by Meg Barron, Vimal Mishra, Stacy Lloyd, Jared Augenstein
The Covid-19 pandemic has spurred a dramatic increase in virtual health care in the United States. The rise has been driven by the need for social distancing and enabled by a wide range of policy flexibilities implemented by federal and state legislators, regulators, and payers. However, many of these allowances are temporary. As the pandemic ebbs, policymakers and payers are deciding whether and how much to pay for virtual care services in the future, leaving clinicians uncertain about whether they will be able to afford to continue their virtual care programs. But parties are often making these decisions based on outdated or limited measures of success that do not holistically reflect the realities of how value is being generated.
To address this need, the American Medical Association (AMA) and Manatt Health, a legal and consulting firm, have developed a framework for assessing the value of digitally enabled care. It accounts for the various ways in which virtual care programs may increase the overall “return on health” by generating benefits for patients, clinicians, payers, and society going forward. The framework can be used by care providers to develop and evaluate new digitally-enabled-care models, by payers to inform coverage and payment decisions, and by policymakers to establish regulations that guide the future of virtual care.
Before the Covid-19 pandemic, virtual care adoption was slow going and represented less than 1% of overall health care volume. In most cases, virtual care existed outside of the traditional health care delivery system and was often uncoordinated with in-person care. A patient would develop a fever over the weekend and would see a virtual urgent care provider who, in most cases, was not his or her primary care provider. Some innovative health systems or tech-enabled health care delivery companies such as One Medical and Cityblock Health had implemented integrated virtual care tools, but for the most part, the virtual care ecosystem existed in parallel to and disconnected from the in-person health care ecosystem.
Accelerated by the pandemic, we are entering an era, where in-person and virtually enabled care will be seamlessly integrated and the mode of care delivery will be based on clinical appropriateness (i.e., when telehealth should and should not be used) and factors such as convenience and cost. When given the option of telehealth during the pandemic, patients largely saw their existing physicians for their needs versus a new provider. Digitally-enabled-care models will be developed across the full range of disease acuity and across all clinical conditions. The integration of new digital health solutions such as video visits, remote monitoring, asynchronous telehealth, continuous and passive sensors, and AI into digitally-enabled-care models offers the potential to provide access to high-quality care and positive patient and physician experiences at a lower cost.
While there has been much progress, the existing body of evidence for telehealth is narrowly focused on short-term measures of the financial value of virtual health. There is much opportunity to now gather details on broader benefits such as improvements in access to care, clinical outcomes, the impact on the patient and clinician experience, the potential for operational efficiencies, and the impact on health equity. These benefits will also vary based on a wide range of factors that affect value and outcomes such as payment models, virtual care modalities (e.g., audio/visual visits, asynchronous), or the clinical use case. That’s why we developed a comprehensive framework to help stakeholders measure the various ways in which virtual care programs can generate value based on their specific imperatives.
Measuring the Value of Virtual Care
To do so, we examined the existing literature on telehealth’s impact and interviewed national experts on virtual care delivery, financing, technology, and research. We also consulted with current and former leaders of Ochsner Health System, Virginia Commonwealth University Health, Cityblock Health, the Healthcare Financial Management Association, Harvard Medical School, the Medical Group Management Association, private practices, and others.
The framework describes several environmental variables that impact distinct value streams, which collectively seek to capture the overall value derived from a specific digitally-enabled model. The environmental variables include practice type, payment arrangement, patient population, clinical use case, and virtual care modality. The framework is flexible because it acknowledges that different provider organizations will have different clinical or business rationales for pursuing different models based on their environmental and strategic context. For example, a small rural primary care practice with a largely Medicare population paid on a fee-for-service basis will experience the value of digitally-enabled care very differently from a large vertically-integrated regional health system.
Next, the framework includes six value streams: clinical outcomes, quality, and safety; access to care; patient and family experience; clinician experience; financial and operational impact; and health equity. The impact of a digitally-enabled-care model should be measured on all these value streams — a Balanced Scorecard approach, if you will, to measuring and realizing the full potential of virtual care.
Some leading health systems are starting to measure value more holistically. One is VCU Health a Virginia health care system, which increased virtual visits from less than 1% of outpatient psychiatry visits to more than 90% last year in response to the pandemic. It has begun to evaluate the impact of its new virtual model on the various value streams in the framework and has identified some novel findings. For instance, the visit no-show rate (an element of financial and operational impact) dropped from 11% pre-pandemic to 6% during the pandemic, and VCU Health is now considering how it can use virtual care to reduce the number of wasted time slots to improve its operational performance and improve access (another value stream). VCU Health is also measuring the impact of virtual care on health equity given concerns that older people may not be as digitally savvy as younger people; it found that there were no differences in access to care by age group when delivery shifted from nearly all in-person visits to nearly all virtual visits. This report provides additional case studies from organizations such as Ochsner Health and Massachusetts General Health and resources, such as upcoming sessions and virtual discussions for the industry to share their own experiences.
Virtual care is here to stay, but many stakeholders across the industry are in the process of determining how best to invest in their programs and measure their success. This value framework can help.