In-Depth: The changing relationship of health plans and virtual visit services

By Brian Dolan
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by Jonah Comstock

Telehealth is officially in its heyday. With Teladoc's recent IPO, major recent venture rounds for MDLive, DoctorOnDemand, and a slew of official guidelines out last year from organizations like the American Medical Association, the Federation of State Medical Boards, and the American Academy of Pediatrics, it's hard to ignore the fast-growing popularity of virtual doctor visits.

"If you look at the aggregate, there has been more telehealth provided in the first half of 2015 than in the rest of the history of American Well, and we’ve been in this business a long time," American Well president Roy Schoenberg told Babyforyou.net.ua. "We’re looking at hundreds, even thousands of percent growth YOY, depending on what metrics you look at. This is booming any way you look at it."

Some of the most recent telemedicine news has focused on health plans, who are starting to add to telehealth offerings as covered options on their network.

In March, Blue Cross Blue Shield of Massachusetts announced a pilot of American Well’s video visit service. In April, UnitedHealthcare announced that it would cover a range of video visits from Doctor On Demand, American Well’s AmWell, and its own Optum’s NowClinic, which is a white-labeled American Well offering. In the last few weeks, Capital BlueCross, a Pennsylvania Blue, announced that starting in 2016, the company will offer telehealth services through American Well to members enrolled in most Capital BlueCross health plans, and Blue Cross Blue Shield of Minnesota announced that it would cover some Doctor on Demand visits.

Payers and telehealth: How new is new?

But while this might appear to be a novel trend, some of the biggest vendors in virtual visits told Babyforyou.net.ua that payers have been their bread and butter since day one, though the ways in which telehealth vendors work with payers have changed. Jonathan Linkous, the CEO of the American Telemedicine Association, told Babyforyou.net.ua a little about those changing roles.

"Most [payers] start out by saying, 'This is available, if our covered beneficiaries want to use this service, they can use it through us, that doesn’t mean it’s free,'" he said. "Then the next step is, we’ll negotiate a reduced price, and then the next step is, it’s a covered service for our beneficiaries. They haven’t all stepped into saying this is a covered benefit, but they’re moving in that direction."

There are a lot of ways payers can interact with virtual visit providers. Babyforyou.net.ua spoke with the leaders of Teladoc and American Well, two of the largest virtual visit companies (Teladoc provides mostly telephonic visits, but some with video, while American Well provides mostly video visits.)

"We’ve been in the business of doing telehealth for almost a decade at this point and the majority of our lives has been delivering telehealth capabilities and services to large health plans," Schoenberg told Babyforyou.net.ua. He explained that American Well has, in the past, mostly worked in the capacity of a back-end technology vendor helping payers like Anthem set up their large in-house telemedicine service LiveHealth. The company's very first client, for instance, was Blue Cross Blue Shield of Hawaii nine years ago, and it was largely a technology system that let Hawaiian PCPs log onto a system at their own discretion to see their existing patients.

"That has been the majority of our business, and it’s a great business, don’t get me wrong," he said. "Definitely pays the bills and keeps the lights on. But there’s a greater and greater demand, both by individuals as well as by larger employers to have telehealth as part of their benefit structure. It’s been a long journey over the years to get to the point where not only are the services running smoothly, but they also come into the fold in terms of management and benefits coverage, but we’re now at the point where this is the norm more than anything else. It’s the point where I’m risking to say if we get to the end of the year and you are a health insurance company and you don’t offer telehealth, you’re going to be the odd one out come open enrollment."

Similarly, Teladoc CEO Jason Gorevic said that payers have long been Teladoc's number one customer -- though that includes about 40 percent health plans and 60 percent self-insured employers.

"If you consider payers to be both employers and health plans, that certainly represents the majority of our business and it has since the inception of the company," he told Babyforyou.net.ua. "The company started in 2002 and I got to the company in 2009, and we started really selling into the employer market, large self-insured employers. We expanded into the health plan market, and then the health system market was really our third market and is a recent part of the evolving landscape."

Gorevic said that some of the payers that have adopted their services haven't made a big announcement because they've gradually added more and more services. For example, Aetna started working with Teladoc in 2012.

"We started with Aetna with about 600,000 of their fully insured members having access to the Teladoc service," Gorevic said. "Today we’re well over 3 million members in multiple segments of the business both fully insured, self-insured, national accounts, middle-market accounts and we continue to see increasing adoption rates across the business. That’s a good example, and we see that kind of trend occurring across almost all of our health plan partners where they adopt in a segment of their business and they expand into their larger book of business."

The Aetna arrangement is still mostly with self-insured employers rather than fully insured Aetna customers, the company told Babyforyou.net.ua in an email. The cost of the telemedicine services is built into the members' premiums. Even though they've been working with payers a long time, Gorevic concedes the conversation is very different than it was six years ago.

"In 2009 I was trying to explain to people what telehealth was," he said. "Today it’s more like how can we collaborate with our partners to achieve the ultimate potential of telehealth, rather than to try to explain to them what it is and how it works."

Jonathan Linkous, CEO of the American Telemedicine Association summed up the value of health systems to telemedicine vendors with a succinct metaphor.

"It’s so much more efficient," he told Babyforyou.net.ua. "Do you want to sell lettuce on the corner or do you want to have Safeway sell it for you? It’s the way to get to market without trying to put the money into going direct to consumer. I mean it’s a huge amount of money trying to launch using your own channel."

UnitedHealthcare's network approach

But while payers have been offering virtual visit services for a long time in different ways through different relationships, what UnitedHealthcare started offering in April is a little different.

"We are offering more than one provider group ... so it mirrors the type of experience that a consumer might have as they seek quality brick and mortar care," Karen Scott, the senior director of product and innovation at UnitedHealthcare, told Babyforyou.net.ua. "We felt strategically it was very important to build this around a network strategy so it really is a level playing field and offers customers the opportunity to have the virtual visit that they choose to use."

The network so far only includes three providers, one of which is United's own Optum NowClinic, an American Well-powered offering. And since another is American Well's AmWell, that actually makes two of the three options American Well. But though the technology is similar, the providers are different. Scott didn't go into detail on why UnitedHealthcare picked the three providers they chose, but she did say they made the decision to go with video visit providers, rather than telephone only, based on the recently-issued guidelines from the AMA and the Federation of State Medical Boards.

Telehealth will be available to nearly all of United's commercial members, according to Scott. In general, most payers have had to leave telemedicine out of fee for service Medicare or Medicaid plans, at least for now, since Medicare and Medicaid mostly won't reimburse for it. Medicare shared savings plans, on the other hand, are some of telehealth's most enthusiastic adopters, according to Gorevic and Linkous.

The network approach potentially amplifies many of the advantages that draw payers to virtual visits in the first place. Cost savings are one big motivator, and by creating some competition, UnitedHealth can potentially negotiate even lower rates than if they were working with just one provider. Access to care is another big advantage of telemedicine, and more providers increases the access that any given member has to care.

And the network approach allows United to create a scalable infrastructure for the future. If the current telehealth leaders come and go, United will be equipped to contract with other providers.

"We have been very thoughtful, we’ve been working on this for really a number of years to get to this point," Scott said. "We believe the approach we’re taking is one that will have the opportunity to effectively expand over time as virtual care becomes more and more prevalent. ... We’re very excited about where we’re at. We’re very excited that we can offer this at no additional cost to our clients. This is simply something you get when you work with UnitedHealthcare, and we feel that is the right approach because this is part of the future of access to care."

What comes next?

Most people agree that more payers are incorporating telemedicine into their offerings. But at the same time, providers are increasingly interested in becoming involved with telemedicine, either through their own independent efforts or as customers of the same vendors that serve payers. Schoenberg thinks this is largely a result of ACOs and a shared savings mentality even among fee-for-service providers.

"What we have seen over the last two years is an ongoing evolution or revolution where the providers, whether these are individual providers or group practices or ACOs, and mostly the large health systems, have made a very bold decision to get into telehealth themselves and began to use telehealth in a variety of different ways to care for their own patients," he said. "We have strategically decided to build infrastructures for the use of telehelath by those health systems, but we have absolutely underestimated popularity, the adoption rates by these organizations. I would even go as far as to say that the fastest-growing part of our business in 2015 has shifted from the health plans into health systems. They are the bigger buyer in 2015 vs the payers, who are, by the way, not stopping anything, it’s just that health systems are buying more than they do."

Gorevic thinks there's room for payers and providers in the telehealth space without them butting heads, even if they often do serve the same patients, because they use the systems in different ways. While patients might use virtual visits through their health plan in place of a primary care or urgent care visit, providers are using telehealth for things like chronic care and surgery follow-ups.

"The hospital systems turn to Teladoc for one of several, or potentially multiple of several reasons," Gorevic said. "One is if they’re a risk-bearing hospital, an ACO. Two is, as a patient acquisition strategy, to help them provide more services into the community such that they can acquire new patients. Three is a tool to improve the productivity of their physicians. And four is ultimately to provide an additional service and cost containment for their employee population. Those aren’t really at odds with the payers with respect to the Teladoc service."

Still as the landscape evolves, payers and providers may start to see some redundancy in the telehealth services they offer to their patients and members. Linkous thinks the future might even see large providers creating their own telehealth networks that compete with the vendors.

Most telehealth companies and payers already have their eye on expanding the scope of telehealth services beyond acute care to include things like behavioral health, dermatology, and smoking cessation. Schoenberg also sees a lot of potential in oncology, since cancer patients need regular follow-up visits but often have weakened immune systems, which means they could benefit from skipping the physical doctor visit.

Gorevic says the new specialty care modules Teladoc is rolling out come from the direct request of customers, especially health plan customers, who are eager to see how far telehealth savings and increased care access will go.

"We built those products in response to demand from our clients, especially our health plan clients," he said. "Both behavioral health and dermatology have tremendous access to care issues, and as a result the health plans are particularly focused on providing increased ease of access and reduced costs."

Working with payers may have big benefits to the telehealth companies, and to payers, but Schoenberg warns that it's not for the faint of heart. Building an effective technology platform, he says, is the easy part.

"This is an extension of the traditional healthcare system into the homes of Americans, and like everything else that we love or hate about the healthcare system, telehealth has to speak that language," he said. "You have to understand claims and deductibles and EMRs and electronic prescribing and ICD codes and CPT codes and network definitions and licensure and credentialing and state lines and formularies. ... When you work with a payer, jumping up and down and saying I have a great technology is a very, very small part of what you need to do."

Roundup: 13 virtual visit telemedicine providers

by Aditi Pai

This year, a number of telehealth vendors have made news. From large investments in Doctor on Demand and MDLive to Teladoc's recent IPO. Babyforyou.net.ua rounded up 13 companies working on virtual visit offerings, which doesn't include in-house offerings from payers and providers. In the past year, two startups that were included in the 2014 version of this roundupRingadoc and Stat Health, were acquired. Another company, MeVisit, no longer be appears to be operating.

Read on for a list of 13 companies in no particular order currently tackling virtual visits -- mostly video visits, but not all -- for primary care, along with a sampling of their customers where available.

Dallas, Texas-based Teladoc, one of the larger virtual visit companies in this space, went public this year. The company raised $156.8 million in its IPO. At the last minute the company increased both the price of its shares to $19 and the number of shares it was selling to 8.3 million. When Teladoc debuted on the NYSE, it began trading at $28 a share, well above its $19 IPO price. Some of the payers Teladoc is working with include Aetna, Highmark BCBS, Premera, BCBS of Florida, BCBS of Alabama, Independent Health, and Universal American.

Teladoc has also acquired a number of smaller telehealth companies. In September 2013, Teladoc acquired Consult A Doctor for an undisclosed amount and in May 2014 . And recently, just a couple months after Teladoc filed for an IPO, the company disclosed that it acquired Stat Health Services, which offers the online doctor visit service Stat Doctors.

Another major player in the video consultation space is American Well, which offers its services both direct-to-consumer and via other organizations like payers, employers, universities, and providers. American Well has raised at least $81 million in a mix of equity, options, and securities to date, though according to a report that surfaced from Globes in June, American Well recently secured an eight-figure investment from Israeli pharmaceutical giant Teva. The company has several apps, many of which are white-labeled, including Amwell, NowClinic, a white-labeled product for Optum members; Online Care Anywhere, which they created with WellPoint’s HMC; and WellConnection, a white-labeled product for Blue Cross Blue Shield of Massachusetts members. American Well told Babyforyou.net.ua the company is working with 25 different Blue Cross Blue Shield plans, Anthem, and UnitedHealth Group. Correction: A previous version of this article incorrectly stated the number of Blues that American Well worked with.

In June, American Well filed a lawsuit in Massachusetts District Court against Teladoc that alleged Teladoc’s technology platform willingly infringes on a 2007 American Well patent. The suit asks for triple damages court fees, as well as an injunction against Teladoc continuing to do business.

San Francisco-based Doctor On Demand also offers its service to patients directly or through employers, health systems, and health plans. The company raised $50 million in a round led by Tenaya Capital in June, bringing the company's total funding to more than $74 million to date.

In June, Doctor On Demand announced that more than 200 employers, including Comcast and Union Bank & Trust, are now offering DOD’s service to their employees. Other groups that use Doctor on Demand include MultiCare Health System in Washington and CliniCloud, which offers a connected medical kit. Doctor on Demand is one of a handful of video visits providers, including American Well, that UnitedHealth recently announced it would subsidize for its members. Through health plans and employer partnerships, Doctor on Demand’s service is available in-network or at a subsidized rate to more than 25 million Americans.

Carena has raised at least $13.3 million to date from Cambia Health Solutions, a health insurance company, McKesson Ventures, Catholic Health Initiatives (CHI), and Martin Ventures. Health systems can either use Carena bank of providers, which includes family practice physicians and advanced registered nurse practitioners, for their virtual clinic, or they can choose to staff the clinic with their own providers. Carena’s physicians, who are salaried employees of Carena Medical Providers, can discuss issues with patients, make diagnoses, and prescribe medications over the phone or video.

Carena first started working with hospital systems in September 2013. Until then, Carena was providing its virtual visits service to employees of self-insured companies, including Franciscan Hospital Systems, which also ended up being one of the first health systems to roll out Carena’s offering to its patients. In June, that they had launched virtual clinics for four different providers including UW Medicine, Integris Health, Froedtert & the Medical College of Wisconsin, and Hospital Sisters Health System. Since then, Carena also signed on University of Iowa Healthcare and OSF HealthCare.

Sunrise, Florida-based MDLive sells its telehealth service to employers, health plans, and providers which, in turn, offer it to their employees, members, and patients. The company also markets video visits directly to consumers. In June, the company raised $50 million from Bedford Funding, bringing the company’s total funding to at least $73.6 million. MDLive said it would use some of the funds to make acquisitions and to forge additional strategic alliances. MDLive has made at least one high-profile acquisition in the past: Last year it acquired online therapy provider Breakthrough Behavioral.

The company's most high-profile partner is probably Walgreens, which partnered with MDLive last December to offer telemedicine services in two states and recently added three more states to its rollout. Walgreens customers can access the video visits from inside the Walgreens mobile app on either Android or iOS devices. In April, MDLive also partnered with Microsoft to deliver telehealth services through Microsoft’s Skype for Business offering. MDLive has previously inked deals with Cigna and Molina Healthcare.

Minneapolis-based telemedicine startup Zipnosis views telemedicine not as a technology offering but as a service offering, and they pride themselves on being adaptable to different contexts, whether it’s retail clinics, traditional health systems, ACOs, or employer-based offerings. This year, Zipnosis received a “significant”, but undisclosed, strategic investment from Fairview Health, the hospital system the company has been working with the past several years. Zipnosis doesn’t do synchronous visits by video or phone, but instead relies on software interactions to treat simple ailments like bronchitis or pink eye, which allows patients to resort to an office visit only when it’s really needed.

Over the last year, Zipnosis has gone from one customer, Fairview, to about 10, Pearce said. Their team is about the same size — they just hired their eleventh employee. He hopes that Fairview will lend them higher visibility and more credibility, as well as continuing to serve as a test bed for new products.

New York City-based Sherpaa also offers asynchronous visits with patients. The startup has raised at least $8 million to date -- the most recent round of funding came earlier this year, in May. Sherpaa aims to help employers cut their healthcare costs by making physicians remotely available to their clients’ employees. Employees can use Sherpaa’s app, the web, or a phone to communicate with doctors that work exclusively for Sherpaa 24-7. Using any of these platforms, users can get in touch with the doctors who can answer questions about a medical issue and send a prescription to a local pharmacy when appropriate.

Sherpaa founder Dr. Jay Parkinson is a bit of an evangelist for text visits over video. He's said in that past that on many occasions that Sherpaa’s asynchronous text communication can solve about 70 percent of medical issues that employees have. In the other 30 percent of cases, users are referred to a specialist for an in-person visit. “Asynchronous, text-based communication is an ingrained behavior in humans,” he . “Video visits are by no means an ingrained behavior.”

Phoenix, Arizona-based eVisit has developed a two-way video communication offering, available on desktop computers as well as iOS and Android devices, that providers can use when treating minor medical issues, for example checking in on a patient after an operation or treating a cold. They raised a $1 million seed round in July from Alan Ram, founder of Alan Ram’s Proactive Training Solutions, Chris Reap, an investor at Northstar Capital, and others.

Providers can use the service to collect payments from patients and access detailed medical charts to download and submit for reimbursement. They can also electronically prescribe medications to be picked up at their patient’s pharmacy. eVisit costs providers $139 per month.

New York City-based Maven Clinic, a video visit service that aims to connect women with healthcare practitioners, launched this year.

Maven’s offers its service on smartphones, desktop computers, and tablets. Through the service, women can book an appointment with a healthcare practitioner, speak with her via video chat, and then pay for their session. Maven CEO and Founder Kate Ryder told Babyforyou.net.ua last year that the price of the visit varies by provider type, but the service will be as low as $18 for a quick appointment with a nurse practitioner.

Washington DC-based telehealth startup, Pacify is initially focused on pediatrics and connecting new parents with lactation consultants, nurses, and dietitians via video visits through a mobile app. Pacify raised $1.1 million from local accelerator Acceleprise and a dozen angel investors in March.

Pacify’s CEO and founder Ben Lundin previously worked as a consultant at McKinsey & Company where he mostly helped large hospital chains and academic medical centers on innovation initiatives, including telemedicine and tech-enabled health care delivery. As of March, Pacify had 80 providers in its network and was able top operate in DC, California, Virginia, and Maryland currently. The service will cost $15 per month.

San Francisco-based FirstLine Medical has launched its doctor consultation service this year, called FirstLine, which is available via iPhone app. The offering allows patients to call, text, or video chat with a doctor, similar to other doctor consultation offerings, but FirstLine goes one step further — if users choose, they can also request a doctor to make an in-person visit to their home or office. FirstLine is backed by e.ventures and Great Oaks Venture Capital.

The app launched a beta in late 2014. FirstLine CEO Bryan O’Connell told Babyforyou.net.ua in March that already the app has more than 20,000 users. O’Connell said he wants the app to eliminate waiting rooms and added that for some patients, it could even take the place of a primary care doctor.

PlushCare's  app-based virtual visit system, which allows users to email, call and video chat with doctors for a subscription fee, is available in California, Hawaii, Illinois, New York, Ohio, Pennsylvania, and Washington. In February 2014, the company and beat its goal of raising $25,000. The company has also received investments from Michael Baum, CEO of Founder.org and Jeff Clarke, CEO of Kodak.

Patients can use MeMD to video chat with doctors about minor ailments. The company to raise awareness about the service and develop a mental health portal, but raised just $703 of its $250,000 in the two months that the campaign ran. Since then, the company has  launched by the Medical Licensing Board of Indiana to test the effectiveness of telemedicine.

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