Essentials for Value Based Telemedicine Models
Telemedicine can improve access and quality of care in addition to greater financial incentives in a value based environment over fee for service, but only when implemented properly.
Summary
Value based payment models made us rethink care accountability.
Telemedicine adds infrastructure and technology, although a strong incentive in fee for service models, it can provide greater financial incentives in a value based environment, when implemented properly.
Addressing cost, quality and disease management will make value based telemedicine an important part of the care delivery model.
Background
Prior to the COVID-19 pandemic, telemedicine payment and regulations were confusing and convoluted. The changes enacted at the Federal, State and Private Insurer level made telemedicine a valuable tool for maintaining patient access to care during the emergency.
Following the initial surge in telemedicine use, peaking at 51.9% in April 2020, the use has been abandoned to the 15-20% range. There are various reasons for this decline, including the financial sustainability for telemedicine. Despite this decline, telemedicine remains in use 30 fold greater than pre-pandemic.
Source: The Chartis Group
Although there are obvious benefits to telemedicine, there are also some concerns.
REVIEW: ESSENTIAL CONSIDERATIONS FOR TELEMEDICINE ON A VALUE BASED APPROACH
Similar to other medical technologies, telemedicine will increase spending. The value question asks how much improvement in care can be achieved and at what cost?
Value in telemedicine should be defined as dollars per improvement in care
This encompasses:
o Quality care outcomes
o Access to care (including travel time, disruption to lives, need for childcare, etc)
o Financial Incentives including payment models
PRACTICE SIZE:
There is a clear association between use of telemedicine outpatient visits based on practice size.
Mehrotra et al. The Commonwealth Fund. June 25, 2020
Powers et al JAMA Health Forum 2021;2(7):e211597
ALTERNATIVE PAYMENT MODELS:
Telemedicine has created strong incentives for fee-for service (FFS) care organizations.
Compared to FFS care, risk payment models (including capitation) reached higher absolute values in 1.1 million Medicare Advantage patients from January 1, 2020 to September 30, 2020.
Powers et al JAMA Health Forum 2021;2(7):e211597
HIGH RISK PATIENT POPULATIONS:
To date, telemedicine evaluations have focused on its equivalency to in-person visits in all patients.
All forms of telemedicine may not be of equal quality.
Specific well defined conditions based on robust or estimated clinical use or provider types may provide greater value.
Coverage for non-high risk groups of patients could be by specific condition or provider type where there is evidence of value or a compelling need.
TELEMEDICINE ADDITIVE vs SUBSTITUTIVE ENCOUNTERS:
Substituting telemedicine visits for costlier in person visits will lower healthcare spending.
However, telemedicine could increase costs if the convenience of use increases visits in an additive manner to in-person visits.
As an example, if audio only visits are additive and not substitutive to in-person visits, healthcare costs will increase. In addition, patients may resent incurring out-of-pocket costs for such phone visits.
The clinical condition will be the key driver in substitutive vs additive care.
Conclusions
As we look toward a post-pandemic world, telemedicine needs to be conceptualized as a value-based care delivery framework.
This can only be accomplished by a systematic evaluation of telemedicine on clinical appropriateness of care delivery.
Practice size, patient conditions and provider types as well as substitutive telemedicine care will all foster value based payment models.
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