Regional Payers Outline Challenges, Successes of Telehealth Implementation

In a panel at the at the 2021 AcademyHealth National Health Policy Conference, representatives from 3 community health plans across the United States discussed how payers are driving telehealth access and utilization in the wake of the coronavirus disease 2019 (COVID-19) pandemic.

Lee Mills, MD, the senior vice president and chief medical officer at CommunityCare in Oklahoma, Richard Isaacs, MD, FACS, CEO and executive director at the Permanente Medical Group in California, and Namita Ahuja MD, the medical director of UPMC Health Plan in Pennsylvania, shared each plan’s unique successes and challenges in the shift to telehealth services.

“While many health plans had already been investing heavily in telehealth infrastructure prior to the pandemic, COVID-19 has been a tremendous adoption accelerator,” said Connie Hwang, MD, MPH, chief medical officer and director of clinical innovation at the Alliance of Community Health Plans, who moderated the discussion.

Although it is based in California, Kaiser Permanente exists in 8 states and Washington D.C. Leveraging existing telehealth infrastructure during the pandemic, the plan was able to easily integrate the technology to expand its breadth beyond tele-dermatology, providing care to hospitals using remote access and other prior uses, Isaacs explained. “The pandemic has really reinforced how valuable telehealth is for providing patients across this country with the needed health care in all settings, including their homes.” In addition, “easing regulatory restrictions on telehealth at both the state and federal levels expanded our ability to provide these services and continue to provide care for our patrons remotely,” Isaacs said.

Currently, COVID-19 e-visits are being conducted across all Kaiser Permanente regions while the plan continues to improve technology for patients with time sensitive and critical medical conditions. One innovation—the acute stroke care program—now features telestroke neurologists and “has reduced door to needle time for most stroke patients to less than 30 minutes,” or 2 times faster than the national average, Isaacs said.

However federal changes are needed to reflect the expansion in telehealth access. “Our colleagues in a fee-for-service setting will struggle bringing expertise into an integrated care delivery system if there isn’t a possibility for the expert to be compensated for that work,” he noted. One way to overcome this challenge is by implementing the care and coverage model of Kaiser Permanente. “It’s all about the patient-centered care and providing the best care with the most convenient access for our members,” Isaacs concluded.

On the other side of the country, UPMC Health Plan, the largest insurer in western Pennsylvania, has been working to do just that. Touching on the importance of addressing potential technology gaps, Ahuja noted “we have to think about the many providers and our patients that we serve, whether they have the same capability and support that they need to help us navigate through these changes, especially in the telehealth space.”

Similar to Permanente, UPMC had made substantial investments into telehealth services prior to the pandemic. With expanded coverage granted by CMS, the plan looked into its previous physical can behavioral health care, triage care support programs, care management and case management. In particular, to increase patient-caregiver interactions, improvements were targeted at video conferencing, secure messaging, remote monitoring, and app-based interventions.

By monitoring utilization throughout the pandemic, the plan found “member-patient adoption for behavioral telehealth is holding on stronger” when compared with visits for physical health. A remote monitoring program aimed at patients receiving palliative care also exhibited peak utilization throughout the pandemic, while a program monitoring postpartum hypertension remotely yielded an 80% follow-up rate 4 to 6 weeks postpartum compared with a 16% prior average.

In Oklahoma, where CommunityCare provides services to roughly 100,000 individuals, there has historically been large telehealth integration challenges resulting from different electronic medical record (EMRs) used in health systems in addition to structural challenges of patient privacy and technology requirements, Mills explained.

“In 2019, we were actively exploring options to launch a telehealth solution, but analysis and coordination with our owners, and the state of the community really showed us that, at that time, outsourcing was probably our only legitimate option,” Mills said. “But [outsourcing] would fragment primary care provider care even further. With no linkage to our owners’ EMRs it would affect quality and risk scores, and it really wasn't the way forward.”

However, with the onset of the COVID-19 crisis, “We immediately enacted payment coverage policies at the individual provider level to leverage whatever capabilities existed. In early March, we provided telehealth visits for COVID-19 at no cost,” Mills said, noting there was no time to wait for the right solution. Afterwards, CommunityCare expanded services to tele-behavioral health and all medically necessary services.

“So suddenly we had the whole gamut of care from virtual check ins to e-visits, telephone encounters, when that was appropriate necessary, full telehealth encounters, and in-person encounters that continued in our community,” Mills said. Regardless of who initiated the telehealth visits and what the outcome was, the plan offered $0 copay for all visits. “Our dominant capitation model made it easy for us to extend that service to our providers and members without worrying about some of the potential consequences at that time.”

Instead of payment policy and technology dictating every problem necessitated an in-person visit, the member and provider were able to decide the right venue and care for each individual situation, Mills explained. Providers were also not required to bill or document in certain formats and members were not required to use a certain platform.

However, the plan’s primary care visit deficit is now at 76,000. While telehealth encounters rose from zero in primary care visits to a peak in April and May, they have now stabilized at around a quarter of all visits. Telehealth “certainly doesn’t replace the missing primary care access,” but is a critically needed venue and has improved access to care within the community, he said.

“We really believe and truly hope that we've passed an inflection point in telehealth and that we will only be moving forward to a new future that's undoubtedly different than what any of us imagined a year ago,” Mills concluded. “We hold firm in the opportunity and value of telehealth and think that the benefits and positives far outweigh some of the concerns and unknowns that still are to be defined.”

When it comes to policy interventions supporting these shifts in care, new guidance will have to weigh patient security with access, so as to not make platforms and technology too restrictive and limit adoption. New legislation will also need to bear in mind certain geographic restrictions to technology use, the experts added. “We think of telehealth as a good resource, but are we going to be increasing the digital divide? …There are a lot of social determinants of health that factor into access and utilization of health care,” Ahuja said.

Telehealth will not be a replacement for all in-person visits, the panelists stressed. Providers and patients can work to strike the right balance of seeing the value in telehealth visits as opposed to traditional care delivery. “I think it's going to be an important tool in the toolbox, [telehealth visits] won't be the tool that everyone can use in every situation,” Mills said.