Telemedicine continues to move from the peripheries of healthcare into the mainstream. Earlier this week, a national review of 145 telemedicine studies conducted by the concluded that the technology likely improves access to care and has clinical benefits in acute and chronic care. This report also found less robust evidence that telemedicine in these settings likely reduces ICU length of stay, mortality, and costs.
As telemedicine becomes more recognized, its role in healthcare is growing. Uses of the technology are going beyond the four walls of a hospital, delivery is becoming less reliant on payer-based models, and government bodies and policymakers are increasingly stepping up to bat when it comes to telemedicine-friendly regulation and government-funded programs. m
Here is a closer look at a few of the leading telemedicine trends that have emerged so far in 2018.
1. VA's telemedicine push is gaining steam
The Department of Veterans Affairs has shown an active interest in expanding telemedicine services for its patients — in fact, when former VA Secretary Dr. David Shulkin accepted the post, he made allowing agency medical providers to practice telehealth across state lines, regardless of their locations, one of his top priorities.
Although Shulkin is no longer part of the Trump Administration, the initiative has nevertheless moved forward. In mid-May, the VA finalized its federal rule to allow providers to deliver patient care across state lines and outside of a VA facility using telemedicine. The new ruling was supported by several bills passed in Congress and senate over the last year, and kicked off in August of 2017 when Shulkin and President Donald Trump announced the initiative.
While this ruling is new, the VA has been developing and rolling out telemedicine programs for some time. For example, at last month's American Telemedicine Association conference in Chicago, clinicians came together to continue the discussion of how video-to-home technology can help deliver psychotherapy to veterans.
“We have a huge area we have to cover and we are trying to reduce health disparity,” Jan Lindsay, a psychologist at the VA, said at ATA 2018. “Most veterans who need mental health care don’t access it and then those veterans who do access care, we have trouble retaining them — especially in psychotherapy sessions where it is weekly.”
Currently the VA is using these video-to-home services to treat a variety of mental health conditions including addiction and obsessive-compulsive disorder. The department is also using these services to help sexual trauma survivors — many of whom are reluctant to visit a clinic.
But it isn’t just veterans that are seeing services through VA telemedicine. The VA has rolled out a telehealth program called teleFOCUS that is a mental health tool designed for veterans’ families. The program, which was originally started as an in-person therapy program, broadened to include telehealth sections to expand access.
“The tele-portion of it grew up out of a recognized need to see veterans who are spread out all over the place. Some were in rural communities that didn’t have access to care. Even in Southern California where UCLA is, there were a lot of barriers to care,” Tom Babayan, clinical specialist at the UCLA Nathanson Family Resilience Center, told Babyforyou.net.ua. “If you are working with the entire family, mom and dad work and kids go to school. It can be hard to find time.”
The program currently caters to veterans and their families, but this summer the VA will run a pilot with a small number of active duty military personnel and their families as well.
Outside of mental health, the VA has also been piloting its two-text patient-provider text messaging program, which is currently at several sites. For example, a VA provider can enroll a patient with high blood pressure to monitor their status at home via text messaging. The provider will be able to ask about specific blood pressure measurements and remind the veteran about their treatment.
“The important part of the program is that it’s a formalized way to collect data,” Chief Officer of the VA’s Office of Connected Care Neil Evans explained prior to a HIMSS 2018 session on the subject. “And with case management for our highest risk patients, we’re not only monitoring them but providing them closer care.”
“There are certainly compelling use cases for connected technologies to allow us to better take care of patients in rural part of America where distance is a barrier to receiving healthcare,” he continued. “The goal is to have increasingly convenient care, but also fully established with the veteran’s care team.”
The home telehealth program services about 147,000 veterans, via interactive voice response, a web app, virtual care, or through a physical hub connected to the network.
2. Telehealth is bringing care beyond traditional settings
While the VA is continuing to expand its services to meet veterans in remote settings, telemedicine services are popping up in unconventional and non-traditional settings as well.
Schools are a key example, as more and more districts are making efforts to extend telehealth services.
“If we are looking for where can I reach kids where they are, and how can we provide access to care where kids are the majority of the time — we go to schools. It just makes more sense to reach kids where they are instead of [them] coming to us,” Dr. Stormee Williams, medical director of school telemedicine at Children’s Health Dallas, said during a session at ATA 2018 in Chicago.
Currently, 18 states have authorized Medicaid reimbursement for school-based telemedicine, and more have required private insurers to cover telemedicine appointments, according to a Pew citing the ATA. This trend for more school-based telemedicine programs has kickstarted discussions among stakeholders over what exactly those programs should look like.
“We wanted to move beyond the idea that schools are a place for urgent care to be provided,” Dr. Steve North, medical director for Mission Virtual Care and a physician at Mission Center for Telehealth, said at the conference. “We want to shift the model of thinking to creating healthier students with virtual care.”
But schools aren’t the only non-traditional setting for telehealth programs. Increasingly, the technology is being used in disaster zones. In January, for instance, the US Army launched the Army Virtual Medical Center at Brooke Army Medical Center in Texas.
“The concept of the Virtual Medical Center is to take specialists from across the [military health system] and take their knowledge and expertise and put it at the point of need — whether it be in the mountains of Afghanistan or the backyard of Camp Bullis in San Antonio,” Major Daniel Yourk, deputy director of clinical operations at the Army Virtual Medical Center, said at ATA 2018.
Although the Army Virtual Medical Center hadn’t officially launched at the time, the organization had a hand in providing medical services in Puerto Rico after Hurricane Maria. Specially trained “mobile” medics were deployed to the region to help facilitate telemedicine services. But there were obstacles to getting the telemedicine services to the point of need.
“Some of the major challenges we had upfront were connectivity,” Yourk said. “Because all of the cell towers were down in Puerto Rico, we couldn’t use the hotspots. So there was a delay.”
Still, the medics helped facilitate 35 telemedicine visits over the course of six weeks. Yourk noted that there was at least one occasion in which a member of the military was able to stay on duty because he saw a specialist through the program.
Telemedicine has been a key tool for helping treat and diagnose patients where there are physical barriers. In fact, at ATA health professionals discussed how provider-to-provider video consults can be used in a jail setting.
“There are some challenges to getting into a jail. You can’t bring a mobile or wallet. It is highly regulated by the Department of Justice,” Mary Sajdak, COO of integrated care services at Cook County Health and Hospital Systems, said at the ATA conference. “Even though the population at the jail has dropped [recently], the evidence is that the people who are staying are much sicker because of mental health issues and opioid [addiction].”
Things can be tricky when it comes to getting a incarcerated patient to a specialist. Due to the exorbitant expense and hassle of transporting patients from a jail to a clinic, some are turning to e-consults, or a web-based portal that is partnered and connected to a network of physicians. These portals allow a treating onsite clinician to confer with a specialist about a patient and determine whether or not they need off-site care.
Part of the aim of the e-consult program at the Cook County Jail is to reduce the number of off-site visits for incarcerated patients. This can, in turn, lead to lower wait times for patients that do need off-site transport, Sajdak said, and increase access to additional specialists within the jail.
3. Deals, revenue reports indicate a lively sector
Advocates of telemedicine should be happy to see this corner of the digital health industry continuing to receive attention from investors and dealmakers. This year has so far seen sizable funding closure announcements from telemedicine provider Doctor On Demand ($74 million), connected telehealth product maker Tyto Care ($25 million), and eye telemedicine company Simple Contacts ($16 million).
The year has also featured some aggressive dealmaking from InTouch Health, which develops enterprise telehealth technology for providers. Alongside a handful of partnerships — including North Carolina-based Mission Health and Pennsylvania-based Jefferson Health — the company announced the acquisition of two other telemedicine companies: TruClinic and and Reach Health. Acquiring the former clearly signaled a portfolio expansion for the enterprise company, as TruClinic’s primary business was direct-to-consumer online virtual care. The latter, according to InTouch officials, broadens the company’s ability to assist customers with telehealth program rollout.
On the same day as the InTouch-Reach deal was revealed, American Well made its own high-profile acquisition announcement: the purchase of fellow telemedicine company Avizia for an undisclosed sum. This deal is expected to expand American Well’s reach in the acute care area, as it would give the company access to Avizia’s hospital-based cart lineup and custom software workflows in more than 40 clinical telehealth specialties.
“I think, candidly, health systems want to expand telehealth and what we bring for them is a complete solution,” Mike Baird, CEO of Avizia, told Babyforyou.net.ua at the time.
While these deals suggest an industry that is preparing to expand its reach, recent revenue numbers from a Teladoc’s most recent earnings numbers offer a more concrete example of ballooning telehealth adoption. While the company’s Q1 reported net loss of $23.9 million was a noticeable increase over the previous year’s $15.7 million, CEO Jason Gorevic boasted the 109 percent absolute basis total revenue increase largely driven by subscription access fees, as well as the 606,000 virtual visits conducted by the company during the quarter (compared to 385,000 in Q1 2017).
“We saw a very strong start to 2018 with continued success across the business and another quarter in which we exceeded our expectations for all of our key metrics,” he said on the call. “… Both average number of visits per user and the number of users per thousand increases with more products. Said another way, by adding more clinical services, we get both greater depth and breadth of engagement with the population. This bodes very well as we continue to expand the scope of our offering, both in the US and globally.”
4. Telemedicine delivery is less reliant on the payer
The incumbent telemedicine business model that initially catapulted companies like Teladoc or Doctor on Demand to success is one where insurers or self-insured employers broker deals with telehealth vendors, giving their members access to 24-7 virtual care. But over the past few years, at an accelerating pace, hospitals and health systems have started to get into the game on the theory that consumers would rather get virtual care from the same doctor they see for in-person care.
“There is a swinging of the pendulum … in that the major health systems have come to realize telemedicine is not a medical carve-out service. And, in fact, it is probably a mistake to carve it out,” Dave Skibinski, CEO of SnapMD, said.
Reimbursement for telemedicine is only now starting to come along — under fee for service, even enthusiastic providers were hamstrung by an inability to pay providers for virtual care.
Other telemedicine proponents fed up with the fee-for-service model are saying not to wait around for payers to dish out reimbursements.
“Instead, look for opportunities. There are other [players] in this marketplace that are not waiting for permission, they are not waiting for reimbursement,” Jodi Hubler, managing director at Lemhi Ventures said. “They are figuring out ways to bring in new ways that will have people practicing at their highest licensure level without waiting.”
One key example of this is provider-sourced telemedicine, which is becoming more and more common among healthcare systems and other providers. One question following the growing model is whether it has a strong enough advantage that it will drive patients, even those who are already using telemedicine via their insurer, through the door. Folks like Skibinski and John Pearce, CEO of Zipnosis, think it does, because the two products are actually very different. Employer-based services can offer access to a doctor, but providers can offer a patient access to their doctor.
“You’ve seen these external networks … kind of come up and meet a market need," Pearce said. "But now we’re seeing the providers get into that game and a lot of our growth in the future is about helping them connect their services, their local brand, back into the market. And we know the economics are going to be way more favorable for them than anything the external people can do. And you’d rather interact with a local Baylor-White physician than a random Teladoc physician, we know that at our core. We’re all about that provider enablement, it’s a clean business model, and it’s giving us some really good success in that side of the market.”
Others, such as Doctor on Demand CEO Hill Ferguson, whose telemedicine company is continuing to focus on the payer market, feel that this selling point doesn’t always hold up against the larger driver of patient behaviors — convenience.
“If you ask a typical consumer who would they rather see, their primary care doctor that they’ve seen for five years or some doctor they’ve never met before, I’m guessing 99 percent would say they’d rather see the doctor they’ve been seeing for five years,” he said. “But then you actually put it to the test in reality and you say ‘Oh you’re going to have to wait a few days to see your doctor, but you can see a doctor right now at midnight on a Sunday night, now what do you want to do?’, that answer’s probably going to be different. So I think the context is really important.”
It’s likely that these two telemedicine models, as well as the direct-to-patient approach, may grow to coexist and will depend on the situation and priorities of the person in need of care, Ferguson said. On the other hand, Skibinski said that parceling out telemedicine care in this way harms the end-goal of providing best-possible care.
“Why would you carve out telemedicine for this low-acuity stuff and have a different platform for that,” he said, “but now your in-network providers are on another platform to do continuity of care and chronic patient management?”
Regardless, if the current status quo of heterogeneous market models is to be maintained and proliferate, Teladoc CEO Jason Gorevic said that a deeper level of collaboration between stakeholders will need to work on their collaboration.
“Some of our most exciting and progressive discussions are with health plans who are coming to Teladoc for an enterprise-wide virtual care solution. In many of those cases the discussion includes bringing their network providers into the fold to provide care through the Teladoc platform. So I think it’s more convergence and cooperation than competition,” he said.