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Guide: Telemedicine benefits held back by lack of reimbursements

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Telemedicine clinics make inroads into primary care

Two approaches to telemedicine clinics, one where a vendor provides the doc, one where it doesn't, expand telehealth's reach into primary care.

This is the first of two parts examining telemedicine clinics that support primary care practices.

The health IT expansion of the last five years seemed to have left behind videoconferencing for remote patient visits. While it would seem a no-brainer that can potentially save time for both patient and provider, telemedicine seems to have been reserved for high-demand specialists, such as emergency stroke physicians and dermatologists who use telemedicine implementations to bring their skills to patients in rural areas. The holy grail for telemedicine advocates has been primary care, which could make video physician visits an everyday occurrence on a much larger scale.

But all that's changing this year, it appears. The major obstacle to expanding telemedicine in primary care has not been technology, but rather a reticence on the part of commercial and public payers to reimburse for healthcare delivered remotely via video.

Two trends are changing payers' minds: New state and federal laws giving Medicare and Medicaid the authority to at least consider reimbursing telemedicine, and accountable care organizations (ACOs) that pay providers not for the number of episodes of care but instead for the overall health of their patient populations.

While the ACO movement is specifically a CMS-created organization funded by the Affordable Care Act, commercial payers are experimenting with their own population-health management programs, such as Blue Cross Blue Shield (BCBS) of Massachusetts' Alternative Quality Contract (AQC).

Several IT vendors compete to provide the secure platform for primary care telemedicine clinics. At least two -- Seattle-based Carena Inc. and Boston's American Well -- are making it happen after inking agreements with both providers and payers. The former provides its own doctors to provide primary care services to patients via phone and video for several groups of clients including payers, employers and private-pay patients as well as off-hours support for primary care at Franciscan Health System in Tacoma, Wash. American Well supports several BCBS organizations, providing telemedicine infrastructure for its affiliated providers, who conduct the patient care themselves.

American Well's AQC experiment

Both models espouse to save the costs of unnecessary emergency room visits by offering an alternative route to seeing a physician in non-emergency room situations. BCBS of Massachusetts hopes to do more with a current American Well pilot project to determine use cases for providers in the AQC (85% of BCBS-contracted docs in the state are in the AQC program), such as post-op check-ins with patients to cut down readmissions and between-visit updates for chronic care patients, and possibly apply it to medication management.

The pilot will run with two physician groups for two years, the costs to be shared by the payer and its providers. "Essentially the purpose is to get a better understanding of the value of telemedicine, to test the financial and clinical effectiveness of American Well's online care platform," said Gregory LeGrow, BCBS of Massachusetts director of network innovation, adding that the groups themselves will determine how to use the platform to best meet their needs for bettering outcomes.

LeGrow said he believes that the AQC, ACOs and meaningful use are coming together as aligned incentives to make telemedicine feasible now, where it might not have been acceptable in the traditional straight fee-for-service model. In the fee-for-service world, providers worry that telemedicine could cannibalize the higher-paying office visits; payers also worry that telemedicine visits would become an added service to reimburse. In the global payment schemes of ACOs and the AQC, "those barriers break down, and it's a lot easier to move forward," he said.

BCBS of Massachusetts stresses that the telemedicine pilot for its AQC docs is not designed to be a Web storefront or a recruitment tool. It's only to be used for physicians to extend their relationship with patients they already have, whether it's for after-hours visits or between-visit care. The more traditional "clinic" part isn't off the table, LeGrow said, but isn't a part of the present implementation.

Technical requirements no barrier

To use American Well's platform, LeGrow said, the entry is low, requiring at its most basic an Internet connection and a computer. However, he said there are options for providers to take on more complicated implementations that include, among other features, EHR integration.

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In fact, he believes that the highest cost of implementing the telemedicine clinic will be the workflow changes and other time investments that will be needed to launch the service, maintain HIPAA compliance and train physicians on how to conduct calls in a professional manner.

American Well CEO Roy Schoenberg, M.D., said that his business has rapidly expanded in the last three years, starting with statewide or regional payers for its few customers to today, where it provides the telehealth infrastructure for several large national payers such as UnitedHealth Group and WellPoint Inc. as well as for Rite Aid Corp.'s retail pharmacy locations.

United and WellPont, he said, provide telehealth visits as part of their covered services. Since American Well has physicians licensed in all 50 U.S. states on its system, the service is attractive for national payers who can turn on telehealth "with the flip of a switch," Schoenberg said.

Large integrated delivery networks (IDNs) that are signing up for ACO and/or AQC-like programs that pay for population health management are also finding benefits to telehealth, he said. "They're signing up for a variety of risk-sharing contracts -- ACOs, medical home contracts -- where they are to some degree financially accountable to how well their patients are doing," Schoenberg said.

"These [IDNs] now realize that if they need to be in closer contact with those patients to make sure they are doing well, telehealth can play a very big role in extending that followup, that envelope of care, closer to where the patients live or to their workplace."

Next: Carena makes its way into the provider telemedicine clinic space.

Let us know what you think about the story; email Don Fluckinger, news director or contact @DonFluckinger on Twitter.

This was first published in July 2013

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Guide: Telemedicine benefits held back by lack of reimbursements

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