Telemedicine's Expanding Options

Spurred by new laws and policies that permit online teleconsultations, both payers and providers are exploring ways to enable patients' access to care in ways that also meet growing industry demands.

This article appears in the April 2014 issue of HealthLeaders magazine.

Spurred by interest from insurance companies and employers, physicians are ramping up their ability to make an increasing number of patient encounters online or over the phone.

"We need to meet consumers where they are, knowing that often consumers aren't able to get to the doctor during the workday or on the weekends, and they end up going to the emergency room or the urgent care room for inappropriate use of care, and so we have a service that truly gets to the consumer 24 hours, seven days a week, 365 days of the year, and it's a real doctor every single time," says Matt Marek, vice president of product and marketing at 2.6-million-member BlueCross and BlueShield of Minnesota.

"We believe this is the next generation of retail care that we saw at Target and MinuteClinic years ago, where we're truly trying to serve the consumer beyond normal doctor hours," Marek says.

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Using technology from American Well, BCBS offers high-definition video consultation between its members and a physician with an average wait time of less than two minutes, Marek says. The service never costs more than $45, and patients are reimbursed by the health plan like a claim. Some employers are even considering moving to a $0 copay to encourage employees to use online care.

Although BCBS of Minnesota has offered this service since 2010, use of the service is now growing 200% per year, and BCBS expects that growth to accelerate this year. BCBS of Minnesota is also expanding the coverage it offers to employers in its service area. After initially serving only employees in Minnesota, BCBS of Minnesota's Online Care Anywhere service now permits employees of those companies to utilize the service in 46 states and the District of Columbia, Marek says. This makes Online Care Anywhere the fastest-growing service in BCBS of Minnesota's set of service offerings.

Spurring the move are liberalized laws and policies throughout the United States that now permit online teleconsultations. "There are many states today that now allow online care or telemedicine to exist, where three, four years ago we never thought we would get as far as we have," Marek says.

These days, those encounters include video over wireless carriers' networks. "We're able to have a high-definition videoconference consult with the doctor without having the very highest-speed network available without having to be connected into a landline," Marek says.

Online consultation cannot and does not replace many in-office visits, Marek notes. American Well physicians perform necessary triage to advise those who should seek in-person medical help.

"The intent has never been to take services away from the doctors or compete with them," Marek says. "This is not a disruptive strategy. Rather, this is a strategy to better serve consumers, and also it has the potential to allow doctors to be more effective and efficient with their services, especially if you can imagine the emergency room doc who may have some downtime could also log on and serve members and patients, and so that is being explored as well."

At Mount Sinai Health System, a relatively new but fast-growing service called Teladoc became part of the organization's rapid response to Hurricane Sandy in 2012.

"We launched it right after Sandy had hit, and it was a direct-to-consumer service," says Adam Henick, senior vice president of network development for Mount Sinai Health System and Mount Sinai Beth Israel, a 1,083-bed hospital with $1.1 billion in annual revenues, which became part of Mount Sinai Health System last year.

Under the program, New Yorkers who were willing to attest to their residency could access a physician via telephone or video chat for $38.

"Teladoc's model historically has been to either contract with an insurer to provide the service to their beneficiaries, or to contract with an employer to provide the service to their employees," he says. "They had not done a direct-to-consumer offering, and we wanted to try that, and so we launched it."

Despite "great media coverage," however, customer turnout for the service was disappointing. "After about three months, we started doing focus groups to figure out what we were doing wrong, and it turned out that the model was you paid an annual registration fee of $30, and that enabled you to get visits at $38 a visit," Henick says.

Those prospective customers who had no healthcare insurance were very unlikely to prepay anything, and those who were insured wondered why Beth Israel was not participating in their own insurance. "So what intuitively seemed like a logical idea to us met resistance because of barriers, even though they were low-level barriers," he says, adding that even for those with insurance, between copays and deductibles, traditional visits still would have cost more than accessing the service. "But I think it's more a psychological barrier."

Last September, Beth Israel added an option to pay $48 a visit without an annual registration fee, which Henick says is significantly less than the cost of a doctor office visit in New York. "We're not getting a particularly robust response to it," he says, so now Beth Israel is modeling the service with its own employees, who pay $15 per Teladoc consultation.

"Every person that goes on Teladoc, one of the initial questions is, 'Where would you have gone for service had you not chosen this option?' so we're collecting that data and seeing what the cost would have been had they not accessed this service, and then balanced it against our cost of picking up the cost of the visit above $15," Henick says.

This time, Beth Israel's internal usage reflects a return of 7 to 8 times the investment required, and as soon as it has collected a sufficient sample, Henick believes it can return to its payers with this data and its direct-to-consumer product will be able to get insurance company participation and enable the service to take off.

Henick sees it all as an extension of Beth Israel's earlier forays into urgent care centers. And the way Beth Israel Medical Group has arranged its Teladoc partnership, all calls go first to its own tier of doctors who have joined the Teladoc network. If call volume rises such that response times lengthen, other patients would be routed to non– Beth Israel doctors, who are licensed in New York and credentialed by Teladoc, Henick says.

"The Teladoc offering is just basically continuing down that path of saying, there are going to be some young, hip consumers that are going to want to be able to video chat with their doctor at 2 in the morning, because they're working on some computer algorithm and don't want to leave their office or their apartment, and they're going to want to access it that way, and we need to be able to deliver it that way," Henick says.

Some physicians also view services such as Teladoc as their new career path. Timothy Howard, MD, was a family practitioner in Huntsville, Ala., for 20 years. In 2009, to earn additional income, he began working for Teladoc as one of its physicians reachable by telemedicine technology, primarily
via telephone.

This January, after providing several months' notice, the 52-year-old left private practice to work for Teladoc full time. "I want to practice actual medicine and take care of people and not a bunch of administrative things," he says. "You're talking directly to the patient. You don't have a third party or someone else telling you 'Restrictions here, restrictions there, do this, this is preapproved,' this kind of thing. It's really pretty straightforward."

At the top of the list of conditions Howard treats via telemedicine: sinus problems, urinary tract infections, allergies, flu, cough, and ear infections. Video is "exclusively requested by the patient, when they desire to either let you see them or their child," he says.

Due to Teladoc's low overhead, "it's very possible to earn a living with it," Howard says. Out of an average of 180–240 patients per week, four or five a week have problems severe enough that he refers them to seek in-person help.

"The key is that we're episodic," Howard says. "We are not seen as the primary care physician. The urgent may take the place of the important. But that's one of the nuances, and I tell patients all the time, 'I said, the best way to be cared for as a patient by a physician is a hands-on exam.' "

Services such as Teladoc also set and monitor their own quality standards, such as whether doctors are overprescribing antibiotics, Howard says.

One chief medical information officer whose health system is moving into this type of telemedicine is leery of allowing services such as Teladoc to permit health systems to outsource their primary care capability.

"Don't ever outsource your core business," says Shez Partovi, MD, vice president of informatics and CMIO in Dignity Health's Arizona service area. "Our core business is delivering care. I'm not sure if health systems should outsource their core business."

Still, Partovi is just as optimistic about the growth of direct-to-consumer telehealth services. Like many other health systems, Dignity already does thousands of internal physician-to-physician telehealth consults annually. As accountable care and patient-centered medical home efforts expand, the demand for direct-to-consumer telehealth at Dignity is the next big telehealth wave, he says.

So far, Dignity Arizona has started with a small pilot, training three physicians to respond to its own direct-to-consumer telehealth service last fall and launching the service in the fourth quarter of 2013. So far, only about 20 consults are happening monthly, Partovi says.

Part of Dignity's approach is to deeply understand how video encounters change the doctor/patient experience, including on-site testing where doctor and patient are both on site, but in separate rooms, and Dignity studies the interaction, Partovi says. "We have a lot of focus on understanding the user experience," he says.

Still, Dignity plans to have as many as 250 physicians trained in the next phase of the rollout, and Partovi is also chairman of the telehealth committee for all of Dignity. Partovi says there are markets where Dignity will compete with the Teladocs and American Wells of the world for the business of employers seeking direct-to-consumer telehealth options.

Ultimately, such competition may also hinge on health systems providing a broader set of offerings to employers than just telehealth, Partovi says.

"Last year we actually responded to two RFPs where it was broader," he says. "It was about providing a medical community for the employer, and we feel that's a key part of our strategy."

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This article appears in the April 2014 issue of HealthLeaders magazine.