COVID-19 pushes healthcare delivery out to the edges

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As clinics struggle financially, technologies like telemedicine are keeping them afloat

(Vator will be hosting its Future of Virtual Care event on July 1. Get your tickets here to see speakers like Carbon Health CEO Eren Bali, MDLIVE CEO Charles Jones, American Telemedicine Association CEO Ann Mond Johnson, El Camino Health Medical Network President Bruce Harrison and more!)

By now, the idea that COVID-19 has accelerated telehealth adoption that could have taken years into weeks is well documented. Visits are estimated to grow to over one billion in 2020, up from 36 million last year. Yet there’s another side to this story that hasn’t received as much attention: the virus is transforming our nation’s clinics to bring their services even closer to the patient.

At one point, clinics were created as outpatient posts so hospitals wouldn’t have to be the central point of care. Now with COVID, care has been pushed out to the edges even more, with much of the interaction happening in a person’s home. The virus forced everyone’s hand to comply but despite the pain of disorientation and loss of revenue, what is left seems a clearer roadmap of how to design tomorrow’s health experiences. 

Clinics have been forced to reinvent themselves on the fly in order to survive. Ramping up technology, despite having little to no experience with it, sometimes in just days, in order to keep up communication with their patients and to stop the bleeding of revenue. For instance, as of the week starting May 10, endocrinology visits were down 23 percent from baseline, ophthalmology was down 39 percent, and pediatric visits were down 45 percent. As bad as those numbers, they’re actually a marked improvement from the month prior. That kind of reduction impacted clinics where it hurts the most: in their pocketbooks. Clinics were already struggling with this before, and when COVID hit, their financial problems were exacerbated. 

This essay was initially to understand how clinics were weathering the storm and to put their front-line hard work into perspective. As I spoke with my peers in this journey to innovate virtual care, what I found was that we are all very much pursuing the same objective: bringing the point of care further and further to the edges. But the payment models have been murky and consumer demand unclear. The COVID experience, however, has awakened everyone to the fact that patients and providers love it. Now it’s a matter of executing on this new world order.  

The best way to appreciate their view is to understand what the clinics went through. Here’s a look at how they reacted to the brutal lockdown; the way they innovated on the fly; and how their experience, however rocky, allowed them to embrace a much clearer vision of how to deliver care at the edges: a world that feels a bit like retail transaction-like experiences, with a bit of on-demand, Amazon-like services from the comfort of our own homes. 

How to survive without in-person visits 

While restaurants and retail shops were able to offer curbside pickups during the lockdown, and online retailers were able to continue to do business during the lockdowns, clinics were left vulnerable.

At John Muir Health, for example, revenue was wiped out instantly. Chief Strategy Officer George Sauter said, “During that period in March and April we saw reductions in cases not obviously impacted by COVID…conditions like strokes and cardiac surgery. Everything was down quite a bit. People weren’t driving around getting in car accidents, which was a good thing, but it also meant we weren’t as busy as usual in our emergency departments and trauma center,” he said. “Financially, we lost $21 million dollars in March, $36 million in April. It’s not looking as bad in May and we’re on our way back up; we were effectively reopening the health system within this new COVID environment. We’ve been doing that since the end of April and encouraging patients not to delay care if they need it since that can lead to long-term complications. So, I would say May it’s probably looking like a small loss, or maybe close to break even.”

The only recourse was to quickly build up telehealth services. 

Bruce Harrison, President of El Camino Health Medical Network, said that the initial drops his clinics saw were even bigger; however, total visits had since come back up, mostly thanks to the implementation of telehealth. “In-person clinic volume dropped by 75 percent in the first couple of weeks, but our total visits in aggregate are now 90 percent of our baseline. Initially, during the peak of Shelter-in-place 60% of our visits were accommodated through video and the phone,” he said. “We have since, seen our in-person visits return.  Video visits are currently 10-20% of our overall volume. There is tremendous value in the use of video visits that are coordinated between a patient and the doctor, where it’s a complementary tool to help support an established relationship.” 

For other clinics that could switch immediately to telephone and telehealth, their bottom lines were not as impacted, and in fact with telehealth, their visits have gone up.  

“The week of March 16, and the following week, I was down 30 percent in my revenue because of a reduction in visits. After that, I was down at 10 percent but, ever since, I’ve had over 100 percent, and most recently 115 percent of my productivity,” noted Jason Cunningham, CEO of West County Health Centers. “My visits coming in have exceeded what we were seeing prior to COVID-19, which I am so thankful for because otherwise we were going to do layoffs and other things because there was no way we could survive. But that only happened because we were able to pivot quickly on the video and the telephone.”

One Community Health, meanwhile, managed to keep its reduction in patient visits down to just 15 percent. CEO Michelle Monroe credits that to the fact that the clinics switched over completely to phone visits in just a few days. “In Sacramento, we went to shelter in place before the state did, so we were already in the thought pattern of how to do care and we knew we had to convert to phone visits ASAP. We switched over phone visits in three days, so we didn’t have that much downtime. And we got the message out to social media, we were proactively calling patients that were on the schedule, and proactively calling patients that needed chronic care and saying, ‘Hey, we’re here for you and we can still see you’,” she said. “During this time, we also continued to accept new patients, where a lot of other clinics did not. Every new patient had a phone consultation with a medical provider.”  

Patients love telehealth; done with parking 

The most telling observation that an Amazon-like world of health services will be popular, is the fact that people have clearly shown their dislike for driving and parking to receive care. Amazon made the deliver-to-your door mentality commonplace. Now seeing a doctor at home has been quickly embraced, leading to lower no-show rates and fewer complaints.

According to Monroe, the switch to phone visits led to One Community’s no-show rates dropping by half, while patient satisfaction shot up. “Our no shows for in-person visits used to be around 20 to 22 percent, and now we’re down to 10 or 11 percent. It’s incredible. It’s more convenient. It’s more efficient, it takes less time, because you’re not having to process the patient through your physical walls of the system,” she said. “Our satisfaction rates had been going down, but then April we saw a surge in patient satisfaction. Is it going up because it’s something we’re doing or is it going up because they’re grateful to have access to services? Is it because of the phone? We haven’t been able to dig into that specifically yet but that’s something that we have on the table to look into.”

Even more telling: despite the fact that the clinic used to get five to eight patient complaints a week, the clinic hasn’t seen a single one for three weeks straight. While there are obviously a lot of potential reasons for why that might be the case, the fact is that nearly a third of all patient complaints were about not being able to find parking. Now that that’s obviously no longer an issue, since patients don’t have to travel to get care.

“Before all of this, when you would look at your no-show rate and ask the clinic staff, ‘Why is our no-show rate so high?’ the very first answer they always give you is, ‘transportation.’ Now, whether that’s the truth or not is another issue but there’s always this mindset that transportation is the reason why people don’t see us,” Monroe said.

Transportation was also a big hassle factor at West County, said Cunningham, and like One Community, satisfaction rates have gone up since switching to telehealth. 

“The same patient who had to drive literally 40 minutes from Bodega to get to my office to sit in my office for probably 40 minutes, and then see me for 20 to 30 minutes, only to have to drive 40 minutes back, that person can be waiting for me while sitting on their own couch. The reaction from our most vulnerable population, who have transportation insecurity or have real anxiety about going out, has been unbelievable. Our no-show rate has plummeted,” said Cunningham. 

“Obviously there are things that we need to have in-person, so we see patients who need EKGs or lung evaluation or a breathing treatment or immunization, things like that. For the most part, though, most of our work is sufficient for a video. That experience, and the convenience, has been a boon for our patients.”  

Reimbursement and the rise in in-home care 

While it is true that patients weren’t taking full advantage of telehealth until recently, it wasn’t the only thing that stopped clinics from fully embracing the technology: it was also the fact that the clinics weren’t being paid for these visits until COVID forced the government’s hand to lift reimbursement obstacles. The CARES Act, signed in March, authorized Federally Qualified Health Centers (FQHCs) to not only set up telehealth services for Medicare patients during the COVID crisis, but also allowed them to get paid for those visits.    

“We knew that there was a better way to provide service. We knew that phone visits, video visits, remote monitoring, we knew that all these things are better for the patients, but we were limited by our reimbursement structure. Now that that reimbursement structure has changed, at least temporarily, we have had the freedom to use technology,” One Community’s Monroe said. 

The hope is that the reimbursement structure also permanently changes as well, even after COVID-19 is no longer a threat, now that telehealth has shown to be both popular and effective.

Even when clinics weren’t being reimbursed, that didn’t mean they weren’t still doing everything they could to bring care to the home; El Camino Health, for example, delivered in-home visits. “Our doctors were concerned about our patients with complex clinical issues who really needed care but were homebound. We collaborated with Pathways, a home care service, to provide a face-to-face nurse visit combined with a virtual visit from the doctor.  Our nurses went into homes with PPE (personal protection equipment) and were able to check on patients vitals. Obviously this was very costly for us. It doesn’t get reimbursed, but we did it because it was the right thing to do,” said El Camino’s Harrison. 

Ultimately, though, these clinics are businesses and they need revenue to be able to continue to offer care to everyone else, so, no matter how much patients like telemedicine, the only way it sticks around for the long haul is if clinics can get paid.

“One of the things that will also drive whether and how telemedicine sticks is payer reimbursement. We’re a business that has historically relied on office visits and fee-for-service billing. In the past, the payers, for the most part, would not reimburse us for telehealth.  I anticipate that there will be permanent reimbursement changes forthcoming that recognize video visits can be efficient and effective for consultative visit types” said Harrison. 

“We’re finding most patients are giving us positive feedback about those using the video visit, and the virtual approach. While a virtual visit doesn’t replace the physical exam, care plans can be adjusted, some visits can be done virtually and it really can be a very effective tool to help support the way in which doctors and patients interact.” 

We need seamless integration

If these technologies are to stick around for the long term, and by all accounts they will, then they need to be fully integrated for patients to get the best, most fulfilling experience. The government relaxed the technology requirements for virtual care during this period and that opened up the possibility to use Zoom, Skype or Facetime to interact with patients. “Before COVID-19, providers had to demonstrate that the technology used was 100% secure and compliant. Zoom has worked well, but the technology used for these virtual visits in the long term will need to be better integrated, more secure and create a better experience for the users.”

“I believe telemedicine is here to stay, so the technology will need to be fully integrated into the electronic medical record. It will need to be just one system where appointments can be scheduled, medical records are accessible and virtual visits can occur.  The patient experience while using this technology will also need to improve greatly.  We had been planning for a fully-integrated telemedicine program prior to COVID. It just so happened that our integration had not been fully complete prior to COVID. And so, when the regulations were loosened, it allowed us to implement this quicker,” El Camino’s Harrison said. “We are now accelerating a more integrated solution for the patient and doctor.

Clinics will need to do this if they want to compete with companies like Carbon Health and One Medical, aka the ones that already have those vertically-integrated models and which are currently looking superior because they are able to do those types of all-in-one solutions, said John Muir Health’s Sauter. “The One Medicals and Carbon Healths of the world, they’re digitally native delivery systems where they almost built the technology and then overlaid how the physicians and patients can interact with it. We have had to overlay technology on an existing, decades-old process. Those with an integrated technology stack are incredibly effective,” he said. In other words, those models are the retail-like, Amazon solutions for care.

“You look at companies like Omada or Livongo, the basic architecture of these providers are very similar. They have some sort of digital connection between the patient, the family, the provider, a call center, which is usually staffed with some pretty sophisticated call agents, often either social workers or nurses or clinicians of some sort. And it all works together so that you can basically point the high cost professional interaction to situations where the value is there.”

The integration of technology goes beyond just video visits, though, with the need to be an all-encompassing solution so that the clinic can truly understand who the patient is and what they need. Only then will the physician and the patient truly be able to maintain the same kind of connection they had through in-person visits, even though they are seeing each other virtually. 

“When a consumer accesses John Muir Health, either digitally or by telephone or in-person or video, we need to know who that person is. We need to be able to anticipate their needs. The consumer experience in the phone, via digital, via telehealth needs to be consistent and the handoff needs to be really smooth. And those are the big challenges,” said Sauter.  

Changing clinic real estate 

If more care is shifted to the edges via telehealth and remote patient care, the question is how does the real estate footprint look? It may no longer have waiting rooms given lifestyle behavior changes due to social distancing. 

“The inside of clinics are going to be different, waiting rooms may be a thing of the past. I always look at them as non-revenue generating spaces anyway, so I’m thrilled that we have this opportunity. On the administrative side, we might have the opportunity to downsize our office space and use that space much more rationally by having people work from home,” said John Muir Health’s Sauter.

Clinics may no longer have the same staff requirements. “If a lot of my visits are done by video, I can even rethink my facility. I can even rethink who I hire because I have a hard time recruiting in my most rural areas and some semi-retired providers might be willing to work if half their time was spent working from home,” said West County Health Centers’ Cunningham.   

Conclusion 

The Alliance of Community Health Plans and AMCP found that nearly three-fourths of consumers in the U.S. have “dramatically changed their use of traditional health care services”, ironically thanks to the virus. 

Bringing care closer to the patient, and meeting them where they already are will lead to dramatic, and long lasting, changes to our healthcare system. We’ve already seen that both physicians and patients love the convenience. Now it’s a matter of moving quickly to adopt these new services, not only because they’re effective, but because we might need them in place should an unfortunate next COVID wave hits us. 

(Image source: aluance.digital)