Is Telehealth a Game Changer for Chronic Disease Management?

Chronic diseases account for an incredible 90% of the United States’ $3.5 trillion in annual health care costs, according to the Centers for Disease Control and Prevention (CDC).

The pandemic drove increased access to, and utilization of, telehealth, and preliminary analysis of the telehealth experience for both patients and providers has been positive. Considering the benefits telehealth has to offer, it has the potential to be a game-changer for patients managing chronic disease.

Increased Access

Access is a huge issue for patients who require ongoing care for their chronic conditions. The barriers to care can range from provider availability to mobility restrictions to transportation challenges. These challenges are particularly prevalent in rural communities. 

Can telehealth provide a solution for patients who experience a barrier to health care, like rural residents?

The report, The Impact of Coronavirus on Households in Rural America conducted by NPR, the Robert Wood Johnson Foundation, and the Harvard T.H. Chan School of Public Health, states, “Since the start of the coronavirus outbreak, more than four in ten rural households (46%) report using telehealth, where anyone in their household has received advice or treatment from a doctor or other health care professional over the phone or through a smartphone, tablet, or computer because they could not see one in person.”

By providing a solution to common barriers to care, telehealth has the potential to enable patients to get the consistent, ongoing care they need to manage their conditions.

Reducing Risk

Many chronic diseases are caused by a shortlist of lifestyle behaviors per the CDC. Those behaviors are:

• Tobacco use and exposure to secondhand smoke.
• Poor nutrition, including diets low in fruits and vegetables and high in sodium and saturated fats.
• Lack of physical activity.
• Excessive alcohol use.

An increase in healthy lifestyle behaviors can result in a reduction of chronic disease. Telehealth enables providers to assess patients and provide counseling, referrals, and access to services to improve the behaviors that contribute to chronic disease. 

The ability of telehealth to have an impact in this area may be expanding. In June, the Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act to support the expansion of telehealth services for substance use disorder treatment was introduced, providing yet another way that telehealth could improve health outcomes for those with chronic conditions.

Mitigating Emergency Department Utilization

Patients with chronic diseases account for 81% of all hospital admissions. 

An mHealth Intelligence article reported, “A telehealth program launched in 2016 to improve care management for patients with chronic conditions who aren’t in home health care has cut ER visits in half and reduced hospitalizations by almost 90 percent, according to hospital officials.”

While there were extenuating circumstances that contributed to the reduction in ER utilization during the pandemic, there were reports of the constructive use of telehealth for residents of long-term care facilities to reduce ER visits.

Time will tell what true and lasting benefits telehealth will offer, but if reports are consistent, it promises to be another avenue for providers to engage patients to help them manage their chronic conditions and to lead to better health outcomes.

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The year 2020 is almost over, and it is safe to say, there is a collective desire to put this year behind us. As we look to the future, what can we anticipate for Medicaid programs? Here are some trends to keep an eye on.

Enrollment Increases

The Affordable Care Act began allowing for voluntary Medicaid expansion to low-income adults in 2014. Since that time, 39 states (including the District of Columbia) have expanded the program. 

The expansion resulted in increases in enrollment until 2018, when enrollment rates began to decline. The decline in enrollment slowed in the beginning of 2020, but then, because of the pandemic, quickly reversed course. 

The Kaiser Family Foundation (KFF) reports, between February 2020 and July 2020, enrollment increased by 4.3 million, or 6.1%. As the US continues to grapple with the pandemic and the economic impact, that trend may continue. 

Continued Reliance on Medicaid Managed Care

Transition to Medicaid Managed Care is expected to continue. According to the KFF: 

· Nationally, 69% of Medicaid beneficiaries are enrolled in a managed care plan.

· 40 states, including the District of Columbia, contract with managed care plans to deliver care.

· In FY 2019, payments to managed care accounted for about 46% of Medicaid spending.

The reach of managed care has the potential to grow as more states consider Medicaid expansion and states trend toward carving in services like behavioral health, pharmacy, dental, and long-term services, and support.

Demographic Changes

Long thought of as a program focused on women and children, the face of Medicaid is changing. 

· According to CMS reports, adults account for approximately 20% of new enrollments. 

· The elderly are projected to be the fastest-growing segment of the Medicaid population. 

Focus on Social Determinants of Health

The Centers for Disease Control and Prevention defines the Social Determinants of Health as the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

KFF reports 35 states to require managed care organizations to use strategies to address at least one of the social determinants of health. These requirements include:

· Screening enrollees for social needs.

· Providing referrals to social services.

· Partnering with community-based organizations.

· Employing community health workers.

We can predict that the emphasis on these areas will continue.

Advancements in Care Delivery

The pandemic quickly shifted how care is delivered, pushing the advancement of both digital solutions and telehealth. 

Digital

The health care industry has lagged other industries in its adoption of digital solutions and behind consumer demand. The Electronic Medical Record Adoption model found adoption rates of electronic medical records to be only about 35% in the United States. However, the McKinsey 2017 Consumer Health Insights Survey reported that 70% of consumers wanted digital solutions.

Telehealth

The increase in telehealth utilization has been widely reported, but the statistics continue to be impressive. TriHealth has seen an increase of 3,650% in telehealth utilization over the last six months. Telehealth is one of the biggest trends coming out of 2020 that will likely have an impact in the future.

As Covid-19 cases rise across the country, we are continuing to see the important role that telehealth can play in our healthcare system, particularly during emergencies. While the public health emergency caused by the pandemic is unique in that it does not result in the destruction of infrastructure, the benefits of telehealth could still be applied in other emergency situations.

The New England Journal of Medicine conducted an interview with Dr. Judd Hollander, associate dean for strategic health initiatives at Sidney Kimmel Medical College of Thomas Jefferson University, on how health systems have used telemedicine services during the Covid-19 pandemic. He discussed how telehealth has played a role in the delivery of care during the pandemic, including providing routine care, triaging emergency care, maintaining ongoing care, screening for COVID-19, providing inpatient care, and maintaining medical staffing levels.

Providing Routine Care

Providers can use telehealth to deliver care to patients who are experiencing non-Covid-19 conditions. Appointments of this type could range from an injury to a non-Covid-19 illness. Telehealth enables the provider to have appointments with patients and address their concerns without risking exposure to Covid-19 that would come with an office visit. It also helps to avoid unnecessary urgent care and emergency department visits during the pandemic.

Triaging Emergency Care

Telehealth can be utilized to assess and triage patients before they arrive in the emergency department (ED). Take Project ETHAN (Emergency Telehealth and Navigation) in Houston, Texas, for example. The program (in place before the pandemic) allows emergency room physicians to connect via telehealth with patients in their homes. This direct connection with a provider has resulted in a reduction in the number of unnecessary ED visits. 

Maintaining Care for Patients with Chronic Conditions

Patients with chronic conditions require ongoing care to manage their conditions. Using telehealth, providers can maintain continuity of care with these patients. With remote patient monitoring devices, providers can even keep track of important vitals, like blood pressure. Once again, being able to provide this care remotely reduces the risk of exposure to COVID-19, which is especially important for a patient who are in a higher risk category.

Screening for COVID-19

 Screening patients for COVID-19 without having to schedule an office visit to reduce exposure for both the patient and the provider. Providers can screen patients for symptoms, refer to testing as needed, and provide guidance on quarantine protocols.

Providing Care to Hospital Inpatients 

Telehealth enables providers to conduct virtual rounds using tablets and other technology. Family members be virtually connected so they can be “present” when a doctor is in the room and providers can conduct video consultations, as necessary. 

Maintaining Medical Staffing Levels

One of the fears during the pandemic has been a patient load that exceeds staffing levels. Telehealth allows physicians who are quarantined at home, but well enough to work to continue to provide care. By protecting providers from exposure to COVID-19, telehealth helps preserve the workforce and the personal protective equipment that is so important during the pandemic. 

The first step Medicaid managed care organizations need to take to deliver care to their members seems simple. They need to connect with members and engage them to be active in their health. 

Often that is more challenging than it sounds. It is a common refrain: Medicaid members are difficult to engage with. But many members may have different challenges, and that means trying a different approach. 

1. Try the Smartphone

Many plans try to reach members through traditional phone calls, but that approach may be becoming less and less effective. The Washington Post reported that robocalls to cell phones increased by 45% in 2018, plausibly crowding out legitimate calls and making it more difficult to reach members with a phone call. Voicemails may be less effective as well as Millennials are less likely to even set up a voicemail than ever before. 

Texting, however, has continued to increase in popularity, with the average American adult texting more than 30 times per day. Text messages also have an exceptionally high read rate. 

The rate of cell phone ownership in the Medicaid population is almost 90%. This may solve some of the historical problems with outreach to transient members as cell phone numbers typically do not change like landline phone numbers and physical addresses.

So, it is time to try leveraging the smartphone for outreach and engagement. 

Take Text4Baby, for example. The maternal and child health program uses text messaging and an app to connect pregnant women with health care through Medicaid. As a result of the program:

• 63% said Text4Baby helped them remember an appointment,
• 47% reported they connected with health services,
• 77% reported opening links from the program.

1. Offer Incentives

The American Journal of Preventive Medicine published a study entitled, A structured review of the effect of economic incentives on consumers’ preventive behavior. Basically, they wanted to know: do incentives work?

The research included a review of 47 trials of incentives to encourage preventative care. The researchers found that incentives worked 73% of the time to encourage preventive care like vaccinations, prenatal care, and weight loss programs.

Buckeye Health Plan offers a My Health Pays Rewards Program for its members. The plan rewards members for taking healthy actions, like getting a flu shot or certain checkups and health screenings, and then funds a debit card the member can use to buy the things they need. 

1. Engage in Community Outreach

Sometimes, to overcome barriers, you need to be where people live, work, and play. An active and engaged Community Outreach Department can reach members who would otherwise be difficult to connect with. Here are some key community outreach activities.

• Set Up Community Office Hours and Satellite Offices

Could visibility and a friendly face help you reach more members? Setting up offsite office hours can help reach members where they are comfortable. 

• Engage in Community Events

Invest in the community and build trust with members and community leaders by sponsoring and participating in important community events, like parades, fairs, school events, and church activities.

• Give Back

Understand community needs and provide support. The CDC says that the social determinants of health have an impact on members. It just makes sense to support social services that will improve their overall wellness. 

Well-child visits are essential for delivering preventive care for children. As a matter of fact, they are so important that the American Academy of Pediatrics has recommended that pediatricians continue to see children for well-child visits during the pandemic, so they get important vaccinations and screenings for developmental and learning milestones.

They also provide an opportunity for pediatricians to help patients and their parents with strategies for dealing with the pandemic. Here are some of the pandemic-related concerns pediatricians can discuss during well-child visits.

Should My Child Go to School?

Parents and kids have gone through a lot of transition in schooling since the start of the pandemic. Parents may have concerns and questions about the safety of schools for children. Pediatricians can address those concerns and help parents to make smart decisions for their children.

Should My Child Wear a Mask?

The research continues to show that masks are an effective step to reduce the transmission of COVID-19. However, some children may have health concerns, like asthma, that make mask-wearing challenging. Additionally, the Centers for Disease Control and Prevention (CDC) states that cloth face coverings should not be placed on children under age 2. Pediatricians can help parents and kids sort through what the right approach is for their health.

Are Playdates and Sports Okay?

It can be confusing to figure out how to balance a child’s social development by reducing the risk of contracting COVID-19. Pediatricians can provide guidelines that help parents make wise decisions, like looking at group size, the location of the event (indoor vs. outdoor), and the activities involved.

How Can We Stay Safe?

The basics – social distancing, hand washing, and avoiding touching your face – are simple to teach an adult, but more challenging to teach a child. Pediatricians can help by offering tips to teach kids these important behaviors to keep everyone healthy. For example, telling a child to keep six feet of distance may be hard for them to understand. Instead, try saying, “if you are close enough to touch someone, you are too close.”

What Should We Do if Our Child is Sick?

It is still confusing to understand when to get tested, who should get tested, how to get tested, and what to do in the meantime while waiting for results. The well-child visit is a perfect time to clear up any confusion.

How Can I Help My Child Cope with Stress?

This is a stressful time for everyone, and children can absorb stress in their home environment. Pediatricians can offer a safe place for parents and kids to express their anxiety and can offer coping skills and referrals to mental health services if necessary.

Finally, the pandemic has had an impact on income stability for many. The CDC lists economic stability as one of the social determinants of health. Pediatricians should consider how they can screen for problems – Does the family have enough to eat? Do they have a safe place to live? – and offer referrals to social service agencies that can help.

The Centers for Disease Control and Prevention defines chronic diseases as conditions that last one year or more and require ongoing medical attention or limit activities of daily living, or both. These diseases affect approximately 6 out of every 10 Americans and include commonly heard-of conditions, like:

• Heart Disease
• Cancer
• Lung Disease
• Stroke
• Alzheimer’s Disease
• Diabetes
• Kidney Disease

When diagnosed with a chronic condition, patients can feel the impact in many areas of their lives.

• Time – Patients newly diagnosed with chronic conditions may struggle to re-align their time as they learn to live with their condition. This may mean diabetes patients being more aware of when they are eating and doing more careful meal planning before trips to the grocery store. For cancer patients, it can mean more time spent in appointments and in treatment.

• Treatments – Patients can struggle to adjust to new treatment regimens. Stroke patients may struggle to be consistent with therapy, or those with kidney disease may have to adjust to dialysis.

• Finances – There is a financial impact to requiring ongoing medical care, like the cost of care, lost time at work or the inability to work, and purchasing home health items needed.

• Limitations – Adjusting to new limitations inability or mobility can be particularly difficult for patients. Some may need extra help and struggle with the loss of independence.

There are small steps patients can learn that will help them live their life with their disease, manage their condition, and improve their health. They can be coached to:

Advocate for Your Health

Ask doctors to explain anything you do not understand, and do not be afraid to ask questions.

Ask for a Second Opinion if You Need One

Getting a second opinion can give you more insight into your diagnosis and treatment options. It will also help you find a doctor who is the right fit for you. If you feel like you need one, ask for a second opinion.

Own Your Response

In the equation Event + Response = Outcome, you can control one piece – the response. Now that you have your diagnosis, it is time to consider how you will respond. Consider the changes to your lifestyle that can help you manage your condition. Think about the adjustments you can make that will ensure you are getting the treatment you need. If you need help managing how you respond, or if you struggle to accept the event or constantly worry about the outcome, consider seeking help from a mental health provider.

Ask for Help

Identify your support team. Do you have close friends who can help when you need it? Do you live close to family who can pitch in? Consider connecting with a Case Manager who can help walk you through your condition.  

Educate Yourself

Take the time to learn about your condition. Ask your doctor questions, and investigate organizations dedicated to them, like the American Heart Association or the American Lung Association. This is another area where care management can help.

Commit to Healthy Habits

Make a commitment to making healthy decisions that can improve your condition and your overall health. Eat the right things, get some exercise, limit alcohol, and quit smoking.

The Centers for Medicare and Medicaid Services (CMS) recently announced that it added eleven new telehealth services to its reimbursement list effective immediately and through the remainder of the coronavirus public health emergency (PHE). Additionally, CMS is providing support to Medicaid and CHIP agencies to expand access to telehealth. There are now 144 services covered during the PHE. (See the full list at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.) The public health emergency was recently renewed for an additional 90 days from the renewal date of October 23.

That update comes as CMS also reported on telehealth utilization for Medicaid and CHIP beneficiaries. From March through June 2020, there was an astounding 2,632% increase compared to the same period in 2019, with a peak in mid-April. That equates to 34.5 million visits during those four months, with utilization being highest for working-age adults. CMS Administrator, Seema Verma, stated, “This revolutionary method of improving access to care is transforming healthcare delivery in America.”

Telehealth was pushed to the forefront when CMS relaxed requirements to ensure access to care during the pandemic. Initial indications are that both patients and providers are successfully integrating this method of care delivery. According to a report by Accenture, 60 percent of patients who have used telehealth during the pandemic want to continue doing so, and the vast majority of patients reported that the quality of care they received via telehealth was consistent with in-person care.

Telehealth enables providers to reach patients during the pandemic, and it also enables them to reach patients who generally face barriers to access, like rural residents. In fact, the Centers for Disease Control and Prevention has supported telehealth projects across the country, both before and during the pandemic, that are delivering chronic disease programs and specialty care to rural areas. The technology’s capabilities reach far beyond a check-up.

Stroke and Cardiac Rehabilitation

Doctors can monitor patients as they do rehabilitation exercises at home.

Diabetes Management and Prevention

The remote delivery of diabetes self-management education and support helps patients manage their condition through nutrition, physical activity, correctly checking blood sugar, taking medicine, and managing stress.

Vision Care

Providers can assess eye health and screen patients for eye disease.

Tobacco Cessation

Specialists can reach patients, especially those who have limited Internet access, with smoking cessation interventions via cell phone.

Epilepsy Management

Patients get access to self-management and telemonitoring programs to manage their condition.

Physical Therapy

Therapists can conduct assessments, prescribe strategies, manage exercises, and consult with patients remotely.

Dentistry

Dentists can conduct assessments via telemedicine, reducing unnecessary appointments and exposure during COVID-19.

Chronic Pain

Providers can conduct virtual visits and monitor patients through devices that track and transmit data.

The future of telehealth continues to show promise as a means for delivering quality care both during the pandemic and beyond. While some services will always require in-person appointments, the availability of telehealth allows providers to limit the spread of disease during the pandemic, to provide innovative ways to deliver care, and to reach patients who otherwise experience a barrier to care.

The pandemic brought about a rapid expansion of telehealth. In response, the National Committee for Quality Assurance, the Alliance for Connected Care, and the American Telemedicine Association brought together experts from across the industry to form The Taskforce on Telehealth Policy (TTP). The taskforce looked at the future of telehealth, specifically considering the quality of care and safety standards. In mid-September, they released a report outlining recommendations for policymakers to consider.

The TTP suggested that telehealth is a natural evolution into the digital age, not a new type of care, and this type of care delivery can be critical in advancing a well-coordinated, patient-centered, value-optimized healthcare system. Based on the review of data during the pandemic, the taskforce believes there is evidence to support the argument that telehealth can be successfully integrated into our healthcare system, and should not be limited as it was prior to the pandemic.

The TPP consisted of three subgroups, which each provided recommendations. Following are some highlights from each subgroup.

Patient Safety and Program Integrity

• Telehealth can enhance safety by preventing care delays, reducing exposure to illness, and minimizing travel necessary for office visits.
• Safety standards should be the same, not different for telehealth. Minimum standards should be identified and integrated into existing standards.
• Emerging tools, like artificial intelligence, can help detect fraud, waste, and abuse. The existing fraud, waste, and abuse protection systems in place should be extended to telehealth.
• Patient privacy should be protected.

Data Flow, Care Coordination and Quality Measurement

• Telehealth is a natural evolution into the digital age, not a new type of care.
• Quality measures should be adapted, rather than reinvented, for telehealth.
• Telehealth platform certification should be required on data sharing, care coordination, and privacy.
• Leverage telehealth to improve care coordination. Move toward care coordination document sharing among all team members (within and outside of telehealth) to remove silos and improve care coordination.
• Pilot digital patient experience surveys.

Effect on Total Cost of Care

• No excess cost or utilization has been observed thus far during COVID-19 because of telehealth. The mix of care weighed toward telehealth, but overall numbers were steady.
  • Behavioral health is an exception. While utilization increased, there is potential to improve both costs and outcomes by reducing untreated behavioral conditions that can result in physical health needs.
• Other ways telehealth shows promise for improving costs:
  • Fewer missed appointments.
  • Fewer skilled nursing facility patient transfers to hospitals and emergency departments.
  • Increased use of transitional care management that results in fewer readmissions.
  • Anecdotally, when asked what they would have done without telehealth, patients indicated they would have gone to the emergency department or urgent care.

The taskforce offered other overarching recommendations, including addressing technology gaps to ensure equity; resuming full HIPAA privacy enforcement; considering access for the hearing or visually impaired; permanently lifting telehealth restrictions as encounters meeting appropriate standards of care; and providing guidance on any new policies.

Read the full TTP report at https://www.ncqa.org/programs/data-and-information-technology/telehealth/taskforce-on-telehealth-policy/.