Roy Schoenberg, MD, MPH: Using Telehealth for Chronic Disease Management
MARCH 13, 2020
Roy Schoenberg, MD, MPH
Roy Schoenberg, MD, MPH, chief executive officer at American Well, spoke with HCPLive® about the benefits of such tools for patients with chronic conditions and comorbidities, telehealth reimbursement policies, and other obstacles providers might face when using digitally-enabled devices.
Editor's note: The following interview was lightly edited for style, length, and clarity.
HCPLive: What are the benefits of using telehealth for patients with chronic conditions?
Roy Schoenberg: The question really translates to a lot of different dimensions in the care of chronic patients that can be impacted favorably with telehealth. The first and most obvious is that when you get to the point that you suffer from chronic condition, just the sheer burden of going in and out of healthcare facilities, physician offices, or outpatient clinics, is very challenging. Some chronic conditions like heart failure and chronic obstructive pulmonary disease (COPD), pose physical challenges for patients to get out of bed. And obviously, any ability for us to take even some part of the healthcare that you need to get, and transition that to happen where you prefer to be, which to most of us is our home, is going to have a favorable effect.
Now there are other elements that in telehealth that have become even more apparent when you talk about specific kind of chronic conditions. Obviously a big one is cancer—where patients are fighting cancer from chemotherapy to radiotherapy. It’s not only that these conditions make you very frail, they also expose you in many cases to a higher susceptibility for infections and exposure to germs that otherwise don't affect other people. Those things can be life-threatening to those patients. Again, the ability for us to move a lot of those required exposures for those kind of patients into the home where you're surrounded by your environment may translate to lower risk for those patients.
But I think with these patients, the other piece of the puzzle, which I think people don’t really see with telehealth, is that, in many cases, patients’ compliance with a very complex, very frequent regimen to follow-up that chronic conditions pose, the lowering of that compliance and the challenges that they face translate into less frequent follow-ups, sometimes inappropriate use of medications, lack of titration and adaptation of the medication regimen that they need. Those require a very, very disciplined regimen to follow up, that if you force that to be physical, including travel and waiting, especially for patients who are challenged by distance or their physical ability, many patients don't have an optimal follow-up. And if you can allow that follow-up to happen in a way that is easier for them to exercise, you're going to be able to follow-up again with them more effectively and increase the chances for managing those chronic conditions more favorably.
And just 1 last thing, another challenge with fairly advanced chronic conditions—we know a lot of people around the country don't have 1, but have 2 or 3 comorbidities or chronic conditions, especially if they have diabetes—they could have an effect on their eyes and on their kidney and their brain. There's a lot of different places the condition could affects, and it gets very complex for the patient to move in and out of all of these different disciplines that they need to see. That adds yet another level of challenge for those patients to follow-up with all of these providers.
If we can create a capability where the different providers, instead of sending the patients to all of the different points around their world that they need to go to with all of these different specialties to treat particular aspects of their condition, if we can unify all of this and allow all of these different disciplines to literally show up in front of the patient, we're not only going to simplify the care of that patient, we're also going to unify the record that's being generated, and we're going to allow a much more collaborative way of holistically caring for that 1 patient.
So, we're going from the obvious to the more wishful or the more advanced use of telehealth, but in any 1 of these cases, the introduction of this technology offers very good news for chronic patients.
HCPLive: You started to mention comorbidities and other conditions besides cancer. Can you dig a little deeper into the ways in which telehealth can be used in areas like diabetes, hypertension, and asthma?
Schoenberg: Sure. So, telehealth is not 1 thing. Most of us think of telehealth as kind of the popular application of telehealth, which is those apps on your phone that allow you to very quickly get in front of any available clinician, usually for the flu, a rash—what we call urgent care telehealth. There’s a reason for that because these types of telehealth really generate millions of transactions a year at this point. So, a lot of Americans get that.
But there are other applications of telehealth that are purposely built to allow patients to interact with their physicians, not whoever is available at 11 o'clock at night when you're sneezing, but rather as a way to allow the relationship that you have with your provider or with your care team, to be handled or to be balanced between physical- and technology-based. Those kinds of applications of telehealth also take advantage have other peripheral technologies that were purposely deals to support that kind of use of telehealth. This is where home biometric devices come in. This is where connected glucose meters come in that allow the physician to remotely see the blood glucose trends of that patient. This is where pulse oximeters come in to help patients with COPD and pulmonary diseases be treated remotely.
And of course, all of these metrics allow the remote physician to try to titrate the medication the patient is taking on a daily basis. We have deeper and deeper technologies to even further allow the remote clinician to examine the patient without being in the same room with them. There are devices today that allow the provider remotely to listen to the lungs, to listen to the heart, to look into the eye and ear of the patient. There are deeper capabilities in those areas.
Now, these devices are not readily available to the public. I mean, you can buy them at CVS and Walgreens. But most Americans don't have them. When you are a chronic patient, the ability of your clinical team to literally interact with you in your home, coupled with those devices that are the key data that those physicians need in order to titrate your medication and give you guidance, is really kind of the base-package that allows us to care for those patients.
Again, just in the spirit of going from what is readily available now to things that are literally around the corner, there are also newer applications of artificial intelligence (AI) that are working in conjunction with telehealth capabilities. Such that the AI in the device next to that patient is looking at the data and if the AI identifies that the data indicate that things are going south, it's on its own has the ability to reach out to the telehealth system and bring live clinicians in to act on those data. So, we're seeing significant investments that deliver significant value in the way that we surround those patients in the home environment.
HCPLive: How prepared, then, are providers to use these technologies?
Schoenberg: The truth is that with these technologies, like any technology, things starts very expensive, and then they go down the price chain and they become more and more available to the public. That's true about almost any technology that we see in our lives, and telehealth is no different. Until over the last the 4 or 5 years, I would say that these technologies have been available to large health systems.
I can tell you that where we come from, at AmWell, the vast majority of our clients on the delivery side of healthcare are reputable health systems—Cleveland Clinic, New York Presbyterian, Intermountain. These are very large healthcare facilities, usually meaning they have deeply embedded telehealth that work flawlessly with their electronic health record (EHR) systems and their admission and payment systems. At those health systems, you see all of the flying colors that I just talked about. But when it comes down to smaller and smaller physician organizations and groups, these technologies, especially at the level that I just discussed, become cost prohibitive.
I think that the reality is that the trend continuously goes towards allowing those groups to take advantage of telehealth. I think that is also coupled with the fact that the payment structure in healthcare in general is getting more and more compatible with a primary care physician using telehealth for their patients. Historically, the payment structure only allowed organizations that got patients on DRG (diagnosis-related group), but large health systems that participate in Accountable Care contracts, in risk contracts that take patience and with DRG for surgery, they really have the breadth or the opportunity to think about how they can utilize telehealth.
If you're a fee-for-service physician in an office that just submits claims and some of the pairs that you work with for your patient panel have either no policy or an ambiguous policy on how they're going to pay for it, the uncertainty itself leads you to not use telehealth.
So, for those 2 reasons, the cost of the technology that's coming down, and the reimbursement policy that still needs to be fleshed out—especially when it comes to the community and public use of telehealth—resulted in telehealth really being the preview of those large organizations. But that is changing.
HCPLive: What specific patient populations can most benefit from telehealth tools?
Schoenberg: The reality is that today in America, people who have commercial insurance, people who work and get health insurance from their employer or relatively, the younger population, actually is fairly well-covered with telehealth. Most insurance companies around the country, if you have health insurance, offer telehealth as a covered benefit for you and your family. And that is the reason why we see millions of telehealth transactions a year, where a couple of years ago these were hundreds or thousands at most. We see exponential and dramatic growth in the volume of telehealth for that.
The pediatric communities, the worried-well communities, the busy mom and pop community, all of those areas are growing saturated with access to telehealth. Funnily enough, however, for that population, telehealth is primarily used for convenience. Now, don't get me wrong, if you live in North Dakota in winter and your child is sick, getting in front of a clinician to telehealth is a lifesaver. But for the majority of Americans, telehealth is just a way of getting to healthcare in a way that is significantly more intimate, quick, and convenient.
The challenges that the population that actually needs telehealth the most—the population that is almost uniformly challenged from getting healthcare—are the elder Americans who are over the age of 65 years old; people who have a much higher frequency of complex conditions; people who take a lot of medications that often conflict or don't work well with one another; patients who need a very frequent kind of healthcare; patients who have significantly less support in managing their conditions because they don't have parents to run them to the pediatrician and so on. That population of patients over 65 that are on Medicare, or even dual eligible with Medicaid, still aren't allowed to use telehealth. There are, in some cases, exceptions of Medicare in very, very rural areas that that Medicare allows. Even there it is very complicated for a physician to get paid by Medicare for better health transactions. But in general, Medicare does not cover that health.
There are signs of potential relief coming. Early this year on January 1, Medicare relaxed some of these rules for Medicare Advantage, which is a small fraction of Medicare and is really operated for the most part by the commercial payers. Medicare says that under certain circumstances, you can begin to try using telehealth for Medicare Advantage patients. I can tell you that even though that was like a breath of fresh air for everybody, when many of AmWell’s clients on the payer side tried to actually apply it, it was still complicated.
There's still a lot of bureaucracy and new codes and different kinds of administrative knowledge that you need to do in order to take advantage of it. For the most part, we are far, far behind on our ability to use telehealth for the population that needs it most.
HCPLive: What are some other obstacles providers might face when implementing or using telehealth tools?
Schoenberg: I think that the technology itself and the reimbursement for the use of this technology are permitting factors. Without those, there's not going to be any kind of health for individual providers and Medicare patients. However, once payment is allowed, you still have to go through a cultural change, both on the patient side as well as on the provider side, to really understand how you can balance the way you interact with patients between the physical interaction and the digital interaction. And that is not something that very busy providers are happily jumping into. Nobody wants to proactively learn a lot of stuff when they have to see 30 patients a day. We need to help physicians along that journey, and we need to help them introduce telehealth to their vulnerable patients. That means not only giving them the technology in a way that is thoughtfully immersed in their workflow on their EHR or practice management system that ties well into their scheduling system so that they can have 2 appointments in-person and then 2 appointments over telehealth and then another 2 appointments in-person without disrupting their daily flow, it's also about giving them the best way to communicate this to their staff. What is the best way to communicate this to your patients to explain to them what are good criteria to select patients that we know are good adopters of this versus not trying to spend too much time trying to persuade a patient that doesn't really need it, that they need to change their ways and interact with technology?
So, there are deeper and deeper layers over this fundamental change of the way the industry works that we need to kind of take head on, if we really want to take advantage of it. If you think about telehealth not as a videoconferencing capability, but rather as what it is, which is the ability to deliver healthcare over technology, if you think about other industries, not healthcare, that have embraced technology to do their business—probably the most prominent is retail when Amazon showed up 10-15 years ago and then the world was never the same—this isn't just about, “Oh, we can buy it online too.” Every retailer needed to fundamentally change their idea of how they were doing business in order to survive. And those that did it really were like Amazon and the likes have done really, really well and those that didn't—Sears, Circuit City—those other guys disappeared.
Let's not think about telehealth as, “Oh, here's yet another channel or another kind of technology gadget that we can use to do healthcare.” Healthcare is going to rewrite itself from the ground up like every other industry because of this technology. And those who are willing to make the investment to learn that new language, are going to prevail and don't those that don’t, just look at every other industry. They’ll be challenged to continue to do their business.