Optimize Virtual Care Strategies to Improve Member Outcomes

Ciji Adams: Hello, everyone, and welcome to The Payer Principle, a Salesforce Healthcare podcast created exclusively for payers. I'm your host, Ciji Adams. On the show, you'll hear insights from healthcare industry experts and trailblazer organizations on all things payers, such as trends, business challenges, and the latest technological solutions. Today's episode focuses on virtual care and extending care beyond the four walls of a hospital with telehealth. I'm joined today by Dr. Greg McDavitt, who is currently a practicing Emergency Care Physician and serves as a Clinical Director of Global Healthcare and Life Sciences at Salesforce. He has nearly 15 years of healthcare experience across various finance, strategy, and operation roles, and is still actually practicing medicine virtually today. Dr. McDavitt, welcome to the podcast. It's great to have you.

Dr.Greg McDavitt: Thanks for having me, Ciji.

Ciji Adams: Virtual care, hot topic right now that has really exploded during COVID- 19, and for good reason. People are sheltering in place and still need medical care, so it has served as a much needed alternative to seeing providers face- to- face during this difficult time. CMS temporarily made policy changes to make it easier for Medicaid, Medicare, and CHIP beneficiaries to have access to medical care through telehealth services throughout the pandemic. Dr. McDavitt, why is virtual care so critical right now?

Dr.Greg McDavitt: Ciji, I think this is a great starting point for this conversation, so let me just first start by sharing what I think is a critical difference between telehealth and the broader term of virtual care, and I'll just do this to set the scene for all of our listeners. To me, telehealth is simply the video or telephonic visit capability between a provider and a patient, me as a doctor being able to connect to a patient to conduct some sort of virtual interview, virtually evaluation. We can see how this is rapidly becoming somewhat of a commodity with the rapid adoption of virtual platforms like Zoom, Teams, Webex, Google, and the list goes on and on, of course. There are so many out there, and healthcare organizations all over the world are using these platforms to connect during this time, but the bigger, broader picture or the broader term for me is virtual care, which is more all encompassing of all aspects of delivering care remotely, including things like remote monitoring, medication management, teletherapy, patient education and adherence, and patient engagement in general.

Ciji Adams: It seems obvious, but in your own words, why is virtual health so critical right now?

Dr.Greg McDavitt: I think we're at a pivotal inflection point in history here. In the immediate future, there are so many people that are uncertain and sometimes very uncomfortable with the idea of being exposed to other potentially sick patients by going out into a doctor's office, or really any other crowded location, and we have to have a way to continue to treat and manage those patients. Just because COVID exists, it doesn't mean all other health issues have stopped. We still have to manage chronic conditions, we also still have to manage urgent care issues that come up every single day. People still need that care.

Ciji Adams: And thankfully, regulatory agencies such as CMS have made changes, although temporarily to allow for coverage of those services.

Dr.Greg McDavitt: Quick action by our regulatory organizations to approve payment for those virtual services has been equally as critical as the technical capability to connect with patients. Without those approvals, many diagnoses and treatment options would not be approved for reimbursement through a virtual care option.

Ciji Adams: Do you think virtual health services are here to stay?

Dr.Greg McDavitt: If organizations like CMS do not permanently adopt those temporary policy changes, then we'll likely see some of that growth and utilization of telehealth slow down. We've seen very dramatic jumps in utilization to- date, especially this year, and we may return to our old ways of operating if we don't see those permanently adopted for approval throughout the healthcare industry.

Ciji Adams: That's such a salient point for people to remember, that these services, these telehealth services are being covered by CMS, and providers are being reimbursed, but like you said, there's the risk that we kind of backslide into kind of our old way of operating and not necessarily making the investments in virtual care to the extent that we're doing now just because we're in a pandemic.

Dr.Greg McDavitt: Right. Yeah, absolutely.

Ciji Adams: I think that you've done a really nice job of laying out the foundation and helping orient us to the why, but I'm curious about what are some of the pros and cons to virtual care.

Dr.Greg McDavitt: Yeah, and there's a lot of them for both sides of this argument, so I'll start out with a few of the pros, at least those that personally, I find to be most important. The first of those is actually just improving access to care. Telehealth is one of the great equalizers in medicine, and one of the biggest pros that come along with it is that it improves access to care for so many people. Oftentimes, your options for care are limited by where you live in the country. If you live in a more rural part of the country, you typically have less options in terms of where you go to get certain types of care, and that could be simple primary care or more complex specialty care. Having the option to connect virtually to providers really opens the door for people to get access to options they would not have historically had in the past. For example, if there's a cancer treatment option available in one of our more cutting edge medical facilities in this country, we could make that available to people all over the country, and they wouldn't be limited just because of distance or inability to travel, and on the other side of that, of course, the cost to deliver that care would likely eventually decrease as more and more patients utilize it.

Ciji Adams: What are some other pros?

Dr.Greg McDavitt: The ability to extend reach. Having the ability to reach out virtually really extends the footprint of a business. The virtual care model allows health plans and their partners to extend their operating footprint. They immediately open the door to customers that would not have been included in their addressable market, so this is really a business consideration here. Of course, the third and maybe biggest pro here is operating costs. Operating a virtual environment for virtual health is much less expensive than operating a physical footprint. The maintenance of operational costs to run big buildings is enormous, and this applies to the administration and service of health plans itself, and also the clinic and the physical facilities where care is delivered by their partners in the payer network, so operating costs come down substantially if we're able to deliver care in a virtual manner.

Ciji Adams: We've got some pros around improving access to care, extending your operating footprint as a health plan, and then, of course, everyone wants to save money, decreasing your operating costs. What about the cons to virtual care?

Dr.Greg McDavitt: Yeah, and there's probably a lot more cons that I am unaware of, but I'll just call out a few here that are top of mind and important to consider. Number one, being that virtual care can be very impersonal, if we don't do it correctly. The patient trusts their doctor. They like to see their doctor. That element of human interaction is difficult to replace in a virtual environment. As I mentioned earlier, virtual care is more than just the video visit. It's the entire experience, the entire journey a patient goes on, and the experience will be different from provider to provider, so as a payer, there must be a consideration to address that inconsistency. Since for many patients, they'll look to see what their virtual care options are through their insurance plan, so their payer may be that first point of contact to look for a virtual care option, and that virtual care option, although less expensive and easier to operate in the long run, may not be the preferred option if we don't deliver it correctly and in a more personal and meaningful manner. That's one of the biggest cons to me. Another big con is around fraud, waste and abuse, and this is again, another kind of business operational issue and reimbursement issue. With this virtual world growing so quickly, we're bound to go through some growing pains in terms regulating it and paying for it. We just don't know yet how providers are going to act, what habits we're going to all adopt and fall into, that may be unhealthy business or clinical practices. Doctors really aren't trained in virtual care. Even today, when you go through medical school and residency, virtual care really isn't a big part of our curriculum, so this is a little bit of a black box at this point, and it's one of those cons that we just don't know enough about. Then, the last con is that this transition is going to require a massive restructuring to migrate our current business operations to a virtual care model, which is not going to be cheap, so this is going to be a big barrier. It's going to be a big drawback for many organizations. We're going to require new equipment for providers, new training, new software, new data storage, new clinical workflows. All of this is going to take time and money, and we'll need to make sure incentives are aligned across payers and providers, and that these changes are supported by our regulatory bodies to make the transition financially viable.

Ciji Adams: What do you feel COVID- 19 has taught us about the importance of expanding care beyond traditional inpatient settings?

Dr.Greg McDavitt: I think that this is probably up for debate as well. You can take a lot of different perspectives on this question itself. COVID- 19 has been just a challenge in and of itself, and so there's a lot left to learn, but I do think one of the biggest lessons learned to this point is that COVID and the pandemic itself has uncovered some glaring gaps in our ability to scale to meet patient needs, so the virtual patient engagement option gives us the opportunity to scale our care delivery. Historically, much of healthcare has been designed not to really scale up or down, but instead, we simply replicate our capability. We add more facilities, more people, more resources, which of course, is very expensive, but we don't scale very well, and you saw that, of course, right at the beginning when the pandemic really kicked off. You saw the need for more hospitals to be stood up on ships or in warehouses, things that we have never seen before, or at least in my lifetime, and it's just a really quick acknowledgement that the resources we had in place when we saw a dramatic shift in demand or a quick shift in demand, we were not able to handle that.

Ciji Adams: Dr. McDavitt, I actually want to double- click into what you were referring to about our healthcare systems in capacity, really to handle virtual care at a macro or a national level for a second. A recent survey from McKinsey& Company states that healthcare consumer adoption skyrocketed from 11% of U. S. consumers using telehealth in 2019 to 46% of consumers now using telehealth. Understanding that the demand for virtual care is growing, coupled with the impact of the pandemic, what does it actually take for payers to set up the infrastructure to offer virtual care services and meet the current demand?

Dr.Greg McDavitt: There's a lot of ways to approach this challenge. As different health plans have different business models, they have different legacy systems, different patient populations that they cover that have different requirements, and of course, different budgets, offering a virtual care option through a health plan can be accomplished in a number of ways with the technology that we have in place today. We just have not historically adopted it very well, but as you've said, we've seen this dramatic leap in percent of our patient populations that are adopting telehealth, though, we need to be aware that part of that is a forced adoption, or being adopted out of necessity. This is just a consideration to keep in mind that one of the reasons people are adopting telehealth is that they don't have another option at this point. When they need urgent care, when they need a consultation, when they need a specific treatment or a refill on their prescription, they don't have the option to go into the office, so some of the numbers we're seeing are forced. It may not be the preferred route that some of these patient populations are seeing.

Ciji Adams: Switching gears a bit, payers have a few challenges when it comes to delivering virtual services. Can you tell us about a few of those and share your thoughts on overcoming those challenges?

Dr.Greg McDavitt: Today, many payers have a partner that they work with that allows them to offer telehealth services to their members. Depending on your health plan, you will often get a little card in the mail after you enroll, which may be one of their partners like Teladoc, or Amwell, or Doctor on Demand or many, many others that are out there, but today, the payer had little to no line of sight into that experience that their members are getting with those partners, which again, may not be the end of the world, but as more and more people are adopting this, it's becoming a concern, and so we need to have some components of the infrastructure to address that. Typically, payers don't know if their members are even using the service, or how often they're using the service, or for what, what services are they going to their Telehealth providers for. The payer doesn't have any control of that experience that's delivered with that partner either. Either before, during or after the virtual visit, there is a big opportunity there to really engage with their membership and create a consistent experience, but what's required there is an integrated platform, an integrated infrastructure in order to do that. Today, you have claims management or claims databases that are separate from their member index, and that is separate from their payment operations, and that's separate from their service center and so on and so forth, and so we have a lot of disparate and siloed data within the organizations themselves, and now we add into that a complex integration into our telehealth partner, and today, we have no integration there, and so we're not sharing information, we're not sharing a lot of data, and so that experience becomes very fragmented from a payer's perspective and they're not able to really capture insights and make adjustments. In order to do this properly, in my opinion, we need to be able to provide a consistent experience for all of our members, regardless of where they go to get that telehealth and being able to route them appropriately and follow up with them consistently, and manage that process is going to be critical.

Ciji Adams: Tons of barriers, potential barriers, at least right to the successful adoption of virtual care services for payers. I want to pivot a little bit just because we've been focusing on what the implications are of virtual care to a payer health plan and talk about what this means from a member's perspective. According to the Salesforce State of Connected Healthcare Consumer report, 60% of consumers have had to manage their care between different parties. As you just referred to, you have to worry about the handoffs between a payer and their partners. Members are getting caught in the middle of this, which tends to make for this fragmented and disconnected experience, which no one wants, so what are some of the implications of receiving care virtually when it comes to a member's experience?

Dr.Greg McDavitt: I think that we can learn a lot from other industries in this type of situation. You can take the airline or hotel industry, the hospitality industry to really learn some valuable lessons about how to manage an experience across so many different partners. For example, I fly a particular airline all the time, and they created a loyalty program in order for me to do that, to really encourage me to continue to use them, and I bought into it, of course, like so many others, and I do the same thing with hotels, but with airlines, a lot of times, they have partners. You'll go from these big international flights that are coordinated with the main airline themselves, and then you'll go to these small connector flights that are operated by some smaller partner. However, the planes may be branded that same airline, and when you come up to the counter, you have the same exact experience from a user's point of view, from a consumer's point of view. Every time I get on a plane, it doesn't matter. My boarding pass is the same, my status is the same, my experience is the same based on my membership and my loyalty in that program. The same thing with hotels. There are so many hotel organizations around the world now that, of course, they run their chains that are owned and operated by them, but they also have partnered hotels that license their name and are able to use their points program and loyalty program to encourage more visitors to stay in their hotel, but when I go to that hotel, that may not be operated by that parent organization, it doesn't make a difference to me. I walk up to the counter, they recognize my status, the experience is exactly the same for me, even though the hotel has different operations in the background, and we have a big opportunity to do that in healthcare. Now, it will be complicated. There's a lot to consider. There's a lot around interoperability and access to that health data that's most important, but today, there's no connection between the telehealth service provider and the payer themselves. There's not a smooth transition there, and there's no reason for that because we have the technical capability to do it. We just haven't taken the steps, and we haven't quite figured it out yet.

Ciji Adams: What's the risk of not having that visibility?

Dr.Greg McDavitt: One of the biggest risks, of course, is not being able to consistently engage with your members. If they go and meet with some telehealth provider and we're not able to follow up with them, that telehealth provider likely isn't following up with them either, because it may have been a one- off visit. You're solving some really quick urgent care issue, they may have an upper respiratory infection, something very simple, but are we able to follow up with them and make sure that that was a positive experience and make sure they're taking their medications, or that they were able to get their medications? Are they wanting to use that service again, because we know it's cheaper? Are we able to motivate them to come back and use it again? Even if they pick up the phone and place that call again, they're going to get a different doctor, and if that experience isn't consistent, that next time they call, if they have a bad experience, we all know that we're really quick to switch, and so if we have a bad experience in telehealth, we may quickly say," I'm just going to go back to my old way, and I'm going to go spend all the time in the doctor's office," which is more expensive, so there's a risk there that if we don't figure out this challenge, we're not going to maintain or retain the patient populations within this virtual environment.

Ciji Adams: I absolutely love that analogy of the airline and hotel loyalty programs because I'm a die hard person when it comes to my loyalty programs, and I think consumers, healthcare consumers specifically have this expectation, right? If I have a good experience anywhere, I expect a great experience everywhere, and that does not remove itself from the healthcare industry. I want to close the episode by asking, where do you see virtual health evolving in the future?

Dr.Greg McDavitt: There are so many things that are going on in virtual care. Some good examples, some great examples of where I can see this going in the future, with the aids of technology are around actual evaluation of the patient. Today, when I conduct a virtual visit, a lot of it is very, very simple or what I would consider simple clinical concerns. You're not talking about difficult to manage issues or patients, you're really talking about really quick fixes, and those can be managed fairly easily, even with a phone call, but moving forward into the future, things like wound care management or physical evaluations that we can't do today could be done in the coming years. Take, for example, if you're trying to manage a non- healing wound on a patient, this would be something like an ulcer on their foot or maybe on their back, and we want to be able to monitor that consistently and determine if they need any change in their care or change in their treatment. Well, today, we don't really use virtual care to do that, but could we? The answer is yes. The cameras on phones and in computers are becoming so sophisticated. They can measure the depth of a wound, they can measure the diameter of a wound, and whether or not it's different from the last time, and using artificial intelligence, we can evaluate historical images of that patient's wound and compare them." Is there more granulation tissue?"" Is that wound actually healing?," and a computer is probably better at that than humans for the most part because we can reference every image we've ever seen and compare it to what we're looking at right now. If the computer is noticing improvements, then using artificial intelligence and decision support in that process, then we can really leverage and speed up the virtual process so patients don't have to come in for that sort of thing anymore. That is all going to be realized, but whether or not we're comfortable with it, that may be one of the biggest barriers to get over before we see it adopted.

Ciji Adams: Yeah, and I think that you make a really salient point there, that it's also going to be about adoption. Ultimately, it's going to greatly depend on what is the aptitude, right? What's the appetite for consumers to have services that include those capabilities? Lots to consider when we think about the future of virtual health and where the potential is for it to go. Dr. McDavitt, thank you so much for joining us today on The Payer Principle Podcast and for all of your insights.

Dr.Greg McDavitt: Ciji, my pleasure. It's been a great time. I'm excited to see where we go in the future.

Ciji Adams: Likewise. Listeners, if you want to learn more about our payer solutions, visit salesforce. com/ healthcare. I'm your host, Ciji Adams. Thank you for listening.