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Welcome to the Future: Telemedicine and Value-Based Payment

Michael D. Fratkin, MD, and Stephen G. Franey, MBA
By using telemedicine and relocating the center of care to where a person lives, we have an opportunity to address more unmet demand for palliative care, while giving more control to the seriously ill to meet their stated needs.
RECENTLY, MICHAEL WAS CALLED TO the hospital for a transitional palliative care consult. He walked into the room to see a Native American man in bed, surrounded by 8 people and a laptop computer on a cart. This man had been a lawyer, activist, probation officer, and more—a defender of his people. At his side was Aggie Pilgrim, chairperson of the International Council of 13 Indigenous Grandmothers, now 92, but still traveling the world with other elder women of First Nation communities to disseminate and preserve their cultures and healing traditions. The others in the room were all ages: from a babe in arms to millennials to baby boomers.

At the end of the bed, the laptop screen showed 8 more family members gathered in support, from Maryland, Los Angeles, Sacramento, and elsewhere. Aggie said a beautiful prayer, pulled out a bundle of white sage, lit it, and passed it around—while, frankly, Michael worried it would set off the hospital’s smoke alarm.

Welcome to the future. This was a videoconference that we, at ResolutionCare,1 had no role in setting up. It was set up by empowered people who used ubiquitous, readily available technology to bridge geographic distance and provide family support. Clearly, there’s a disruption afoot.

Telemedicine’s Evolution

The arc of remote consultation support through videoconferencing, or telemedicine, is an evolution from high-cost, technologically complex systems to readily available, low-cost technology that is easily used by both physicians and people receiving care.

Telemedicine 1.0

Fifteen years ago, Telemedicine 1.0 was the first effort to connect subspecialists in tertiary referral centers to satellite clinics. It involvedthe use of fiber-optic cables, expensive carts at both ends, and dedicated telemedicine centers. Because it was so capital-intensive, it never really took off in northern California, our home base. Although it did provide a great service for many remote communities outside of major metropolitan areas, its high barrier to entry limited its use.

Telemedicine 2.0

Telemedicine 2.0 has leveraged the rise of ubiquitous smartphones, always-on connectivity, and cloud-based processing to deliver a sizable impact on how physicians provide care. Organizations like Doctor on Demand, Teladoc, and American Well have activated networks of remote-working primary care physicians to provide low-cost, effective telemedicine encounters for episodic problems (such as a sniffy nose or sore throat). Both consumers and employers see huge value when someone can see a doctor while on a coffee break and go back to work. The low barrier to entry has been responsible for an explosion in service providers and locations—including kiosks in CVS and Walgreens. This is driving growth in teledermatology and behavioral health, among other fields.

Telemedicine 3.0

What we’re doing, as palliative care specialists at ResolutionCare, is what we call Telemedicine 3.0. In some ways, version 3.0 represents the evolution of the technology so that it can disappear— and thus allow for the return of the deep relational work that’s always been at the heart of caring. We’re using these technologies to reach people with ease via technology they already have at their fingertips (or that we provide) to reach them in their homes, to unburden them from travel and transport, and to offer a patientand home-centered locus of care. We’re discovering substantial benefits for the patients, unanticipated efficiencies, and surprising nuances that are intrinsic to this new medium.

Telemedicine and the Seriously Ill

The evolution from the episodic care of Telemedicine 2.0 to the use of telemedicine for the longer-term, chronic issues faced by individuals who are seriously ill (Telemedicine 3.0) eases the burdens of both sick patients and their doctors, and lets us go back to the raison d’être of most physicians: caring for people. The Patient Experience Some cancer patients will make more than 150 trips in their last year of life for infusions, physician appointments, lab draws, imaging, and fractionated radiotherapy. Removing the need for yet another clinic visit can have an immeasurable impact on that patient’s quality of life (QOL). When people must drag their tired, broken bodies into clinics to satisfy every stakeholder but themselves, when they have to take time off work, deal with parking, and leave their own turf to sit in a doctor’s office and wait (and wait) to be seen—while surrounded by other really sick people— you can imagine the negative effect on their physical, mental, and spiritual states.

Home Visits

Home visits, by contrast, remove many of those burdens for sick people. For the physician, seeing individuals where they live, and gaining all the extra information gleaned just by walking into their homes, has many real benefits that can improve care. However, the doctor may be viewed as an invader—there’s a power dynamic, and simply by being a doctor and walking into a person’s home, you shift the control from them to you. When sick people know the doctor is coming, they work really hard to get the home all cleaned up, to appear a certain way, to take a shower and fluff themselves up. Even though a home visit frees them from certain burdens, they burden themselves in other ways because they have a sense of what’s acceptable for the doctor to see.

Telemedicine Visits

Now compare that to telemedicine and a videoconference using a cloud-based platform, where the person doesn’t need to travel or clean up, and simply needs a wall that looks presentable. The burden of preparation and getting everything ready has been removed. From the doctor’s perspective, you don’t have to allow for commute time and traffic—the “house call” can seamlessly fit into your day without disruption.

Surprisingly—at least for those who haven’t done it yet—the intimacy, the immediacy, the feeling of being right there in the room together, is palpable. One would think that the technology might get in the way somehow, but instead, it disappears. The call is an interaction between 2 people, face-to-face, sharing and talking intimately. Yet, that connection takes less time overall. Whereas an in-person home visit for a new-patient consult takes between 90 to 120 minutes, a telemedicine first consult takes 60 to 70 minutes.

Because we work as part of an integrated, multidisciplinary team, some of our telemedicine sessions include just the sick person and the physician, while other sessions might include other care providers, such as a nurse, social worker, chaplain, or family members. The needs of the person we’re caring for tell us what to do, whom to involve, and when. As we often say at ResolutionCare, “We do what makes sense.” This doesn’t, however, totally remove the need for in-person visits. The information gained in those visits is brought back to the interdisciplinary team and helps us understand the full context of this person’s living situation. We do a better job of shared decision making when we have that complete picture.

Locus of Control

Besides improving a person’s QOL and gaining efficiency for the physician, one of the most important benefits of telemedicine for palliative care is that it helps the sick person retain a feeling of control over his or her life. This is in sharp contrast to the market view that takes sick people and makes them “patients,” subject tothe rules of our medical world, where they often have procedures done to them rather than for them.

Sick people aren’t patients; they’re people. Over the past 50 years, we’ve medicalized illness and our natural progression toward death. We’ve constructed our technology-intensive, industrial model around “fix it, fix it, fix it”—and that model fails sick people miserably. By relocating the center of care to where a person lives, we release them from being patients and offer them guidance within the medical landscape that we’re familiar with and they’re not. How ironic that innovative technology is responsible for bringing us back to the human-centered, relational model of care that’s been subverted for the past 50 years. Our experience at ResolutionCare suggests that our use of telemedicine in palliation will increase—because of the efficiency of the approach, the opportunity to address more unmet demand, and the increased control afforded patients.

Value-Based Payment for Telemedicine

Much of the fix-it model, and the reason we do procedures to people rather than for them, has come about because of how payers traditionally reimbursed for services. The fee-for-service (FFS) model is a one-size-fits-all, check-the-box, and move-on-to-thenext- patient approach. Each person receiving palliative care has the same menu of possible services, and his or her individual situation or needs have no place in the formula. This assumed homogeneity does not match our experience in practice, as differences in socioeconomic class, disease type, and length of time on service can greatly impact the depth and scope of care required and the patient census each multidisciplinary team can accommodate.

But the landscape is changing. Payers, providers, and people receiving care are seeing the need and are demanding that palliative care be available as a covered benefit. In California, Senate Bill 1004 requires Medi-Cal managed care plans to offer access to palliative care programs—and 4 other states have similar laws either in place or on the horizon. This is occurring while the supply of specialty palliative care resources is overwhelmed by the number of sick people who are clinically appropriate for care.

In contrast to FFS, value-based payment allows for coverage of the entire multidisciplinary palliative care team, rather than just the physician and nurse practitioner. This, in turn, helps increase the capacity of subspecialty palliative care across all disciplines and is an investment strategy by insurance partners to entice more providers into the field. With value-based payment payers say, “We’ll pay you not on the basis of doing X, Y, and Z—but on how you address the life goals articulated by the patient and family.” You can then use an adaptable and nimble response to the individual circumstances of an individual person to try and reach those goals. It’s outcomes-based (see Table).

Table. Difference in Focus: From Volume to Value-Based Payment

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