Tuesday Sep 15, 2020
Retail Telehealth Isn’t the Call Policymakers Should Answer
Telehealth is a no-brainer -- a powerful tool for value-based primary care that we know patients embrace and that this year has been dramatically expanded following AAFP advocacy. As is often the case with something obvious, though, telehealth is the sort of no-brainer that's easy to overthink.
Unfortunately, that's just what a prominent new report from the Taskforce on Telehealth Policy(www.ncqa.org) does.
The Academy was anticipating this report, which resulted from workgroup discussions touted in a recent National Committee for Quality Assurance white paper that reflected some AAFP priorities.
This newer report -- released Sept. 15 by the NCQA, the American Telemedicine Association and the Alliance for Connected Care -- does not.
Yes, it endorses some of the most obviously no-brainer elements of telehealth. Its authors favor eliminating restrictions based on geography and originating site, aligning quality measures, and expanding universal broadband access, as does the AAFP.
The problem is that instead of amplifying the streamlined telehealth principles and urgent policy objectives that the Academy has called for during the COVID-19 pandemic, it proceeds from some faulty premises and dallies in administrative cul-de-sacs.
"As in-person care began to resume in May, telehealth visits dropped to 30% but there was still no net visit increase, clearly demonstrating that telehealth substituted for in-person care without increasing utilization," its authors note. But no utilization pattern has returned to normal, and it's impossible to know what "normal" is going to look like post-pandemic, or when that era will begin.
The report also presents with enthusiasm an unwelcome suggestion for federal policymakers.
"CMS should develop and pilot a 'virtual medical home' with a bundled telemedicine reimbursement model, using digital tools to maximize data-sharing and care coordination," the report advises. The pilot would center on "coordination across care sites provided by community health workers or community-based organizations to ease the burden on clinician and other providers."
That too many communities lack health workers and care organizations, perhaps on top of a shortage of physicians in particular and a leaky primary care physician pipeline, is not addressed here. More important, neither is the reasoning behind calling for this clunky reinvention of the wheel when primary care is already equipped to deliver virtual care as part of the patient-centered medical home.
The Academy is on the advisory board of the Alliance for Connected Care but was not part of the task force that prepared the report. Instead, we -- like other stakeholders -- were asked to comment on a set of questions(www.ncqa.org) seeking input. Some of those questions had a push-poll feeling, presaging what the finished product confirms: that the recommendations are skewed toward virtual-only telehealth vendors and large medical systems with established telehealth infrastructure at the expense of independent practices that need guidance, support and payment advocacy now.
The report suggests that telehealth (which the authors never manage to concretely define) should be considered on the same plane as in-person care, yet it also attempts to make a case for pilot programming -- the "virtual medical home" -- that would differentiate such care. Meanwhile, the "findings" here turn up almost nothing on how to support the adoption or scale-up of telehealth in smaller practices, a crucial next step for which we've pressed.
It's important to object clearly here. If this paper influences decision-making on telehealth, we can expect existing disparities in virtual access to widen, with care becoming more fragmented when we have the chance to make it more cohesive.
We're going to start hearing players in this booming but still unformed marketplace(www.statnews.com) say they've set out to offer "comprehensive virtual primary care," backed by, as this report puts it, "telemedicine data registries." The former is impossible, and the latter doesn't exist yet. But if policy solidifies around these hollow concepts, patients will suffer and administrative complexity will increase for physicians who already provide real long-term care.
The AAFP understands telehealth to be a complementary way to deliver coordinated, longitudinal care. We know from an internal survey that our members and their patients have expressed high satisfaction with telehealth and significant interest in continued access to it. We know that patients using telemedicine prefer to see their own health care professionals.(www.ncbi.nlm.nih.gov) And it's well-documented that the patient-centered medical home improves health care quality, utilization and cost outcomes.
Outsourcing to retail telehealth providers would undermine the medical home and fracture relationships and care. Instead, the AAFP recommends that telemedicine be thoughtfully incorporated into existing alternative payment models, such as CMS' accountable care organization programs and Primary Care First.
As the Academy continues its vigorous advocacy in this realm -- seeking standardization among payers, appropriate licensure flexibility and maximal health equity, among other goals -- pushing back against ill-conceived new models now must go on the list.
Posted at 06:00AM Sep 15, 2020 by Stephanie Quinn