On the surface, telehealth is booming: According to a recent Mercer survey, 59 percent of employers now offer some level of telehealth coverage as part of employees’ health benefits package. This is up from 30 percent just a year ago.
Yet, the familiar telehealth narrative of increased coverage and availability is starting to sound somewhat hollow — among health plan executives, it remains an open secret that the actual utilization of plan-sponsored virtual visits remains low.
The past: “If you build it, they will come”
This mantra has been disproven in digital health, most notably with the app explosion of the early 2010s, then with the thud and skid of the patient portal in Stage 2 of the Meaningful Use Program. Telehealth hasn’t failed on those proportions – but while may seem ubiquitous to those of us in the industry, on the ground, most offerings have yet to mature into enough of a value proposition.
“Our patients who use it love it – it’s getting 4.8 out of 5 stars. But adoption is actually quite low,” noted Mark Long, VP of Innovation at Providence Health Services, at a recent conference on consumer retention. “One theory is that we’re just waiting on a customer inflection point to happen – but that’s not very satisfying. We’ve been trying to get people to understand their benefits better.”
“The health insurer wants to respond to consumers’ needs, but right now people are getting [telehealth] through a third party, which fragments care,” noted Corbin Petro at the same session. Petro is CEO of Benevera Health, a payer-provider collaboration based in New Hampshire. “We’ll ultimately need to bring together payers and providers to find the right solution,” she added.
The provider may indeed be a key piece of the puzzle (more on that below), but the elephant in the room may be that couching virtual visits into a complex, user-unfriendly benefit design isn’t a good enough strategy to drive use.
Of course, this hasn’t stopped the big insurers from signing big new deals to prove their commitment to digital health: Cigna recently announced the addition of telehealth vendor American Well to their virtual coverage network, noteworthy because Cigna already has a contract with MDLive.
TelaDoc, the only publicly traded telehealth vendor in the US, continued to tout new employer deals and broker relationships on their Q3 earnings call. Their mostly flat stock price over the quarter tells a different story however, speaking to the need for real, utilization-driven revenue.
“Anemic performance is the reason members of the established telemed companies are renewing contracts with no base charge to clients and are willing to operate at a loss in defense of their market share,” points out Dr. John Dutton of CirrusMD.
Such signals underscore how telehealth vendors are gradually becoming commoditized in the payer market. Over the weekend, I was helping my girlfriend select a United Healthcare benefits package through her new employer. I couldn’t help but notice, in fine print inside of a complex chart of percentages and acronyms, that virtual visits were available for a flat $10 co-pay in the PPO offering. No specific vendor was named, and no specialties were listed.
Sure, it was just a piece of paper in a folder from HR – but it points to the total cluelessness of these huge, consumer-unfriendly behemoths when it comes to user experience design in digital health. In theory, they ought to be baking video visits into their mobile app directly, where they could include the payment/administrative pieces and make utilization as easy as a few swipes.
Like most payers however, United’s actual mobile app is, as The Donald would say, ”a total disaster.” If payers as experienced as United treat telehealth as a cheaper, second-tier alternative to regular care, while missing their biggest opportunity to onboard a captive audience, they’ll need a whole lot more of those funny commercials.
Present day: Shifting toward provider-driven models
Will providers fare any better in offering consumer-friendly virtual care that people actually use? I recently spoke with Ralph Derrickson, CEO of Carena, a Seattle-based telehealth vendor geared towards provider systems and physician practices.
“Health systems need to address this by engaging with consumers where they are looking for health information,” he noted. “Health systems are used to using traditional marketing methods to attract and engage patients, but consumers are going online to find health information. I suspect that today, systems aren’t seeing utilization because they aren’t marketing to reach online consumers.”
Speaking about health plan model, he added: “Health plans are the last thing consumers think about when looking for medical care. People stressed about health think about the three hopes: I hope it’s not serious, I hope I can see my doctor, and I hope it’s paid for…providers are the most trusted source for medical care — This shouldn’t be different for virtual visits.”
While consumer onboarding will be critical, so too will be the provision of an appropriate technology-powered care model for this segment of the market.
A couple of years ago I predicted that that the major telehealth vendors’ default approach – selling access to rental physician networks and using proprietary records – simply wouldn’t cut it for provider clients operating in a value-based era because it is too fragmented, too proprietary, and not interoperable. The market has spoken, and vendors have begun re-thinking their offerings to come up with a value proposition that fits.
Jason Gorevich, TelaDoc’s CEO, made it a point on the aforementioned earnings call, to note the company’s distinct provider offering, “designed to first defer to the provider’s doctors and then move to [the] Teladoc School of Physicians if the provider’s doctors are unavailable.” Teladoc currently counts 80 hospital systems as clients, and a recent endorsement by the American Hospital Association may drive that number up.
And just this month, New York Presbyterian, one of the more progressive hospital systems for consumer-friendly tools, signed a similarly structured deal with the other telehealth giant, American Well. Under this new offering, patients will be able to access New York Presbyterian’s own network of physicians for urgent care and standard virtual visits.
This will prove critical – driving utilization of virtual visits is like driving utilization of stethoscopes: Make sure the doctors know how to use it and you’ll be fine. This is part of the reason why Carena’s hands-on approach is seeing early success with the risk-bearing provider market. We’re likely to see the big telehealth vendors pivot towards services over the coming years: physician onboarding, DTC marketing, and technology customization.
According to American Well CEO Roy Schoenburg, this is “in-line with the company’s strategy looking forward.” Their deployment at New York Presbyterian, “doesn’t look anything like the American Well app…[the provider client] completely design[s] everything from the ground up and American Well simply provides the nuts and bolts of the technology.”
What happens when health systems realize that most of those nuts and bolts are already built in to everyone’s smartphone?
A not-too-distant future: There’s (any) app for that
As recently as a year ago, the big delivery systems like Mercy and Partners were the first to come to mind when thinking about provider-led telehealth. Now, it seems like the future of virtual doctor visits will come from digital health startups.
Over the summer, I sat down with the Twine Health team in Cambridge to talk about value-based care models and the role of digital health. When I asked about telehealth, CEO John Moore, MD, said bluntly that he “just didn’t find telehealth that interesting.” When pressed, he shrugged and said that any digital health platform that texts or messages or calls is already enabling some form of virtual care. Is throwing video into the mix really that big of a deal? For physicians of the future (read: most millennial doctors, residents, pre-meds) the involvement of a video camera is a means to an end, not a standalone goal or solution.
Dr. Jay Parkinson of Sherpaa is another enterprising doctorpreneur whose platform, Sherpaa, takes a similar tact when it comes to virtual (text, call, e-mail) versus in-person visits. Video is not a part of the offering today, but it’s not difficult to imagine it fitting in seamlessly moving forward.
Dr. Jordan Shlain, founder of HealthLoop, says that the secret sauce is not in the technology itself, but in the empathy of the care team: Knowing patients’ histories, understanding their needs, and being available when they are needed. His approach is rooted in operating his own private practice for years, in which he is available for his patients around the clock by phone, text, e-mail.
When it comes to consumer-facing offerings, carving out video-based visits from texting, health coaching, primary care, urgent care, specialty care, and so forth may make it easier for insurance companies to price and sell their wares – but it doesn’t make those care modalities more effective, and it certainly doesn’t make them any easier to use.
Will we soon be looking back on the once-mystical, hype-fueled telehealth platform wars as a flash in the pan? Video cameras have already been sitting in people’s pockets and purses for most of the last decade. What if the virtualization of care depended on the trust, ease, and accessibility of the whole experience? This is why the insurance-driven model of telehealth is likely to become irrelevant by the end of the decade.
Put it this way: Having the dispatch number for yellow cab on speed dial is not the same as having Uber.
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