain a lot of the same information that they do in face-to-face clinical encounters. Additionally, Kahn mentions that we are in the midst of a generational shift: “If you ask your parents to use an Xbox, they may struggle.” But as the digitally-native demographic enters the healthcare market, patients are likely to be more comfortable and adept with telemedicine.
To address privacy concerns, it is recommended that any hospital using telehealth services conduct security risk analyses and have privacy and security professionals participate from the start in the design to its implementation.10 TruClinic prioritizes data security through ongoing internal audits and external audits are provided by independent external network security companies.
Most importantly, many experts explain that, in order to expand while simultaneously preserving high-quality healthcare, telemedicine must act as a supplement (and not as a complete substitute) to traditional healthcare.11
As Kahn states, “Telemedicine is medicine,” and there is huge potential for telemedicine to revolutionize the delivery of healthcare.
As it stands, telemedicine is the most promising field in digital health to address access (one of the three corners in The Iron Triangle of Healthcare – Access, Cost, and Quality).12 But, to ensure telemedicine grows with legitimacy and reaches its full potential, we will have to tackle many of these current issues. From a policy perspective, the American Hospital Association (AHA) recommends that we: expand the services covered by telehealth, harmonize state laws, and promote telehealth parity in reimbursement.10 Additionally, we must establish clinical protocols to streamline the telemedicine process and create standards to protect patient privacy and security. Providers, perhaps the most important piece of the puzzle, must support both growth and innovation in telehealth, while being mindful of quality of care. Startups and developers in telehealth must realize that videoconferencing is a commodity – and the winners will be those that can integrate a diverse set of experiences (e.g., e-prescribing, care planning, scheduling) around the video conference and existing EHR systems. As Kahn states, “Telemedicine is medicine,” and as we continue to iron out the kinks in policy, design, and usage, there is huge potential for telemedicine to revolutionize the delivery of healthcare.
1Malay Gandhi & Teresa Wang. Digital Health Consumer Adoption: 2015. RockHealth.
3Health Policy Brief: Telehealth Parity Laws. Health Affairs. 2016.
4Meg Bryant.ATA: States show mixed progress with telemedicine. Healthcare Dive Briefs. 2017.
5Total Number of Medicare Beneficiaries. Kaiser Family Foundation. 2015.
6NHE Fact Sheet. Centers for Medicare & Medicaid Services. 2015.
7State Telehealth Laws and Medicaid Program Policies A Comprehensive Scan of the 50 States and District of Columbia. The National Telehealth Policy Resource Center. 2016.
8Shivan J. Mehta.Telemedicine’s Potential Ethical Pitfalls. AMA Journal of Ethics. 2014.
9Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Cisco Newsroom. 2013.
10Realizing the Promise of Telehealth: Understanding the Legal and Regulatory Challenges. American Hospital Association. 2015.
11Susan D. Hall.ATA: Telemedicine meant to supplement, not ‘totally replace’ in-person care. FierceHealthcare. 2014.
12Aaron Carroll.JAMA Forum — The “Iron Triangle” of Health Care: Access, Cost, and Quality. news@JAMA. 2012.