Episode 28: JoAnna Younts - The Future of Telemedicine
In this episode, we speak with BRG Director JoAnna Younts. JoAnna, working out of Washington, DC, is a member of BRG’s Health Analytics practice. We cover the regulatory landscape surrounding telemedicine and talk about state and federal statutes that have guided both commercial insurers and federal programs. She also shares her prediction and hopes for what the future of telemedicine will look like in the US.
Hi, ThinkSet listeners. Eddie Newland here. As you might know, Phil Rowley, BRG's executive director and chief revenue officer, is getting into the podcast game. Check out his conversation with Jaime Diaz at the Golf Channel and other experts on leadership. Phil's podcast is called Intelligence That Works, and it's available in this feed and wherever you get your podcasts.
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On today's episode of the ThinkSet podcast, we'll be speaking with BRG Director JoAnna Younts. JoAnna is a member of BRG's industry leading Healthcare practice. Having worked in the healthcare industry for over thirty years, she has provided strategic advisory services as well as expert support in disputes and investigations regarding billing and coding, provider costs, and reimbursement rates.
During her career, she has worked with a variety of providers, payers, and government agencies on coding issues including evaluation and modification of reimbursement approaches, billing and claims analysis, reimbursement benchmarking, and fee schedule design. Today, we will speak about the regulatory landscape surrounding telemedicine. We will cover the various state and federal statutes that have guided both commercial insurers and federal programs. In the end, she will share with us her prediction and hopes for the future of telemedicine looks like in the US. And with that, let's get started.
JoAnna, thanks so much for joining us on the ThinkSet podcast today. How are you?
S2 01:35 I'm doing great. Thanks.
S1 01:38 Great. Well, let's dive right into it. You had written an article for ThinkSet magazine earlier this year talking about telemedicine, and there's a lot that we felt was left on the cutting room floor that we wanted to dive in here to today. What is your definition of telemedicine? I presume there's more than just one. But how do you define it? Or how does the industry currently define it?
S2 01:59 Most people, when they think of telemedicine, think of companies like Teladoc, which is essentially an organization that helps patients and doctors do virtual office visits, and that's really what I always thought telemedicine was, even though I knew that there was also phone and data technology that was used to monitor patients who have pacemakers and things like that. But what I didn't realize is that if you're an Apple watch wearer and you're giving that data to your cardiologist to show him or her that you're getting your 10,000 steps in a day, that's telemedicine.
And so I think we've really evolved to the point where we can say that telemedicine is just another form of technology that helps physicians and patients enhance their relationship. So it can be everything from a virtual office visit like something Teladoc would provide. But it could also be a consult for a patient who's in a rural area where there's no psychiatrist, and they need to see a psychiatrist, and they can do a virtual visit with a psychiatrist across the country. There's also a program I learned about in Texas where paramedics can do a virtual consult with an ER doctor before they get to the hospital with a patient to determine whether the hospital's actually the right place for the patient, and they can do triage before they even get there.
So, I mean, there's just so much to telemedicine. So I think— kind of back to the definition question—I think it's really any technology now that's used to enhance patient engagement, so communications between patients and physicians, virtual office visits, patient monitoring. I think it encompasses a lot of different types of interactions.
S1 04:01 Yeah. And given the rate of change with technology, I can only imagine that that category is going to continue to grow and add more and more definitions. And one thing that ties into with a lot of the work that you do and that we know about in the healthcare industry is reimbursement. So can you give us an overview of what's been going on as it relates to telemedicine now when it comes to reimbursement?
S2 04:23 Probably Medicare is the best place to start, because Medicare is the largest payer. And Medicare does pay for telemedicine, but Medicare also places a fair number of restrictions on coverage and reimbursement. So, for example, a patient has to be located in a specific type of healthcare facility. They can't be at home. They have to be in a clinic, or a hospital, or some other approved location. And then the provider that's actually providing the consult or service on the other end has to be licensed as a physician or a mid-level practitioner. And so a lot of mental health counselors and other types of providers wouldn't be eligible to be paid for that telemedicine visit under Medicare.
The other thing is that the patient has to be outside of a metropolitan area or in a health professional shortage area. So Medicare has expanded its coverage and reimbursement in some ways in the past few years. For example, dialysis patients can actually be at home for a consult or a telemedicine virtual visit, but it's been slow to expand. Now, in terms of fees, Medicare does pay a fee to what's called the distant site which is where the provider is. And then usually, it's the same fee that would be paid as if the patient were in an office. And then Medicare also pays a small fee to what's called the originating site, which is where the patient is. But it's all very code driven in terms of Medicare reimbursement.
Medicaid really varies by state, as you would expect, since each state has its own Medicaid program with its own rules; that means telemedicine reimbursement is going to be different depending on which state you're in. All fifty states’ Medicaid programs do cover telemedicine in some form or fashion, particularly live video consults, but they have restrictions just like Medicare does in terms of where the patient can be and what kind of provider can deliver the services. Some states allow the patient to be at home, some don't. Some pay a fee to the originating site, some don't. Some will pay for what's called store-and-forward technology. So that's when, for example, a patient's MRI is transmitted to a provider in another location to be interpreted. So some states will pay for that, and some states won't.
There's a lot of variation in the Medicaid world. In the commercial world, there's also a tremendous amount of variation in coverage and reimbursement, and that's really for several reasons. Health plans just vary in terms of culture and policies and things of that nature. So it's partly that and it's partly a geographic location, but I would say a lot of it depends on regulations, just the way that Medicaid and Medicare coverage and reimbursement is dependent on regulations as well. So if a commercial plan is in a state that has pretty stringent regulations on patient location and provider licensing and things of that nature, then perhaps the telemedicine coverage and reimbursement might be more limited. It's interesting: some plans actually are paying for telehealth without even realizing it. I have client health plans say the providers can bill for this, and we would never know, because they're not using the codes and modifiers that they're supposed to be using.
So it's happening, and the commercial plans are paying for it. But what I am seeing is that some of the plans are actually trying to have a formal telehealth program in place, and so some of them are now contracting with companies like Teladoc or some other vendor to provide a more formalized way for their members to access virtual doctor visits and things like that.
S1 08:32 Probably when you touched on that, I think a lot has to do with, from a regulatory perspective, having it be so different with Medicaid state to state. If there were more federal regulation around this, how would that change with the commercial but then also Medicaid would do? Do you think it, obviously, can make it simpler? But in many instances, sometimes federal regulation can make things more complex.
S2 08:54 Yeah. I think there's probably already enough federal regulations. Most of the regulations focus—at the federal level—focus on Medicare and what Medicare can cover and what it will pay for. And then, as I said, the Medicaid plans, the states make those rules. I think a lot of the opportunity lies with just the plans being able to be more innovative. I think regulation probably hampers that in some ways. It seems to me that Medicare or the federal government has a really great opportunity to not only just expand what it's willing to cover and pay for in a Medicare environment in terms of fee for service, but also through other payment models.
So Medicare has this huge accountable care organization program, ACO program, and I think that would be a great vehicle where providers can incorporate telemedicine. And I think the commercial plans that are contracting with ACOs can do the same thing. Because in an ACO environment or any payment model where the providers are at risk for a group of patients, or group of people, or a population, then they have the freedom to decide how they're going to take care of those people. And if telemedicine is a part of that, usually it means that it's cheaper. And so then the providers have an opportunity to save the health plan money just by managing patients and their services more efficiently and potentially keeping them out of the hospital, which is really what saves the most money.
S1 10:46 Yeah. And I think I'm going to transition a little bit to something you mentioned earlier when you were talking about the reimbursement and what some of the restrictions can be when I think telemedicine. You mentioned earlier about somebody that's in a rural population dialing in where they might need to see a psychiatrist across the country to find somebody that they can work with. Should urban populations care about telemedicine? Or is this something that's only beneficial to rural? I know some of the examples you gave of what means telemedicine, your iPhone or your iWatch being able to speak to your cardiologist, can be done anywhere. But how does that fit in an urban versus rural? Does it work for everybody? Or is this really focused on enabling rural populations?
S2 11:28 Well, I think probably the benefits are more obvious in rural areas. So if it's clear that there's a shortage or a lack of certain kinds of providers, obviously, you see that clear need for people to be able to access those providers remotely or virtually. But I think people in urban areas can certainly make use of telemedicine. And I think younger people, whether they're urban or rural, are probably the ones that are going to be more inclined to use the technology. I'm thinking of millennials and even younger. I'm Generation X, but my kids are twenty-one and eighteen, and their daily lives revolve around their phones. They're perfectly comfortable video chatting, FaceTime, or Skype, or whatever all the time, and so to me it's kind of a natural extension of their normal life to do a doctor's office visit on their phone. And so that could be in an urban area or a rural area and still be an effective way for a patient to communicate with their doctor.
S1 12:40 What you just described, I'm a millennial or I fit into it according to that definition. But I was on vacation and I had an outbreak or allergic reaction, so I use the app that comes with the doctor's office that I go to to be able to FaceTime, send photos to the people so they could tell me what it was. But then also, they were immediately able to direct me to, based on my plan, the nearest facility that would accept my insurance and it was just down the road, went there and got everything taken care of. And I probably may have ended up at the facility anyway, but I wouldn't have done it with such certainty that I was in the right place if I hadn't been able to send photos and then literally FaceTime with a provider at our office. And I was certainly more comfortable doing that than just showing up at the ER, then sent me to a dermatologist that they knew that was in at work that I could go see.
S2 13:29 Right. So I bet that dermatologist visit was a lot less expensive than it would have been if you'd had to go to the emergency room. That's so important, because it's not only more efficient and less headache for you as a patient, but it also can save the healthcare system money just by not sending you to a place that's more expensive. The other thing about people in urban areas using this kind of goes back to my point about managing population. So it doesn't matter where you are, if a provider or your doctor is trying to manage a group of patients, they can use telemedicine as just another touchpoint with you. And that might help you to be more compliant as a patient if you're on the specific medication protocol. It can be easier for the doctor to monitor that and keep in touch with you about what you're doing through telemedicine than having to see you all the time in the office.
S1 14:29 Yeah. I can imagine something like a digitized or a connected pillbox that everybody has that when you open the Tuesday it can trigger a message to your doctor that, "Okay. They've taken their medicine on Tuesday."
S2 14:41 Yeah. It's a little Big Brother-ish, but yes.
S1 14:46 And you probably know this better than I. But as the different generations get older, and I just know this from speaking with my parents and their friends, but they would like to avoid being as dependent upon healthcare providers, nursing homes, and things like that for as long as possible now that they've seen not just one but two generations of their grandparents and now their parents going through it. Something like that. It's just a little thing, but it's part of the reason why somebody ends up getting into a care situation is because you can't trust them to take their medicine. But if there is a way without having to send somebody to check in every day that you can know, okay, that they have taken their medicine, or they have done their 5,000 steps, or whatever the prescribed plan might be it would delay or could delay them having to go to a facility every day, or have somebody live in, or have to actually live somewhere.
S2 15:36 Yeah, definitely. And I think, certainly, my generation and even our parents’ generation, I think, is getting more comfortable with the wearable technologies like the Apple watches and so forth that are collecting all of this data. And then I know a lot of us are nervous about sharing data, but if they feel like they can share that with their healthcare provider that would go a long way toward facilitating their medication protocols and just being able to manage their healthcare as they get older.
S1 16:08 So we've kind of touched on it as the person receiving the care and as the people paying for it. But in your opinion, how did the physicians feel about this? If payment wasn't an issue, how do you think they would prefer to integrate telemedicine into practices? Do you think they'd adopt more of it, or are there certain folks that they just don't? I guess it might depend on what the practice is, but there may be some that are ready to adopt a bunch of it but they can't because they're not able to get reimbursed for it.
S2 16:35 Yeah. I think there're certainly physicians and others out there that are just uncomfortable with it and are reluctant to use telemedicine. But I've talked to a number of physicians that not only use it but want to use it more and want to have the freedom to use it as they see fit in their practice, whether that is doing virtual visits when it makes sense or monitoring patients remotely in a more structured way. It's interesting. I worked for a cardiology clinic back in the 1990s, and we used to call our congestive heart failure patients at regular intervals. I don't remember exactly how often we called them, but we would call them and ask them to weigh themselves and collect their weight data. And then we would record all of that so that the doctors could manage their diuretics and their other medications.
It was a very labor0intensive process. But now, that same clinic, I don't know if they're doing this, but they could use people's smartwatch data or apps on their phones to not only get their weight, but again, like we've talked about, their exercise, their 10,000 steps, the information about their diet, and all of this data, and then the doctors can use that much more efficiently and identify problems or issues before they become major and the patient ends up in the hospital. So the physicians I've talked to have said I would just really like to be able to incorporate technology or telemedicine. However, I feel like it would work well in my practice and not have to worry about whether I've coded something correctly to get paid for a specific code. And I think that's going to depend on how we evolve in terms of our payment models over time and getting away from fee-for-service.
S1 18:35 Yeah. And that probably ties into the regulatory aspect of it as well, if the federal government were to say we're now open to a lot more of this. That could then lead to the commercial insurance companies being open to allowing you to charge more or charge more towards these things as well, I'd imagine at least.
S2 18:52 Right. Yeah. And just allowing for—I think everybody gets hung up on the coding. And so in our fee-for-service world, Medicare's answer to this has been, we'll just create more codes, and that's what they've done. So now there're a lot more codes for telemedicine, but it's still fee-for-service. So the provider still has to worry about, well, have I coded this correctly so I can get paid for it, versus if you're in a payment model where you're just getting paid to take care of a patient for a year and you get maybe a care management fee or a per-member per-month fee or something like that. It doesn't matter whether you use telemedicine, or office visits, or whatever else you're doing, you don't have to worry about the coding for each individual service.
S1 19:41 Yeah. That kind of leads me to where I was going to go as we wrap up with our podcast. We'd like to do sort of the final thought as I'm looking forward what's next, where again an industry be five, ten years down the road. So without being able to predict obviously what regulations might come down the pipeline or what technology may be created, as you sit here today, is there anything that you see on the horizon that is being adopted more and more that could become standard or just everybody is doing it in five to ten years? And is there some sort of reach goal that you think would be, at least, for what you can see on the horizon would be ideal if we're able to get to in that time?
S2 20:20 I wrote a white paper four years ago on telemedicine regulations reimbursement, and I went back and looked at it and I realized that things haven't changed as much in four years as I thought they would. It's a little bit hard for me to not be a skeptic. I have no doubt that in five to ten years, the technology will be there to do just about anything remotely. It's just payment models have to catch up to the technology. Now, I'd love to think that physicians and others would be able to use the technology without worrying about whether they're going to get paid for it. And I think it's the young physicians and young patients that are really going to be the ones that drive this and demand that telemedicine technology be incorporated into everyday life or everyday practice.
And I think the tech companies may also jump into the game. It wouldn't surprise me a bit if we see Google or Apple getting into the telemedicine space. Just what we're seeing with these big tech companies getting involved in other aspects of healthcare, I think telemedicine would make a whole lot of sense. And I think that would be a game changer and then you would see telemedicine in the mainstream.
S1 21:40 Yeah. That's actually a really good prediction. I guess, that if you see if Google, or Apple, or Amazon pops up, once they get there, it quickly becomes a talking point that pushes the conversation forward a lot quicker than just maybe a startup with that same idea it could get to.
S2 21:55 Absolutely.
S1 21:57 Well, JoAnna, thank you so much for joining us today on the podcast. We'll look forward to catching up again down the road.
S2 22:01 All right. You're welcome. Thank you.
S1 22:04 [music] This ThinkSet podcast is brought to you by BRG. You can subscribe to the podcast and access other content from ThinkSet magazine by going to thinksetmag.com. Don't forget to rate and review on iTunes as well. I'm Eddie Newland, and thanks for listening. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the opinions, position, or policy of Berkeley Research Group or its other employees and affiliates.