Martin E. Doerfler, MD, SVP, Clinical Strategy and Development, Associate Chief Medical Officer, Northwell Health
It is often stated that it takes 17 years for routine adoption of promising medical innovations. In June of 2000 Dr. Gene Burke worked the first shift at the helm of the first commercial eICU (Tele-ICU) in Virginia Beach VA caring for patients at Sentara Norfolk General Hospital, miles away. The Sentara program showed significant improvements in severity adjusted mortality rates for ICU patients and significant improvements in ICU and hospital length of stay1. Yet, in 2019, Tele-ICU has yet to achieve mainstream adoption as routine standard of care.
"The possibilities for TeleHealth to markedly improve access and timeliness of care for patients of all types and illnesses is enormous"
Tele-ICU is far from the first successful use of Telehealth in the care of patients. It has been decades since audio video communications were first used to allow specialists to assist with the care of individuals in mainly rural communities. It is also, far from the only arena where the ability of skilled clinicians to assist with care via modern communications technology have significantly impacted, for the better, the care of individuals in need.
In addition to a successful eICU program, at Northwell Health we have a robust TeleStroke program that has led to improvements in “door to needle time” and increased TPA administration. We have a robust Emergency TelePsychiatry program that has dramatically decreased the time between initial request and start of Psychiatrist consultation for individuals in crisis from > 12 hours to 30 minutes. We have a Tele-SNF program connecting skilled, awake and alert physicians to Skilled Nursing Facilities in the middle of the night and weekends avoiding transfers to the emergency department and significantly improving the timeliness and outcomes of our patient’s care. I could spend paragraphs listing the scenarios where the Northwell TeleHealth programs are connecting physicians, surgeons, and other clinicians to patients in their homes or varied practice locations offering major improvements in access, care coordination, and availability of primary care or specialist expertise. Though almost none of our programs are unique to Northwell Health, the breadth and depth of our programs is matched by a select few with the focus, insight and ability to invest to this degree.
Why would this possibly be true given all of the benefits and advantages possible? In addition to all of our programs being effective and virtually none of them unique to only us, the major thing they have in common is that none are adequately reimbursed by third party payors, and, except for the TeleStroke program which recently changed in January 2019, none are covered by Medicare.
Though I always cringe at describing Healthcare as a business it absolutely needs to be run with solid business principles. I learned early in my career at Bellevue Hospital the concept of “no money, no mission.” There are many impediments to the routine deployment of robust TeleHealth programs including the processes for credentialing providers at every hospital and out of date requirements for ED coverage and Medical Staff dues for folks who likely never set foot inside. State licensing requirements makes it difficult taking care of patients who travel to your office from another state but is sitting in their living room for a follow up TeleHealth visit. Technology is no longer a significant issue. Smartphones, the internet and the ‘cloud’ have changed that though patient education will be an issue once routine TeleHealth offerings exist at scale; a problem I’d love to have.
In my opinion, all other obstacles pale beside the adverse impact lack of balanced reimbursement for TeleHealth services on developing sustainable business models. Starting TeleHealth programs or routine incorporation of TeleHealth tools into existing practices of multiple clinicians, primary care, medical specialists, surgeons, psychiatrists, and many other clinicians including therapists, nurses and clinical educators all require adequate reimbursement for professional services. Healthcare remains largely Fee for Service and even managed care plans include internal FFS based distributions amongst the participants. Whether dollars or RBVUs, a currency for compensation is required.
Though I call out Medicare for special attention in this area; how can any clinician offer a service to her patients and community that is not covered by Medicare given the large fraction of the healthcare delivery covered by Medicare? It is not just Medicare. At the state level, TeleHealth Payment parity for commercial insurers is needed. Some states have TeleHealth coverage parity but many commercial insurers are seeking to pay inadequate rates and often invoke ERISA for large self-insured plans to avoid even this requirement. Professional and Industry groups are not innocent. TCreating new CPT codes starts when industry, health professionals, insurers, government officials or others, submit an application for a new CPT code that reflects a unique medical service.
Some will read this missive and be perplexed given the oft stated statistics on the large number of insurers and employers now covering “TeleHealth Services” and wonder where the disconnect is. The missing detail being that covered services are routinely limited to Virtual Urgent Care and often with exclusive panels connected to large companies. Coverage for your child’s Pediatrician seeing her for a new rash, swollen eye or flu-like symptoms is not included. Coverage for your aunt in a skilled nursing facility with a change in respiratory condition or confusion at 3 AM is not included. A follow up visit at home two months after an office visit for a recent stroke to see how therapy is progressing is not covered. A college student on antidepressants with bothersome side effects consulting with their psychiatrist from their dorm for medication revision is not covered. This list is near endless.
The possibilities for TeleHealth to markedly improve access and timeliness of care for patients of all types and illnesses is enormous. Accelerating availability and adoption so we don’t wait another 17 years requires payment mechanisms creating true parity for the time and resources required of clinicians to incorporate these tools into their services for their patients and communities. Legislators and policy makers of all stripes should do what is in their power to rectify this situation expeditiously.