Penny, an 85-year-old woman with chronic heart failure (CHF), has an unusual dizzy spell at 9 p.m. Though it passes, she’s worried. Since her doctor’s office is closed, she wonders if she should to go the ED — just to be safe.
Instead, Penny goes to her kitchen and turns on her telehealth monitor. A doctor’s face appears on the video screen, and Penny describes her concerns. The doctor notes that Penny’s weight and vitals — which are monitored remotely — have been normal lately. He determines that Penny does not need to go to the ED. Instead, he notifies her primary care provider and recommends scheduling her for a follow-up appointment the next day. Penny is able to sleep, her concerns alleviated.
Just a few years ago, Penny’s story might have sounded like science fiction. Today, it’s increasingly commonplace as hospitals and health systems seek to contain costs, reduce unnecessary emergency room visits, and proactively manage patients’ health. They do so by delivering care outside of the “bricks and mortar” hospital settings.
In today’s post, we will discuss telehealth and how hospitals, health systems, and payers can leverage it to better manage patient health and resource utilization in the coming era of value-based care.
From Managed Care to Population Health
The keen interest in telehealth has been driven in part by the expansion of population health management (PHM).
PHM grew out of an earlier cost-containment strategy that gained prominence in the 1990’s: managed care. Managed care’s goal was to reduce costs by carefully controlling patients’ utilization of services.
Almost all payers now manage patient care to some degree. And yet, healthcare costs have continued to rise at alarming rates. Despite efforts to curb overutilization, managed care has done little to reduce the overall demand for healthcare services. In fact, that demand continues to rise sharply. Heathcare consumption tends to increase with age, and 22 percent of the U.S. population will be 65 or older by 2040 (versus about 14.5 percent today).
Meanwhile, physicians, nurses, and other healthcare providers are becoming scarcer. Outpatient practices in many parts of the country are already operating above capacity, with the first available appointments being scheduled three weeks in the future. Patients are enduring increasingly long waits for office visits and have limited options for managing chronic diseases or low-acuity injuries or illnesses.
The result is the exact opposite of what managed care intended. Americans with non-emergent conditions are increasingly presenting to EDs — a very expensive care setting by any measure.
And finally, managed care did little to reward providers for coordinating care and maintaining an overall quality of care. For example, a family physician and a cardiologist had little incentive to coordinate complex patient care for patients like Penny.
Because managed care has not succeeded in containing costs, payers and healthcare organizations are exploring other options. They are looking at strategies that limit consumption by keeping patients healthy. This approach, known as population health management, is changing how and where healthcare is delivered.
Population health management focuses on delivering healthcare in places that are more affordable than the ED and inpatient units. The most promising approaches involve the use of technology to support our heavily burdened system in caring for the chronically ill patient like Penny, who requires a number of carefully orchestrated services to manage her condition.
Winning With Telehealth
Telemedicine, or more broadly, telehealth, is one of several tools that has the potential to positively impact both utilization and population health.
Potential telehealth applications span the Acute Care Continuum. Low-acuity urgent care, remote patient monitoring, inpatient monitoring, chronic disease management, and post-discharge follow-up can all be accomplished across distances, increasing patients’ access to routine and specialty care.
The growth in telehealth parallels the explosion of “retail clinics” embedded in stores like Walgreens and CVS. These companies discovered that patients were increasingly seeking care outside of the “normal” hours physicians were likely to keep in their offices. They turned their brands and their locations into more than just “drug stores” and built pharmacies on nearly every corner in urban areas. They are providing consumers with a lower-cost alternative to the primary care physician, urgent care provider, and ED visit.
Telehealth lowers the cost of low-acuity care even more than the retail clinic and offers patients the flexibility of receiving care at home or work. Consider the average costs for payers and patients (especially those with high deductible plans) for healthcare services in the United States:
- Primary care visit: $131
- Urgent care visit: $163
- Emergency department visit: $1,477
By contrast, the average telemedicine call costs $40 to $50. By diverting a primary care, urgent care, or emergency department visit to a telehealth call, there is a potential savings of $79–$1,427 per visit.
A Spectrum of Telehealth Applications
Low-acuity teleurgent care was one of the earliest and most widespread applications of telehealth. However, innovative companies and healthcare organizations are pushing the boundaries with new technologies and delivery models.
Other examples of telehealth impacting population health include:
Monitoring patients with complex chronic illness at home. Studies have shown remote patient monitoring reduces unnecessary emergency department usage by 25–50 percent. Several models have proven to be beneficial:
- Providing patients with CHF, COPD, and other chronic conditions with remote monitoring devices to track their vital signs and symptoms.
- Offering people with limited social support the opportunity to have their medications and circumstances monitored and reconciled by a care coordinator (often a nurse or social worker).
- Monitoring patients post-discharge to improve outcomes, medication compliance, and reduce preventable readmissions.
Monitoring inpatient outcomes in the ICU. Offsite intensivists now monitor about 10 percent of all critical care patients, and the results have been rewarding. Banner Health’s eICU program has saved lives while reducing costs and preserving resources. The program is run from a central operations center staffed with critical care doctors and nurses. These providers remotely monitor more than 600 ICU beds in more than 25 hospitals in seven Western states, providing welcome clinical support to hospital staff. Since launching the program, Banner Health ICUs are reporting some of the lowest ICU mortality rates in the country. In 2014, Banner Health reduced predicted ICU days by 20,000, saved $68 million, and saved an estimated 2,000 lives.
Monitoring the tiniest of patients. Multiple health systems promote the benefits associated with teleneonatal monitoring, including positive outcomes for baby and attachment between child and parent. Utah Valley Regional Medical Center in Provo, Utah, partnered with VSee, to support the 60-bed NICU. The system provides two-way communication between physicians and parents. What’s more, families can access a live stream of their baby 24/7, which helps them stay connected between visits.
Providing emergency telepsychiatry access. With only 35,000 psychiatrists in the United States, patients suffering with a mental heath crisis are often held in the ED for many days waiting for a psychiatrist to diagnose and treat them. The topic was discussed on John Oliver. Telepsychiatry provides emergency physicians with prompt access to a psychiatric consult. The results: faster relief for patients, reduced care costs, and less burden on ED resources.
Providing timely telestroke evaluation. If an ischemic stroke is diagnosed within four hours of onset and a special “clot busting” drug administered, the likelihood of permanent disability diminishes significantly. Telehealth facilitates this process by connecting emergency physicians with stroke neurologists within this critical window of time if there is not a neurologist onsite. This is especially beneficial for rural and community hospitals that don’t have these specialists on staff.
The opportunities to promote population health and ensure all patients get the appropriate care they need when they need it via telemedicine will only expand as technology advances. Hospitals will benefit from great care quality and more favorable utilization by patients. Meanwhile, high-risk patients like Penny will rest easier knowing that medical advice is just a few clicks away.