Chasing the ROI of Telemedicine

Virtual visit savings are promising but aren't moving the needle yet.

This article first appeared in the November 2016 issue of HealthLeaders magazine.

While some providers are finding a return on investment in telemedicine, measuring such returns involves a multitude of factors.

At the 2016 Healthcare Information and Management Systems Society's annual conference, Kaiser Permanente exhibited its exam room of the future, showing physician-to-physician telemedicine consultations now widely available throughout the Kaiser system.

"It's really personalized, and it builds on our existing relationship with our patients, and it's connected to our electronic medical record," says Angie Stevens, executive director of virtual care IT at the integrated health system and payer, which serves 10.6 million members in eight states and the District of Columbia.

Through this technology, Kaiser physicians can treat a broader range of conditions by conferencing in specialists at other Kaiser facilities, she says.

"In our smaller medical office buildings, such as in the mountains of Colorado, we can't staff all those specialties," Stevens says. Kaiser members can schedule video visits at outlying offices with specialists who join the meeting at the appointed time from wherever they are located in the Kaiser system, she adds.

Members can schedule video visits through traditional means such as the Kaiser call center, and then join the video visits from devices running the app, removing the need for the member to travel to a Kaiser office, she adds.

On the physician or specialist end, within the Epic electronic health record run throughout Kaiser, the clinician's schedule includes a video visit icon at the appropriate time, then turns green to indicate the patient is ready. Then the clinician can join the video visit by clicking on the icon, Stevens says.

All Kaiser regions went live with video visits by the end of 2015, and although Stevens cannot say how many encounters now occur this way, the number is on the rise.

"We also are working on a whole national marketing program so that we can educate our members on the option and what it means and what it's like, and what they can expect from it," Stevens says.

As it expands the range and nature of conditions for which a video visit is appropriate, Kaiser is noting the efforts of a growing number of independent telehealth providers, such as American Well, Teladoc, and Doctor on Demand, Stevens says. "These companies are often limited in the conditions that they can treat, and they often have little background on the patient, unlike our virtual care physicians who have access to their patients' complete electronic medical records," she says. "As the number of video visits at Kaiser Permanente continues to increase, we'll be able to look at a variety of use cases and determine where virtual care adds the most clinical value or personal value for our members."

But like other providers, Kaiser is pursuing hard numbers to justify its investment in telemedicine.

One study published recently in Kaiser's peer-reviewed Permanente Journal quantified how neurologists performing telestroke medicine via Kaiser's infrastructure increased their use of life-saving clot-dissolving medication in patients with ischemic stroke by 73%. The study was a retrospective analysis of all ischemic stroke presentations to 11 emergency departments between 2009 and 2013 in the Kaiser Permanente Southern California region.

By using telestroke, physicians in outlying Kaiser facilities lacking in-house neurology and neurological ICUs are able to contact a neurologist at a remote location, reducing the number of minutes needed to determine whether the patient should receive tissue plasminogen activator (tPA), the FDA-approved treatment for acute ischemic stroke.

"The part I think is unique to Kaiser compared to other versions is the telestroke physicians are able to see the lab values and CT images" during the telestroke session, says Adam L. Sharp, MD, lead author of the study and a research scientist and emergency physician with Kaiser Permanente Southern California's department of research and evaluation in Pasadena. "They're even able to write the order for tPA, and that's unique to our kind of integrated health system." In other institutions, attending physicians on the patient's side of the telestroke session often must write those orders, he notes.

Doctor choice enters the picture
Stevens says Kaiser is also working on developing options for members using telehealth to see their own primary care physicians at a later date, or choose instead to see a different physician on the same day.

This trend attracted major attention at the 2016 American Telemedicine Association conference. A number of providers, including the Cleveland Clinic and Nemours Children's Health System, participated in the launch of the American Well Exchange, a method of offering their services via American Well's LiveHealth Online platform, which offers live video consults with providers for treatment of common urgent care conditions around the clock. LiveHealth Online is operated by Health Management Corporation, a wholly-owned subsidiary of Anthem Blue Cross. American Well partnered with LiveHealth Online in 2012.

In the case of Cleveland Clinic, patients accessing LiveHealth Online in Ohio, West Virginia, and Pennsylvania can connect to Cleveland Clinic nurse practitioners via the Cleveland Clinic Express Care brand.

The alliance between Cleveland Clinic and American Well originated three years ago when Cleveland Clinic President and CEO Toby Cosgrove felt the organization needed a bigger telemedicine focus, according to Peter Rasmussen, MD, a Cleveland Clinic cerebral vascular neurosurgeon who also serves as medical director of distance health at the organization.

Rasmussen now heads up all Cleveland Clinic telemedicine efforts. He started Cleveland Clinic's own telestroke network, now active in more than a dozen sites in western Pennsylvania, Florida, and northeastern Ohio.

"We think that there isn't any aspect of medicine that can't have some component of it practiced via telemedicine or at a distance," Rasmussen says.

In keeping with the American Well LiveHealth Online direction as well as its own, Cleveland Clinic telemedicine customers can choose the provider they wish to see, as well as schedule interactions. Until now, most direct-to-consumer telemedicine services have not given patients the ability to choose which provider will see them.

"That really encompasses a broad range of almost everything that we do at the clinic, with patients being at home using their desktop, tablet, or mobile device," Rasmussen says.

Telemedicine also works well for follow-up patient visits, because many patients travel long distances to be treated at the Cleveland Clinic. "That keeps patients out of the facilities, and is a little bit more convenient for them at a lower cost and a better format for them," Rasmussen says.

Cleveland Clinic's own homegrown e-hospital system "has been a wonderful technology that's afforded us some modest improvements on length of stay, and reduced mortality over time," Rasmussen says. This summer, the organization also began pilot testing virtual chronic disease management, starting with hypertension, COPD, and pediatric asthma patients, he adds.

"It will be a combination of wearables or consumer-grade devices that patients have purchased, or we supply to them, that will generate data at home and will be displayed to us by dashboard, hopefully integrated with the electronic medical record by the end of the calendar year as well," he says.

Although hard financial numbers remain a matter under study, Cleveland Clinic is no stranger to measuring patient experience, and Rasmussen says for follow-up visits with providers, patients are happier doing virtual instead of in-person visits. "We are using this strategy to drive patients with minor complaints away from brick-and-mortar to free up the primary care physicians for more chronic disease management or a way to manage matters that require inpatient visits," he says.

Perhaps nowhere is the bottom line of telemedicine's advent being felt more than at health insurance companies.

"As most people know, health insurance has not been known for being differentiated in the consumer experience side of things," says John Jesser, vice president of Anthem, Inc., and president of LiveHealth Online. "So this is really a great opportunity to create a capability for Anthem that would be remarkable."

Anthem, which currently offers telemedicine as a covered benefit to 18 million Anthem customers, was attracted by the fact that the common retail price of an online visit is $49, Jesser says. "There's a ROI right there, because if you walk into a retail clinic, you're going to spend between $80 and $90. If you walk into urgent care, it will sometimes be over $200, and the emergency room goes up from there. So the ROI for one person is immediate."

FedEx, an Anthem client, knows that at least 20% of the emergency room visits its employees make are unnecessary, Jesser says. "We've been trying to help people with solutions for this for years," he says. In exit surveys after LiveHealth Online encounters, by asking members what they would have done had the telemedicine option not been available, Anthem has determined that telemedicine is generating "considerable savings across the board, every time someone's having an online care visit." Jesser says this cost savings information will find its way into a peer-reviewed journal soon, drawing on Anthem claims data.

A major task ahead for Anthem is educating its members that the telemedicine benefit is available.

"This is such a new way to get care that until you've actually seen it or been exposed to it directly, you don't know that you actually have the ability, that you have a doctor in your pocket."

"Do they all know they have this benefit?" Jesser says. "No. This is such a new way to get care that until you've actually seen it or been exposed to it directly, you don't know that you actually have the ability, that you have a doctor in your pocket."

Anthem is aggressively marketing the telemedicine benefit, "but it's not one of those things like a dental plan or a health insurance copay that you just put on the ID card and everybody understands it. You really need to address people directly through email, sometimes through direct phone calls, and video. We've been working very hard at that. One of the other challenges is just simply obtaining people's email address to let them know they have such a thing," he says.

In addition, Anthem telemedicine services are available to nonmembers as well through the use of a credit card, although they must arrange individual reimbursement for these services, perhaps claiming them as out-of-network services with their own health insurer, Jesser says.

For now, telemedicine represents a small part of Anthem's overall business. "You need millions of visits to even move the needle," Jesser says. "It really wasn't done as an economic growth engine. It was done as a differentiation feature. It's steadily growing, doubling and tripling year over year."