Innovation in Delivery: How can the U.S. health care system connect people with appropriate care?

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Our work in this area focuses on:

  1. Examining the use of telehealth during the COVID-19 pandemic
  2. Assessing the impact of innovative arrangements, such as the integration of primary and specialty care, primary care medical homes, and accountable care organizations (ACOs)
  3. Exploring health information technology’s (HIT) ongoing impact on delivery of care

Telehealth

Mother and child on a video call with a doctor, photo by FatCamera/Getty Images

The use of telehealth, already growing before COVID-19, exploded as the pandemic first began to spread, when social distancing and lockdown policies limited in-person encounters. Compared with March 2019, telehealth usage in March 2020 rose 4000% percent. The biggest jump was among mental health visits. In-person primary care visits fell during the first months of the pandemic and preventive and elective care both dropped dramatically. However, the increase in telemedicine use was not enough to offset the decline in the number of in-person primary care visits.

Varieties of Telehealth

Telehealth (sometimes also called telemedicine) can refer to several different types of remote patient-to-provider interactions.

Video conference icon, image by musmellow/Getty Images

Synchronous Interaction

  • Real-time visit between a patient and a provider
  • With the patient's usual provider or a new provider through direct-to-consumer telehealth
  • From a clinic (e.g., to provide a specialist consult from a primary care physician's office) or from home
Icon of a laptop with a health care symbol on the screen, image by Arafat Uddin/Getty Images

Asyncronous "Store-and-Forward" Consultation

  • Collection of patient data, which are stored and analyzed by a provider in a different location at a different time
Heart monitoring on a smartwatch icon, image by Turac Noruzova/Getty Images

Remote Patient Monitoring

  • Technology-enabled monitoring of patients outside health care settings (e.g., in the home)

How have providers adapted to this change? RAND work has begun examining clinicians’ experiences in practicing virtual medicine during the pandemic. A sample of psychiatrists reported switching to telehealth for the majority of their encounters during the initial spread of COVID-19 in March 2019. The psychiatrists reported overall positive perceptions of the transition, though some raised concerns about decreased clinical data for assessment, diminished patient privacy, and distractions in the home setting that reduced the quality of interactions.

In the context of COVID-19, opioid treatment providers transitioning to telehealth during the pandemic quickly switched to providing telemedicine visits in high volume—most of these clinicians were using some telehealth, and half were using only telehealth. Most reported changing their care patterns to help patients stay home and minimize exposure to COVID-19. Some clinicians identified positive impacts of telemedicine on patient interactions, including increased patient access, while others observed negative impacts: less structure, less clinical data, technological difficulties, and shorter visits. Telehealth treatment for patients with co-occurring opioid and mental health disorders also became more prominent.

One notable feature of the early spike in telehealth use: an overwhelming majority of telehealth visits involved a patient seeing a familiar provider, a feature of telehealth that may be difficult to preserve in the post-COVID environment.

There was evidence, however, of disparities in access to telehealth. The upsurge in telehealth use after March, 2020, was concentrated among patients in counties with low poverty levels, among patients in metropolitan areas, and among adults compared with children 12 and under.

By December, 2020, the early surge in telehealth use had largely waned, returning to pre-pandemic levels for many providers, including primary care physicians and dermatologists. However, certain specialty physicians, including behavioral health providers and pulmonologists, were using telemedicine at rates far above their pre-pandemic baseline.

It remains to be seen whether the shift toward telemedicine is a temporary response in a time of crisis or something more permanent. Policymakers had to rewrite or waive many rules (such as state licensure requirements) temporarily to enable widespread use of telehealth. For policymakers who want to extend the benefits of telehealth beyond the COVID-19 crisis, RAND analysts created a guide to clarifying policy choices based on the goal policies are trying to achieve: improving access, improving quality, bolstering emergency preparedness, increasing provider supply, or reducing disparities. These goals are not always mutually exclusive, but there are trade-offs in prioritizing one above the others.

RAND's telehealth work began well before the pandemic. Earlier studies examined telehealth through multiple lenses, from its origins in the "convenience revolution" to its effects on costs and quality of care.

Earlier work examined telehealth’s potential to reduce costs and to address quality concerns. Other studies compared the quality of telehealth and face to face care.

Comparing in-person visit costs to telehealth analysis found that use of telehealth does not necessarily reduce costs. Because of better access, more patients seek care, suggesting that telehealth was tapping into unmet need.

Another study found that physicians tended to overprescribe antibiotics at the same rate in face-to-face and telehealth encounters, suggesting that quality on this dimension is roughly equivalent between face to face and telehealth visits.

Our work has also examined the impact of telehealth on specific populations:

  • Users of federal safety net clinics in California. Safety-net medical providers can increase telemedicine services with modest investments in new staff and technology, a move that can help them expand patients' access to specialized medical care.
  • Veterans with mental health conditions. Prior to the pandemic, veterans of the Afghanistan and Iraq conflicts had limited access to virtual mental health care. RAND researchers explored strategies for increasing veterans’ access to mental health care in the COVID-19 environment.
  • Virtual first responders. Telehealth platforms are also useful as part of disaster response to deliver care to populations affected by displacement, unpassable roads, or emergency closures. During the 2017 hurricane season, several telemedicine companies offered free visits to hurricane victims. RAND analysis found that one key advantage of telemedicine in disaster response is that out-of-state providers can be tapped to expand the response workforce quickly and cost-effectively.

Innovative Delivery Models

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Innovative arrangements for delivering care feature designs intended to improve quality and cut costs. RAND studies have assessed the processes and costs of transforming conventional practices into alternative models as well as the impact on patient access and health.

Integrating Behavioral Health into Primary Care

Recent policy changes have encouraged the integration of behavioral health care into primary care settings. RAND work found that despite policy incentives, integration of behavioral health into primary care practice in the U.S. remains uncommon. Practices attempting this integration face cultural, informational, and financial barriers to implementing and sustaining integration.

Despite this general picture, specific models of care integration are emerging. RAND researchers have examined several models for integrating primary and behavioral care and developed tools to help practices implement them.

Converting Practices into Medical Homes

Medical homes are integrated practices intended to improve quality and cost-efficiency by putting patients at the center of a provider network. Most practice leaders had local control of PCMH transformation decisions. RAND analysis found that transforming practices into medical homes is complex and difficult. Practice leaders in charge of the transformation highlighted the need for leadership support and direction throughout the transformation. Leaders also noted the need for staff knowledge about specific quality improvement processes and an understanding of how to implement simultaneous changes.

  • An evaluation of a large federal experiment to transform safety net practices into medical homes showed mixed results; overall practices that transformed showed only modest gains in quality and efficiency. However, medical home arrangements with better communication led to high levels of patient satisfaction.

Creating Accountable Care Organizations (ACOs)

ACOs consist of doctors, hospitals, and other providers who organize to deliver coordinated care. The goal is to avoid unnecessary duplication of services and improve patient safety. Following passage of the ACA, a large number of Medicare ACOs formed. RAND analysis found that ACO formation was associated with greater health system integration but not with higher medical costs. A subsequent study showed that hospitals participating in ACOs or other innovative Medicare arrangements experienced a reduction in rehospitalizations, a key measure of hospital quality.

Health Information Technology

Electronic medical record screen superimposed over a doctor looking at an electronic tablet, photo by stnazkul/Getty Images

Health information technology (HIT) is slowly transforming the way physicians practice medicine, the way health care systems do business, and the way consumers get information and make decisions about their health. For more than a decade, RAND researchers have studied how HIT is changing health care as well as the challenges of implementing and using HIT systems.

Early RAND work established HIT’s potential for reducing costs while improving quality of care and patient safety. Recent analysis has examined HIT uptake at the practice and system levels. One study found that the use of electronic health records by ambulatory care providers increased from 77 percent to 91 percent based on the latest available data (2014-2016); however, only about a third of clinics reported having the full range of HIT functions, suggesting that uptake of HIT during this period remained surprisingly low. Another study explored the innovative use of HIT to improve care for complex patients.

Multiple studies have examined the use of HIT to improve health system performance. A sample of health care systems reported that their HIT adoption focused on two activities: laying the foundation to improve performance with IT and using IT to improve performance. Most activity was focused on laying the foundation, and systems’ progress varied widely. The results suggests the policy debate should move beyond federal incentives and requirements to adopt health IT. Instead, policy should be reoriented toward creating and disseminating best practices for how to use technology to improve performance.

Studies also showed that adoption of specific types of HIT continues to progress slowly. For example, despite substantial federal support for practices to adopt clinical decision support (CDS) tools, only 45 percent of systems reported using CDS tools (based on 2016 data).

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