Joseph Kvedar, MD, Senior Advisor, MGH Center for Innovation in Digital HealthCare
Dealing with Covid-19 has been a true game of whack-a-mole for all healthcare stakeholders. Here in the United States, so much of telehealth’s penetration into care delivery is dependent on the state of the public health emergency, during which flexibilities put in place by the Administration have enabled utilization through generous reimbursement. On March 15, President Biden signed the omnibus spending bill, which included a 151-day extension of temporary telehealth waivers after the PHE is lifted. So, what are the scenarios we should plan for?
Scenario 1: The Ice Age
If Congress does not permanently change the law to extend telehealth access during this 151-day window, we will go back to a life much like what we had in 2019. Medicare recipients will have minimal access to telehealth (rural citizens only will need to go to a qualifying facility). Private payers will continue to offer telehealth, but as a highly controlled option and probably not delivered through your doctor. This will lead to more fragmented care.
Scenario 2: The Stutter Step
In this scenario, policymakers elect to ‘kick the can down the road’ by either extending the PHE another three months at a time or passing short-term reimbursement extensions while ‘studying’ the effects of telehealth on cost and the potential for increased fraud. Healthcare providers keep the door open by encouraging evangelists/enthusiasts to continue to practice but avoid large-scale investments because they cannot count on a long-term reimbursement strategy. Payers continue to offer telehealth as a highly controlled option but begrudgingly continue to support local providers’ participation in telehealth as the government plods along.
Scenario 3: The Breakthrough
Here, Congress votes on permanent reimbursement for telehealth before the PHE expires. This scenario has two versions: lawmakers legislate reimbursement for telehealth at parity with in-office visits, and a second option in which they legislate reimbursement at a discount to office visits.
Scenario 4: Consumer-focused Primary Care Takes Off
The hottest ticket in digital medicine these days is, arguably, virtual-first primary care. Market entrants as diverse as Amazon, CVS, Best Buy, United Health, and most large provider health systems are implementing or contemplating virtual-first primary care offerings. These programs are offered at a lower premium cost to members and revolve around the concept that the first interaction with the healthcare system will be virtual. They are more convenient and possibly more efficient.
Scenario 5: Value-based Reimbursement Takes Off
We’ve been talking about value-based reimbursement for at least a decade now. This is the scenario where providers get paid for efficient care delivery across populations of citizens and are rewarded for keeping people healthy. It hasn’t taken hold yet, with notable exceptions, such as Kaiser Permanente. This model of reimbursement is like gasoline on the fire of telehealth.
It’s important to note that these five scenarios are not mutually exclusive. For instance, if we see a combination of scenarios 1, 4 and 5, we will have a healthcare delivery system that is heavily payer/member-focused. It is interesting to contemplate the role that each of the main stakeholder groups plays as individual scenarios play out, as well as combinations.
I have deliberately not said which scenario(s) I favor. What do you think the most likely combinations are? What scenarios have I missed? What are the implications?
This piece was written by Joseph Kvedar, MD, Senior Advisor at MGH Center for Innovation in Digital HealthCare, and Professor of Dermatology with Harvard Medical School. It was originally published on his blog page.
