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Transcription:

Nick: Hello and welcome to Avalere’s fourth episode in a series of podcasts focused on the COVID-19 response efforts. My name is Nick Diamond, and I am a one of the public health policy experts in the Policy practice at Avalere. I am joined today by my colleagues, Chad Brooker, an Associate Principal in the Policy practice and Josh Seidman, Managing Director for the Center for Healthcare Transformation at Avalere. In today’s episode we will discuss what COVID-19 means for healthcare delivery, with a focus on the telehealth dimensions. Let’s start with you Chad. We have recently been hearing a lot about telehealth in the news in response related to the recent pandemic at the federal and state levels. Can you tell us about what is going on with Medicare in this related space?

Chad: Yes, it is important to make sure people can still access care. More importantly, that they can access care through providers that they are used to working with. A lot of the new previsions allow them to maintain those relationships directly with those providers, or providers in the same practice. That should help with the continuity of care concerns. Telehealth is going to allow people to not only maintain that access and get necessary continuation of care, [but also] to be in a setting that is convenient, as a patient, and reduces the risk of transmission of COVID-19, or acquiring COVID-19. This is aligned with the stay indoors orders that have been issued throughout the country, specifically in certain geographic areas. We have also seen orders from the federal government, asking that telehealth be used as a mechanism to reduce the strain on critical resources in our healthcare sector, especially within hospitals and acute care settings—so that they can devote their attention to critical needs, in order to respond to COVID-19.

Telehealth is an important modality to be able to ensure critical resources are directed to response efforts to flatten the curve. Medicare has traditionally had a love-hate relationship when it comes to telehealth as a modality. In the past couple of years, there has been an increase in flexibilities around coverage of telehealth and reimbursement for telehealth, but there are also restrictions, such as the care needs to be for existing patients, there needed to be an in-person visit before going to a telehealth setting, needed to be a rural setting, that have been revised because of the COVID-19 outbreak.

We have seen on the coverage stance, that Medicare has increased access to telehealth by removing the ruralness requirement, which was a flexibility afforded to them through recent legislation that has passed. In addition, we have seen the federal government add flexibility for waiving things like cost sharing for using telehealth. There is an appreciation from individuals who may be more at risk for COVID-19 because telehealth can play an important role in ensuring access to providers and can do so by providing minimal risk to exposure to COVID-19.

Nick: Great, thanks Chad! Josh let’s turn to you. Obviously, telehealth is only one component of the broader delivery care system that has been getting a lot of attention lately. But there are broader picture issues around COVID-19 that might relate to specific sub-populations, or the role of certain provider response efforts. Can you speak to these considerations?

Josh: Yes. And, to reiterate what Chad was saying, I agree that telehealth is important right now. I think what is remarkable, is how quickly providers and patients have adjusted to everything—at least, from what I have heard from clinicians and patients. So, that is interesting. Private payers have been following suit for the most part, even if it is not as uniform as the federal government. With respect to the impacts of COVID-19, to other aspects of care delivery, there are certain populations that are going to be affected.

• Our vulnerable elderly populations who are experiencing social isolation, which is likely to increase, especially if based off institutionalized settings, where outside population visits have been limited.
• There are also impacts to function for our elderly. For example, 10 days of bed rest can reduce muscle mass by 7%. This can have an impact when you think of patients who are largely confined to limited settings for long periods of time, and what is going to happen after the restrictions have been lifted.
• There are also huge impacts on other populations that do not have good access to care or have options to telehealth, if they cannot get to the general care they need.

Nick: Josh, as we talk about telehealth, we have been thinking about this purely in the sense of physical health. However, there is a strong mental and behavioral health component to the current pandemic. Can you speak to how you see telehealth as a tool to help with some of the behavioral and mental health issues?

Josh: Yes, I think it is important to speak to. This pandemic is having a big impact on all of us. People who are suffering from various mental health issues have several concerns, such as:

• Access to providers in a timely manner.
• Various support systems that may not be there. For example, individuals with substance use disorders, may not have the same access to support groups which could play a role in recovery.
• Issues surrounding general social engagement for support.

People with various types of mental health issues – social anxiety, depression, PTSD – could be in a position that makes it more challenging to balance everything.

Nick: Thanks Josh, as we are thinking more on the behavioral and mental health issues involved, this brings up the bigger picture of social determinants of health. I think we are seeing more of those core determinants – the physical and mental – come up in this situation. But we also have people out of work, economic pressures, and social pressures around isolation. How are you thinking of these social determinants of health in your current work?

Josh: Yes, this is a big issue. First, the populations that have economic barriers to health and healthcare are facing increased barriers. Some of us have the luxury of preparation for isolation, stocking up on food and so forth. However, many people do not have the resources to do so. There may be those with heightened food insecurity. We talked earlier of those who may have limited access to telehealth, in addition there may be issues with access to providers for basic health needs. Much of the elective care, which includes preventive care and chronic care management, are being delayed, so that can also be a barrier to getting what is needed.

Chad: Adding to what Josh shared surrounding barriers to care, the financial barriers to purchase devices for access to information and the internet – which allows people to engage in telehealth related visits or access providers in other mechanisms and share information – is something we are looking at. It will be a challenge unless there are reforms to allow payers, providers, and manufacturers to have more flexibility in supporting social determinant of health-related considerations. Especially those limiting how effective telehealth and other remote care delivery mechanisms can be. When we think about anti-kickback statutes and beneficiary induced provisions limiting the ability of providers and manufactures, even on a temporary basis with iPads or other devices or paying for internet connection—mobile apps, tracking patient health and vital signs, like blood pressure and heart rate, can be utilized to share patient diagnostic information with providers to be more effective in treatment. We have had a lot of advancements in digital health, except there has been a lack of regulation that provide guidelines. And the regulations that are there, have been stuck in an antiquated era. There is a lot of room for advancement, not only during these national emergencies, but after these emergencies that bring to light gaps in care.

Nick: Thanks Chad, and this raises an important question for both of you: After this pandemic is resolved, what do you think the current flexibilities and the way we are approaching these issues mean for care delivery in the future, specifically for telehealth? Josh let’s start with you.

Josh: Sure. I have spoken with providers, and I mentioned that things have gone reasonably smoothly. This does not mean that there have not been issues, but I have been hearing, “we are not going back”. People have grown used to this, and they are going to say, “why don’t we do more of our engagement virtually?” I think there is always going to be room for improvement for in-person engagement in the clinic, but there is an opportunity to move more of the interactions between clinician and patients to a virtual setting. Some of the push is based on convenience, which has a big impact on people’s lost time at work. With hourly wage workers, this has a big impact on them because there is time spent on transportation and parking, which all amount to a cost. For people with economic instability or insecurity, this shift can be important in removing barriers.

Chad: Yes, I agree with what Josh said. To add, I think that this will also become market specific. From the commercial market capacity, we have seen many commercial payers that have used this as an opportunity to expand and explore how to use their telehealth platforms moving forward. As Josh suggested, telehealth has played, for some time now, a big role in the behavioral health space, especially in the commercial market. Also, a lot of the employers have been using telehealth to provide an amenity for behavioral health engagement, to access the care you need. It has proven to be effective as a tool for ensuring proper and efficient use of resources, and I think you will see this spread into the government markets as well. Commercial payers for some time now, have been using remote type systems to evaluate if a patient is having certain symptoms. They can check-in instantaneously, triage diagnosis, and make sure that person is going to the right site of care—with the best quality, the most affordable solution for treatment, and with the best track record in terms of outcome for patients.

For the Medicare space, it could see significant changes, given that Medicare’s telehealth restrictions have been the strictest of the government programs. You may see Medicare:

• Permanently reduce the requirement to have the initial in-person meeting before having an established telehealth connection with a provider;
• Permanently removing the ruralness requirement around telehealth access; and
• Make provisions around telehealth access that makes it the less affordable way to communicate between providers.

As we think about transparency, interoperability, and the amount of data going back and forth between patients and providers, telehealth is going to play a huge role in equipping patients to play a more active role in their acute care and long-term disease management decisions. This also provides opportunity for providers to continuously engage with patients more effectively. The commercial market is going to more heavily embrace telehealth than they already have, and Medicare is going to use the opportunity to reduce the inherent antiquated flexibilities it has had for some time. We have seen some chipping at the inflexibilities over the years, but this is a shot in the arm from the telehealth space for the Medicare space. We will see more expansive aspects even outside the Medicare Advantage space, and general openness to telehealth.

Nick: All very important considerations we look to during and after this pandemic. Chad and Josh, thank you for your time today and for discussing care delivery and telehealth issues with the COVID-19 pandemic. My name is Nick Diamond, and we have a series of podcasts at Avalere responding to the ongoing considerations to COVID-19 on our website, and more to come in the coming weeks. Feel free to check those out and stay safe!

Listen to other podcasts in this series:

E1 – Get the Facts on COVID-19: Vaccination Affordability and Access

E2 – Get the Facts on COVID-19: Patient Out-of-Pocket Costs

E3 – Get the Facts on COVID-19: A Comparison to Other Outbreaks