Telehealth in the COVID-19 Era

Transcript

Ateev Mehrotra

On behalf of RAND Australia and the University of Sydney, I'm pleased to welcome you to this webinar on telehealth in the COVID-19 era. My name is Ateev Mehrotra, I'm a physician and researcher at Harvard Medical School and at RAND. And I'll be privileged enough to be your moderator for today.

The goal for this hour is to have a cross-national exchange on telehealth and describe how telehealth has been used both in the Australian and U.S. context. Based on national numbers, the uptake has been quite similar of telehealth in the two nations. But behind that, there's a lot of variation. And I think what we're hoping to explore is how is it deployed in both countries? What has worked? What hasn't worked? And the question that I'd like to also pose to the participants is the question so many are asking, what will telehealth look like after the pandemic in both how it is used and how will government and private insurers reimburse and regulate for telehealth?

To help answer these questions, we have four great panelists, two from Australia and two from the U.S. We'll be starting out with Rachel Reid. Rachel is a practicing physician and a policy researcher at RAND. She'll be describing both her personal experience with telehealth, but also at a higher level, the experience within the U.S. health care system of how telehealth is being used. She'll be followed by Len Gray. Len is from the University of Queensland, and he's a practicing geriatrician. I've had the privilege of joining Len for some of his own telemedicine visits, but he's also the director of the Center for Health Services Research, which has done a tremendous amount of work looking at digital health within the Australian context. Len will be followed by Lori Uscher-Pines, who is a senior policy researcher at RAND, who's conducted a number of critical studies on telemedicine use in the U.S. across numerous applications from stroke care to urgent care to lactation support. And she'll be discussing some of her ongoing work with clinics who care for a disadvantaged population and their personal experience with telehealth and issues of disparities. And last but certainly not least, Teresa Anderson will be speaking. She's the chief executive for the Sydney Local Health District, and she'll obviously be providing her experience, deploying telemedicine options and how they have impacted the patients in her community. So with that, let me start with Rachel.

Rachel Reid

Thank you so much for the opportunity to speak to you today. I'm going to give an overview of the cumulative telehealth experience across the U.S., specifically in our Medicare program, as well as the experience within the academic medical center in Boston, where I practice as a primary care physician and have practiced a good amount of telehealth over the last year.

So the United States Medicare program is an insurance program that is administered by the Federal Government, specifically for the aged population and the disabled population, providing about 60 percent of the insurance or insurance coverage for about 60 percent of that population, the remainder getting their health insurance coverage through a parallel program called Medicare Advantage, administered by private health insurers.

The United States Medicare program dramatically changed its coverage of telehealth services and reimbursement during the COVID-19 pandemic. And understanding those differences in payment and coverage policy underlie some of the trends that have been seen in the United States during the pandemic. Before the COVID-19 pandemic, the Medicare program reimbursement for telehealth services was limited to patients who resided in a designated rural area; who came physically to a clinic or other medical facility to receive telehealth services—so they were not at home; from a provider, who was themselves located at a health care facility; for a limited set of services, and some subset of those were indeed limited to established patients only—so new patients weren't eligible to get them; and those services will reimburse at a lower rate relative to comparable in-person care.

During the COVID-19 pandemic, the Centers for Medicare and Medicaid Services, the office of the Federal Government that administers the federal Medicare program, changed coverage and reimbursement policies for telehealth in a relatively dramatic way. The changes allow providers to conduct telehealth services for patients located in their homes and outside of designated rural areas. It allowed providers to practice across state lines to deliver telehealth services to both established and new patients, and to build for telehealth services as if they were provided in person at a comparable or parity rate. And it also expanded the telehealth eligible providers, services, and modalities. Previously, there were restrictions on the type of mechanism one could use to deliver on audio or video based telehealth services. There temporary exceptions to privacy laws that allowed one to deliver telehealth services, even using FaceTime on one's Apple products to provide additional flexibilities at this time when providers were ramping up.

So this kind of represents the federal Medicare program. There was a lot of diversity at the state level in that kind of commercial insurance or insurance for populations other than the aging population is regulated at the state level. And there is a good amount of variation in terms of the regulations and statutes on the books with regard to both coverage of telehealth services and payment parity for telehealth services. About north of 40 states have telehealth coverage laws on the books for the commercially insured populations—that non-Medicare population. Of those, a small minority, less than 15, have current statutes on the books with regard to parity of payment for telehealth services relative to in-person services.

So that is the underlying regulatory bounds of the discussion in the United States. On this next slide, what I'm showing you is a line graph that represents the couple of months preceding the pandemic and the earliest months of the pandemic. This is a study that was an analysis that was done by the Office of the Secretary of Planning and Evaluation at the U.S. Department of Health and Human Services. And it represents a graph of weekly primary care visits by modality with dark blue representing the combination of telehealth and in-person services, telehealth in the yellow, and in-person services, in the light blue. What we can observe is that as the pandemic ramped up in the United States in mid-March, we saw a dramatic decline in in-person services and a more gradual ramp up in telehealth services. As the pandemic continued, we observed that telehealth services declined slightly and then plateaued. In-person services rebounded, but not quite to the level that existed preceding the pandemic.

In analyses we've done at RAND looking at telehealth data across specialties—not limited just to primary care visits—we've observed a similar pattern in that a rapid decline in in-person services early in the pandemic, followed by a recovery not quite achieving baseline for the combination of in-person and telehealth services later in the pandemic, and that telehealth services increased and then decreased slightly, plateauing at a more moderate level, but still substantially elevated relative to their pre-pandemic baseline. This graph does not specifically address audio versus video telehealth visits, but in forthcoming analysis that we've done at RAND we see about a two-to-one ratio of video-to-audio in service delivery in the Medicare population in terms of visits.

This next slide is a different study representing the experience in the academic medical center where I personally practice. A colleague of mine in clinic, Ishani Ganguli, has done an analysis based on the electronic medical record visits of primary care providers and specialists within our large academic health system, the Mass General Brigham system affiliated with Harvard Medical School in Boston. And this graph represents the daily visit rates of in-person telehealth, audio and video visits during the early days of the COVID-19 pandemic. What it shows is that there was a relatively rapid uptick in audio visits in the light blue, followed by a slight decline. A slower decline in video visits in the green, eventually slightly surpassing the audio visits.

This next slide shows that the experience of our health system varied somewhat by the characteristics of the patients who are receiving the service, in that patients who were Black or Hispanic were less likely to receive video-based services as compared to audio-based services. Older patients were less likely to receive video services as compared to audio services, and non-English speaking patients were less likely to receive video services as compared to audio services. And this experience of my health system across patients and across specialties is also reflective of my own experience as a primary care provider during the early days of the pandemic. Thank you.

Ateev Mehrotra

Thanks so much, Rachel. And let me now turn it to Len to start with the Australian experience.

Len Gray

I'll start with just a couple of slides for our U.S. colleagues about how the world of health operates in Australia. So the national government operates a system called Medicare, which is at its heart, a fee for service mechanism to provide for ambulatory care and the medical services in private hospitals for both primary care, or general practitioners, and specialist consultations. And the government also at the federal level provide some level of subsidization through a variety of mechanisms of private hospitals, and it operates the aged care program nationally.

Whereas the state governments and territory governments, which there are nine, they operate public hospitals, with funding support from the Federal Government, that they are responsible for administration. And that represents about 70 percent of hospital beds in Australia, which are, public hospitals are open to all individuals whether insured with private insurance or not. And the state governments also provide specialist clinics with ambulatory care clinics, but not primary care clinics.

A couple of other points to note, that in Australia, health insurance principally is designed to cover private hospital admissions. It doesn't cover really much in the way of ambulatory care at all, very different from the U.S. environment. And specialist consultations in this country require a referral from a GP, so that the door is not open to specialists directly to the public.

In regard to support for telehealth in Australia, psychiatry support through the Medicare fee-for-service system, psychiatry has had some financial support since about 2003. But most importantly, in 2011, specialist consultations to people living in rural communities and in aged care facilities everywhere, and indigenous communities everywhere, had access to financial subsidization for video consultation only. Whereas the state governments have had a variable approach to supporting ambulatory consultations and inpatient consultations in state by state by state. Really, most of the states have an activity-based funding model, and within that model they are subsidizations for telehealth. And that really got started in Queensland, where I live, in about 2012.

And all of the video consultation item numbers also offer a payment to the patient-end to support a GP or practice nurse to accompany a patient. So it turns out to be a rather more expensive interaction than a traditional face-to-face in the doctor's office. Just to point out, there's no direct financial support at any level, apart from the odd demonstration or innovation, for remote monitoring or telephone consultation. So this is what's happened since about 2011, when subsidization of video consultations occurred. And this slide shows the hosting events and specialists events, so the green bars demonstrate a pretty steady increase, but a very small proportion of total consultations were offered by video conference. And, of course, that proportion's driven to some extent by the restrictions on rurality, but also on just relatively limited uptake. But nonetheless, quite a steady increase over the years.

And similarly, just looking at state governments, see pretty dramatic growth since about 2012 in each of the states, but highly variable amongst the states in terms of the uptake in the public hospital ambulatory clinic environment. And here, for example, is Queensland Health. It began offering subsidies about 2012-13, and it's been a steady increase, and it continues to this day, in the use of video conferencing consultations both to inpatients in rural hospitals, but also to ambulatory services in rural communities.

So with the COVID event back in March 2020, the government introduced what it calls temporary medical benefits schedule (MBS) telehealth items. And the big change here was that the telehealth became available for use by metropolitan-based general practitioners and rural GPs, previously not available, and for specialist consultations in metropolitan areas, whereas it was previously restricted to rural patients. And also an increasing number of allied health consultations also became reimbursed or reimbursable through the Medicare system.

So what's happened as a result of that is specialist consultations, and I'm borrowing or showing you very nicely presented material from the Center for Online Health within our center at UQ where there's a very nice website you might like to look at, I'll show you it in a moment, where my colleagues presented this data in a very nice fashion. But so what you see here on this chart is the black bars show, the rural consultations for specialists, essentially a bit of an uptick when the COVID started. But what really happened with the introduction of these item numbers for telehealth was a very dramatic increase in the number of the onset of a lot of reimbursed telephone consultations. And at the start of the COVID, there was a sort of a lockdown period, a reduction in face-to-face to about half of what would normally have been in the first instance. But you can see subsequently a gradual return to normal in terms of the number of face-to-face consultations. What's happened with telephone consultations is that they've steadily declined, but certainly a large number of telephone consultations and not many video consultations—these are the red bars. So what we have today is essentially a normalization of the traditional face-to-face consultations with the added, I don't know you might call it an enhancement or the added cost, of telephone consultations, depending on your perspective, which is certainly nowhere near what the situation was prior to. What we don't know is, of course, what sort of telephone consultations occurred prior to the epidemic. It just wasn't recorded. These telephone consultations with patients, were not reimbursed and not recorded in any methodical way. So we don't know whether this is a normal situation now or it's just an added cost and added enhancement to the system.

And similarly, going to general practitioner consultations. There were virtually no video consultation happening prior to COVID era. Very, very big increase in the... or large number of telephone consultations. About 30 to 40 percent of interactions early in the COVID period were mediated through a telephone consultation. But again, you're seeing it's somewhat of a decline, but now an uptick back towards normal in terms of the in-person consultations as we speak and but very little in the way of video consultation right across the whole time period.

So just to draw, Ateev is an author on this paper, but it's a nice a nice summary of why what's needed for sustainability of telehealth, and it's a good, good read for those of you who are interested. But there are a number of factors that have probably restrained the use of video consultation in primary care practice and to some extent in specialist practice as well. And we could talk about them in the discussion. Just I mentioned the website, the Center for Online Health at UQ has prepared and it keeps it very much up to date. It's a tremendous source of information around what's happening in the COVID pandemic and also a number of really excellent papers, at least if you're interested in reading some of the work that Anthony Smith, Ateev himself, and others have prepared in regard to this epidemic. Thanks.

Ateev Mehrotra

Well, thanks so much, Len. That was perfect. Let me pass the baton over to Lori, who will now focus on some individual practices she's been working with.

Lori Uscher-Pines

Great. So excited to be here today. I'm going to talk a little bit about two different studies that research teams that RAND have been involved in. The first study, as Ateev mentioned, is tracking Federally Qualified Health Centers, serving low income populations and how they are experiencing the shift to telemedicine services. And then the second project is actually a longitudinal study that we've been doing using the American Life Panel, which is a nationally representative panel of U.S. residents. And what we've done over time is looked at their experiences using telemedicine, both prior to and during the pandemic. So two very different studies, but I'm going to tie them together you'll see in coming slides.

So first, to talk a little bit about our health centers. So when the pandemic hit, the California Health Care Foundation funded us to track 41 health centers with over 500 physical locations throughout the state of California. So these are really large organizations that served approximately two million patients in 2019, and they represent about 20 percent of all of California's Federally Qualified Health Centers. And like Federally Qualified Health Centers located across the United States, they focus on disadvantaged population Medicaid patients. What's interesting is that they did almost no pre-pandemic telehealth with patients at home. They occasionally hosted patients who would then receive telemedicine services from remotely located specialists. But they themselves were not delivering telemedicine services. And that all changed when COVID hit.

We are collecting two types of data from these health centers. One thing that we're doing is looking at visit volume and then we're also doing interviews with them throughout the pandemic to really understand what barriers they're facing and to make sense of the quantitative data. So I'll be talking a little bit about both the quantitative and qualitative today, because the qualitative has really provided some nice insights as to what's going on on the ground.

So this slide shows what happened with primary care delivery at Federally Qualified Health Centers. And as you might expect, and as others have shown, in March 2020, in-person visits took a major hit. What I'd like to draw attention to, is similar to Len's trends here, we see a lot of audio-only visits for primary care. In fact, that's the dominant modality throughout the pandemic. And what surprised us is not so much that there was a lot of audio-only, it's that there was very little video visits—there are very few video visits, both at the beginning of the pandemic, and then as time went on. We anticipated, OK, maybe there'd be a rocky start to all of this, but over time, as health centers became more comfortable with video visits and gained implementation experience, video visit volume would grow. We're not really seeing that. Video visits have remained about 6 percent of all primary care visits, and that's remained really stable.

I also have a slide that shows behavioral health visits. It's remarkably similar. I'm going to just skip it in the interest of time today. It's very similar, although in-person visits are even lower and there's a little bit more use of video, around 13 percent. But still, you're seeing a lot of audio-only visits and the audio-only visits are really hanging on as the dominant modality.

Even though most of our health centers weren't doing much video, there were a few outliers who, despite the fact that they were still serving the same population of disadvantaged patients, despite that they were actually successful in delivering more than 25 percent of visits via video. And we wanted to know, "what is critical to your success in this area? What has enabled you to to really transition to more video visits than than other health centers?" And this slide shows a number of different promising strategies. I'm going to draw your attention to a few that we're particularly excited about. One is a relatively simple strategy that when the patient calls to schedule, you actually say that the provider recommends that you do a video visit instead of just offering all the options and letting the patient choose, you really have this extra nudge of saying "the provider wants to see you this way, please consider a video visit." We heard a lot about about these organizations combing through the schedule in a given day and thinking about which visits can be flipped from phone appointments to video. We heard a lot about conducting pre-visit calls to ensure that the patient has the technology and digital literacy to participate in the visit. And we also heard about cases of leveraging support from health educators or student volunteers so that when a patient was actually in the clinic in-person, a volunteer could sit with Mrs. Smith, for example, and sit with her and walk her through what it's like to have a video visit. And then she could then do a video visit follow-up at a later point. But she was empowered to do that when she was in the clinic in person.

So there are a number of promising strategies here that we've heard about and we're hoping to disseminate more broadly so that over time, health centers can transition to more video visits, especially because the fate of audio-only visits in this country is in question. We're not sure if those will continue to be reimbursed after the public health emergency.

So, like Rachel, we also looked at inequities and access and what was going on with respect to different patient populations and their use of telemedicine. Interestingly, we didn't see any significant differences with respect to race, ethnicity, payer, or language preference with respect to audio-only visits. So the folks accessing audio-only visits were really representative of the clinic population in general. Where disparities start to emerge is with the limited-English proficiency population. So we do see that they are underserved, underrepresented, I'm sorry, with respect to video visits. So that's something that we continue to track.

So I mentioned that prior to the public health emergency, Federally Qualified Health Centers were not serving patients at home. They might be hosting patients who were seeing specialists, but they themselves were not delivering telemedicine services. So this was a big change. Federally-qualified health centers are like many primary care providers in the United States in that those brick and mortar locations that were seeing patients in person typically weren't delivering telemedicine services prior to the pandemic. And so now in this country, what we're seeing is this tension between these usual providers who have now gotten into the telemedicine game, versus direct-to-consumer telemedicine providers who've always been part of the landscape. We're seeing a little bit of a tension—how do we incentivize the appropriate balance of those two providers in health care delivery?

As I mentioned, we've been using the American Life panel to look at U.S. residents and their experiences with telemedicine. And in the last survey that we ran in March, we learned that about 20 percent had a video visit with their own doctor during COVID-19—and that's a huge change because that just wasn't happening prior to COVID—versus 11 percent who had a video visit with an unfamiliar doctor. And that can include maybe a doctor at your practice that you usually go to, but you just don't have a relationship with, as well as direct-to-consumer telemedicine companies, so that's kind of a mix of both of those is our guess. But in general, what you're really seeing is a lot of these brick and mortar practices now offering telemedicine and patients deciding that that's where they want to go for telemedicine care.

So I think the U.S. is going to have to deal with this in the future. Just how are we going to incentivize the right balance? Because there are some advantages to direct-to-consumer independent telehealth companies. There's a lot of innovation in that space, but there are disadvantages as well. Your usual provider typically has access to your medical records, maybe you have a long standing relationship and that can improve the quality of care. And so there's concerns about quality if direct-to-consumer telehealth grows too big. So something that I think that policymakers are grappling with and I'm looking forward to seeing how all of this evolves. Happy to take questions.

Ateev Mehrotra

Thank you so much, Lori. Last but not least, Teresa will be presenting some of her experience from Sydney.

Teresa Anderson

So thank you very much for allowing me to join you all. I'm going to talk a little bit differently about our experience with rpavirtual, which is a truly virtual hospital that we've developed during COVID. And this was a new initiative to initially not manage COVID, but to address some of the population issues that we were having within our local health district and the projected growth in activity.

While I was in Israel a number of years ago, we looked at projections for the development of the emergency department at Royal Prince Alfred Hospital, which is a major quaternary hospital. And we were concerned that the emergency department was going to be as large as some of our local district hospitals. And obviously that wasn't going to be possible. And so we decided that we would invest in a different approach to virtual care that was different to telemedicine, a truly integrated virtual hospital that was similar to a normal hospital with all of the specialties and the models of care, but was provided virtually. And we were looking at how we would scale our models of integrated care to supplement our capital redevelopments, take advantage of the explosion in technologies, and respond to a more flexible approach that our consumers were wanting in relation to care and obviously avoiding unnecessary hospitalizations. So we were planning how we would do that, and we had a number of underpinning technology principles, which I won't go into in great detail. But technology has been key to the way in which we have rolled out rpavirtual.

The issue is that in the beginning of March, it was really evident that we were going to need to manage people who were COVID positive within the community and we very quickly adapted rpavirtual to be able to do that—to manage people who were working, who were living at home, who required monitoring, because we didn't want to overwhelm our public hospitals. And we then started our quarantine hotels. So in Australia, we had a system for all returning travelers having to come through a quarantine program for 14 days. And obviously with that, we had people who were COVID positive and need to effectively manage them. So we set up some special health accommodation, and in that special health accommodation, we were able to manage people who were COVID positive. We have an electronic medical record within the special health accommodation and it's basically apartments of one to three bedrooms and the rpavirtual reaches into those apartments with staff also on the ground.

And the model has evolved using a risk stratification approach so that we can effectively manage those patients. And the care is provided 24 hours a day, seven days a week. We also manage a whole range of patients who are not COVID positive within the hotel quarantine program. And at any one time we have around 650 patients within the special health accommodation that are managed through rpavirtual plus staff on the ground. And I'm sure, as many of you have experienced, in terms of the patients who are in our quarantine hotels, often they have a whole range of health care needs that are much more complex than we anticipated. And being in quarantine for 14 days may seem like a short period of time, but many have complex conditions that actually do need to be managed and managed safely. And that included, I've never realized how many people leave Australia to do IVF treatment overseas and then come back and require antenatal care within our special health accommodation. But we've also had to manage complex pediatric care, including a large number of children with autism, patients with drug and alcohol problems, aged care issues, mental health.

And so rpavirtual is really about supporting patient flow for our hospitals and reducing unnecessary emergency department presentations and enhancing the patient experience, and we've used it to inform the adoption of virtual health care across our district. So the relationship between the bricks and mortar hospitals' specialists has been really critical to this model because it's not just about the team who are located in our 24/7 virtual care center. It's very much about the ability to pull in specialist services both into patients' homes, but also into the special health accommodation.

As I said, in terms of the quarantine program, we have had over 163,000 patients who have come through the quarantine program. 11,000 of those have either been COVID positive, have had conditions that aren't appropriate to be managed in police-managed quarantine hotels, or who are at risk of requiring admission to... at risk of having COVID. And so the special health accommodation with rpavirtual has been able to basically be a large hospital of over 650 beds without taking up beds within a public hospital. So we've managed more than 12,000 unique patients and 90 percent of those have been pandemic related, over 2,000 COVID positive patients and 9,647 patients who are non-COVID but have required care within our services. And that includes things like palliative care monitoring, remote lung monitoring for cystic fibrosis patients, medication monitoring, and mental health. And mental health has been one of the big successes for us.

We've looked at the patient experience and it's been overwhelmingly positive. The one low one is whether or not people recommend virtual care for their family. Remembering 90 percent of these people are in quarantine programs, so they don't really want to be there—they actually would rather be at home. And we looked at the experiences of our staff. And again, I think that the results for a new service are very positive. We've been involved in evaluating the results of rpavirtual with the University of Sydney. And the feedback is that we can provide high quality care successfully in a truly virtual model. This is not a telehealth model. It's an integrated care model. So I might leave it there and we'll take questions. Thank you.

Ateev Mehrotra

Tereasa, fascinating. Thank you so much for that, the model, and amazing the numbers in terms of what you've had to manage virtually. I also had not recognized the variety of problems you might have to face with people returning to Australia.

So why don't we turn to the Q&A. But I want to start with the future. That is the question that so many people are thinking about, as many of you alluded to in your talk. There are a number of issues that relate to that. I might start with Len—I guess I have two questions for you Len. The first is in the U.S., the concern has been very much that the expansion of telehealth will increase utilization. We really haven't seen that as illustrated by Rachel and Lori's work. But in Australia you have. You have seen with the addition of... now we're seeing increased utilization post- than compared to the pre-pandemic, at least in both in primary and specialty care. So I guess, A) how has that influenced the conversation? And then maybe if I can put your ability to predict the future, what's your best guess on what the reimbursement landscape is going to look like post-pandemic, both for phone calls as well as video visits?

Len Gray

The interesting question is to what extent those telephone consultations are really recording what was previously occurring to some extent and to what extent they represent an enhancement or a burden on the overall system. And so that's something of an unknown. But now one could argue that they're an enhancement of practice or genuine reimbursement for something that was happening previously. Remember, these are time-based consultations, so in theory, if the workforce is finite, then there's only a certain amount of time available. So to what extent is an expanded cost or gaming going on here is unclear. And I guess that's what the regulators and the funders are anxious about—to what extent this is a value proposition that's positive, and to what extent it's just paying more money for the same service that preexisted the pandemic.

And my guess is the government's (who essentially pay for this) view is that telephone is... their philosophy has always been that that's just built into the cost of the in-person visits effectively. And they really don't want to pay twice for the same service. And I guess it's a problem of the fee-for-service model, fullstop, in the sense that everything's divided into little packets that you pay for on a time basis. And so whether whether the funding model is really contributing to this problem is, of course, a matter that would always be commented on. So I'm guessing the government's going to reduce the support for the telephone, but it may take a different view of video. It's much more proximate to a traditional visit and perhaps a better value proposition. I think that's our view in the Center for Online Health, that we'd like to see some support for video over and above telephone because it's a better form of interaction, probably a better value proposition. That's about all I can say about that, I think.

Ateev Mehrotra

It's so hard to know, but I think there's so much uncertainty that is right now. I might Lori, I know that you've been speaking to a number of policymakers who are grappling with this issue. Again, I know I'm putting you on the spot, but what is your sense on where the U.S. is headed, both with telemedicine in general, but maybe specifically around the phone visits? Because that has become quite a critical issue.

Lori Uscher-Pines

Telemedicine used to be really restricted in the United States. And then when everything changed with COVID, a lot of telemedicine advocates were saying, genie's out of the bottle. I think we should have a genie-out-of-the bottle drinking game because we hear that so often. That's a really common phrase. And I think the truth is we're going to end up somewhere in the middle and we're not going to be as flexible—things will not be as flexible. Because it started off and folks were worried about quality concerns of telemedicine, and then the conversation really shifted to costs and concerns about overutilization. Now everyone's talking about fraud. So that's telemedicine's new problem. So policymakers are very worried about that, about if we open up access and we're going to have bad actors who are dialing for dollars and trying to drum up demand for telemedicine visits when it's unnecessary.

So I do think that to the disappointment of many telemedicine advocates, we're going to end up with many of the flexibilities rolled back, and I'm worried about what will happen with phone visits. There's concern that Federally Qualified Health Centers may not continue to have access in the Medicare program or in various state Medicaid programs because they get a different payment, they have a different payment framework, and their visits are fairly well compensated. About $250 per in-person visit on average, although it varies by Federally Qualified Health Center. And giving that rate for a phone visit just doesn't seem feasible or doesn't seem to really even capture the cost of providing the care. So I remain a little worried about what's going to happen with audio-only going forward.

Ateev Mehrotra

And the issue of audio-only is tied together very closely to this issue of disparities, where the concern has been that with the expansion of telemedicine, what we will see is, both in Australia and the U.S., we see substantial disparities between our urban patients and our rural patients, and our poor and the rich. And the concern is that telemedicine will widen that well-established disparity. Rachel, if I could turn to you, you showed some work highlighting those differences in the type of uptake. I'm curious, do you think this concern is well founded? And I guess what should be done to address this, if it is a valid concern.

Rachel Reid

That experience and that kind of concern feels well-founded. My own experience practicing and that of my colleagues in my health system in that, similar to what Lori expressed, I expected that population of patients for whom I was speaking with via phone to eventually get more comfortable or for things to ramp up over the course of the visit. But over the last year now of experience delivering telehealth, there is still a population of patients who strongly prefer to see their encounters via telephone. Some of what I'm hearing is that they don't have a data plan on their cell phone; they don't have reliable broadband access at home; they don't have an environment in which they feel comfortable engaging in a video encounter, be that because of their work, be that because of their home environment. And I do distinctly worry about what that will look like in terms of their access to services, particularly for some of the services for which it feels like telehealth is particularly at—some of the behavioral health services I feel like are a window for which access has been facilitated via telehealth. And I wonder if there could be an approach that specifically targeted telehealth phone access for some of those services that are harder to get or more well-tailored to that phone environment in particular. And I'm seeing Lori nodding as well, and I'm betting a lot of what I'm saying was reflected in her qualitative experience, too.

Ateev Mehrotra

It's a critical issue in the disparities that might emerge. Teresa, I was going to shift gears—a number of the participants were very intrigued by rpavirtual, and there were a couple of questions that I might put to you—there were a lot of interest in some of the logistics of it. The first is what the technology is patient-facing in the dedicated health centers, and who's on the other end? Is it nurses, is it medical staff? And then there was also the interactions themselves. What were they like? Where they done by video, phone call, was it remote patient monitoring? So if you could provide some more context there, they'd be very useful to the audience,

Teresa Anderson

Thanks Ateev. And so rpavirtual has a 24/7 care center that is staffed by nurses, doctors, and allied health, including psychologists. And during COVID, we've significantly lent on our mental health staff for all of the obvious reasons. The technology involves both phone and iPads. And if I think about our mental health services, we've actually provided the iPads to many of our mental health clients and we're doing an analysis around the costings for that. What we found with mental health is that the patients actually feel much more autonomous, that they feel that by having virtual in reach, that they have some autonomy and self-determination rather than someone coming into their home. But having video conferences with the clinical staff, it gives you a sense of what's happening in the environment around them, gives you an opportunity to look at how the person is coping with the current situation. And we're doing our remote medication monitoring with them. With our patients with cystic fibrosis, we use Bluetooth peak flow monitors trying to keep them out of hospital. And that's been really successful. And as you know, a lot of our patients with cystic fibrosis are quite tech savvy. But we've also got an ICT team that we can provide support to people in their home to help them with the technology, and I think it was you, Rachel, you were talking about some of the learnings in relation to how do we increase the capabilities of the patients that we have. But I think one of the real successes of rpavirtual has been the ability to use our on-call rosters at a quaternary hospital and all of the specialist services and pull them into rpavirtual when that's required for the patient.

We're doing costings with New South Wales government in relation to rpavirtual compared to normal brick and mortar service delivery. My view is that we need to have both. They need to be truly integrated, that we have to have face-to-face interventions. And a virtual health care should supplement that. And hopefully what we will see is a decrease in presentations to hospital, but also if people present that, we've got a reduced length of stay because that care is truly integrated. All of our virtual care is linked into the electronic medical records, so all of our staff can see that no matter where they are.

Ateev Mehrotra

It's fascinating. One thing, just as a quick note here in the U.S., which is the growth of what has been termed here, hospital at home, where patients will enter or present at the hospital, the decision will be made to admit the patient, but then they'll say, well, for patient with cellulitis, let's do those antibiotics at home and to produce using telehealth as well as other monitoring to be able to do it. And we'll see how that plays out also post the pandemic.

And sticking with the theme of remote monitoring, Len you alluded to it early in your talk, that remote patient monitoring has not been something that Australia has really embraced to the same degree, at least in terms of reimbursement. There's a lot of enthusiasm—but for remote patient monitoring versus video visits or more synchronous visits, I'm curious how you see the landscape playing out. Do you see it's going to be shifting to remote patient monitoring, or do you think it's still the mainstay is going to be these video visits or phone visits in the future in Australia?

Len Gray

Well, first, I'd say these two things are not mutually exclusive. They are mechanisms to interact with patients and to provide care. So it's not either/or, it's what what is the blend of these things for particular patient circumstances and conditions that is best suited to those individuals? So remote monitoring, obviously, for glycaemic control in diabetics is an important capability. But that needs to be coupled with some mechanism to communicate with the patient about their care, and that would be best mediated by text, email, or video or telephone consultation. So configuring a care plan for an individual really depends on constructing the right blend of these capabilities to suit that particular person's circumstances. So I don't see it as a competition or an either/or, I see it as another capability to draw on to provide a comprehensive solution for people.

Ateev Mehrotra

And Len, just building off of that, it gets a little complicated in terms of, as a GP, providing care for patients with the fee-for-service system. Do you see in Australia a movement towards more capitated payments so that the GP doesn't have to decide, and the phone visit and that particular code and visit, etc.?

Len Gray

There has been and there is an effort in Australia to find another way to reimburse for care, taking into account the sorts of things I've just talked about. And it's complex as you know, it's not simply a matter of a talk session that lasts three minutes and then you get reimbursed. It's a whole lot of capability that goes with it. But, yes, some new kind of financing model needs to be constructed, at least for folks with particular types of problems, say, complex diabetics with complex needs or people with cystic fibrosis. Such individuals need particular programs of care very different from the kind of relatively well-ambulante citizen that has occasional problems or minor chronic disease. I think finding a model that supports people with complex needs is probably the thing that we really need in this country.

Ateev Mehrotra

One of the questions Lori was posed by one of the participants was related to what first started with the concern that when we add these technologies, often it increases spending. So then the question is, telehealth may do the same. Where is the right applications in terms of, again, in your view, what are the best applications, both either clinically, in terms of which patients, which conditions, or which modality you see as those higher value applications of telemedicine?

Lori Uscher-Pines

It's interesting, we talked a little bit earlier about where we were seeing evidence that telemedicine was increasing costs, and I think Len had mentioned they are seeing greater utilization because those phone visits are additive. We're also seeing that with the Federally Qualified Health Centers. On the behavioral health side, they are able to deliver more visits now than they were prior to the pandemic with this combination of in-person phone and video. And one of the reasons that they are saying that they're able to do that is because the no-show rate is down. So it's not that the visits are shorter or... none of that, that's not going on. It's really the fact that just the patients are actually showing up and they're showing up for all the different visit types because they're now choosing the visit that they prefer and that works the best for their schedule.

So I think as time goes on, we may see evidence of additional utilization beyond pre-pandemic in different pockets, maybe not for all specialties, but certainly for some. I don't know that that's a bad thing, because especially in some of the behavioral health, we know that there are many populations that don't have the access that they should and I personally think our goal should be to increase access and utilization of services like that. So I'm particularly excited about telemedicine for behavioral health and for opioid use disorder. Ateev, you have made this point in testimony that telehealth for skilled nursing facilities can be a really good idea and can actually save money because certain nursing homes, for example, may not have 24 hour access to clinicians and they may be sending patients to the emergency department who don't need to go there. And so in that case, telemedicine really could prevent potential ED visits and hospitalizations and that that could be an interesting area where we're actually reducing costs.

Ateev Mehrotra

Thanks Lori. Let's try to see if I can squeeze in a couple more questions here. These are great and thank you again for all the people who pose questions. Rachel, turning to you. There's been a lot of enthusiasm, I see all sorts of start ups in the United States who say, you know, what we need is we need certain technology in the home to facilitate these telemedicine visits from digital stethoscopes to oxygen O2 monitors, digital otoscopes to look in the ear, and so forth. I'm curious, clinically, are there particular areas or technologies that you think would really enhance your ability to care for patients in their homes? Or maybe all of this equipment is unnecessary. And just the video encounter or the phone call is sufficient.

Rachel Reid

If I were a pediatrician, I would probably be very pro the otoscope, but as an internist seeing only adults, that matters a little bit less for my personal practice. The big one for me is when a patient has their own blood pressure cuff—that is hands down the most common thing that I find myself wanting actual data for having a decent proportion of the time, but not all the time. It's amazing how much information I can get from a video interaction. Do they look well? How are they breathing? All of that stuff that you realize you can get via video just as well as you can in person. But that piece of data that I most often want is a blood pressure cuff. To be clear, I wanted that at home before the pandemic, just like obviated the need a little bit more. So it's given me an additional onus to connect people with insurance coverage for that cuff when they have it or to educate them on where to get it, how to use it during the pandemic. And honestly, I don't know if I always need the stethoscope. And sometimes what I'll do is the telemedicine visit, figure it out if I need that additional data and then bring them in the next day to get the EKG, get the listen to their heart and lungs, get that additional data, if I need it. Most often the blood pressure cuff is high-yield.

Ateev Mehrotra

We have so many more questions and so many more things I want to ask you all, but then the time has escaped us and we're done with the hour here. So thank you all for participating, presenting, providing your views. Thanks to all the participants for joining. And we will see where we're headed with this telehealth journey. Thanks again.