The telehealth policy changes enacted for short-term control of the coronavirus disease 2019 (COVID-19) pandemic present an opportunity to address the fundamental gap in health care underutilization.
Am J Manag Care. 2021;27(1):9-11. https://doi.org/10.37765/ajmc.2021.88571
Despite the high and rising costs of health care in the United States, major gaps in care delivery are leading to health care underutilization, including care avoidance and care postponement, that are now being exacerbated by the coronavirus disease 2019 (COVID-19) pandemic.1 Health care underutilization, especially undertreatment of chronic disease, has negative health and economic effects. Nearly 40% of all deaths in the United States can be attributed to undermanaged chronic medical conditions such as smoking, poor diet, lack of physical activity, and excessive alcohol use.2 Moreover, chronic diseases are the leading driver of health care costs in the United States: If the economic productivity lost due to chronic disease burden is considered, the total cost is approximately $4 trillion per year, about one-fifth of the entire US economy.3 Yet chronic disease prevention efforts, such as cancer screening and influenza and pneumococcal vaccination for the elderly and at-risk populations, continue to prove to be cost-effective, suggesting that underutilization of chronic care management is contributing meaningfully to rising health care costs.4-6
Unfortunately, this underutilization of care is now being intensified by the COVID-19 pandemic. Not only are individuals dying from COVID-19 in hospitals and at home, but rates of avoiding or delaying care have increased, precipitating a 20% to 40% decrease in hospital admission rates compared with pre–COVID-19 levels.7,8 Furthermore, chronic care management is inhibited by reduced access to in-person care due to the pandemic.9 In response to this drastic mortality exacerbation and reduction of in-person health care feasibility, a plethora of interventions and policy discussions are being introduced, many of which revolve around telehealth and access to digital health communication strategies. While addressing the pandemic itself, the health care system is simultaneously presented with decisions on how to improve acute care and address the concurrent problem of health care underutilization to both enhance quality and manage costs.In this paper, we argue that the same policy changes being enacted for short-term control of the pandemic, specifically those increasing telehealth modalities, present a scope for major change to address the fundamental gap in health care underutilization and directly improve chronic care management over the long term.
A key promising opportunity that is already burgeoning is the increasing usage of innovative disease management strategies such as telehealth, which encompasses the provision of health care services over the internet.10 Numerous barriers limited the uptake of telehealth prior to the COVID-19 pandemic, including reimbursement gaps resulting from many third-party payers not covering telehealth, as well as interstate medical licensure limiting the scope of telehealth.11 However, these barriers have been directly addressed in attempts to improve health care access during the pandemic, leading to modifications in telehealth reimbursement and elimination of many restrictions on practicing telehealth across state lines.10,12-14 These changes have had drastic effects in telehealth utilization already. In 2018, only 18% of doctors practiced medicine with some component of telehealth, compared with nearly 50% now.15 To exemplify the profoundness of this point, at Mount Sinai Faculty Practice in New York, New York, more telehealth visits occurred per average day in April 2020 during the height of COVID-19 than in all of 2019.16
In light of the boom in telehealth use, current evidence suggests a cost-reduction potential for the health care system and insurance providers, not to mention the financial incentives that accompany an increased ability to care for chronic diseases.17 Furthermore, of the 4 areas of spending on chronic disease management that account for two-thirds of all health care costs, both high volume and administration would be directly affected by sustained telehealth expansion.18 The increase in telehealth as a result of the COVID-19 pandemic is a prime opportunity to improve the effectiveness of health care expenditures by filling the void in chronic disease management and increasing access to care overall. This would not only be beneficial during times of social isolation but would also continue to improve health care once the pandemic is controlled.
Remote patient monitoring (RPM) is another disease management strategy that utilizes and builds upon the expansiveness of telehealth to reach underserved populations and fill an unmet need in American health care.19 RPM is a cost-effective method of engaging patients and promoting continuity in care that can integrate care teams and target high-risk groups through multiple channels.20-22 Effective RPM can improve access to chronic care management and help reduce unnecessary admissions, thereby reducing nonessential expenditures and cost burden from more acutely sick, hospitalized patients.23 CMS has issued a number of changes that tear down prior barriers to RPM as a means of providing care during the pandemic. One such change is fundamentally redefining RPM to include care for both acute and chronic conditions, instead of only chronic conditions, which permits new patients, rather than only previously established patients, to access RPM.15,24 Moreover, through changes to reimbursement approaches, incorporation of RPM will enable medical practices to financially benefit, in addition to improving access to chronic disease management for patients.25 Given the financial stress that COVID-19 is having on medical practices, this presents a win-win opportunity.26 We recommend, along with expansion of telehealth and RPM, the concurrent expansion of paramedicine, which allows for remote, rapid evaluation and stratification of patients and has led to fewer unnecessary emergency department visits, ambulance transports, and inpatient health care services; these changes have reduced costs and achieved high patient satisfaction.27
The incorporation of community health workers (CHWs) with telehealth advancements presents an additional opportunity to advance patient care during times of reduced in-person health care contact. Prior to COVID-19, CHWs, who served their respective communities through culturally appropriate health promotion and patient education, had demonstrated vast improvements in access for patients by improving care efficiency and reducing the need for emergency and specialty services.28,29 Moreover, incorporation of CHWs—as well as, similarly, care managers and navigators—has been associated with overall cost savings in addition to improved management of chronic disease and successful outreach attempts through multimodal communication efforts such as cell phone messaging.30-33 In light of the COVID-19 pandemic, a response effort that uses established CHW networks for short-term pandemic suppression with text messaging and virtual health outreach programming will also enable long-term amelioration by strengthening established care avenues.34-36 Although national policies promoting CHW telehealth strategies to combat the pandemic have not yet occurred, some states are upregulating CHW involvement as a short-term pandemic suppression strategy. Incorporation of CHWs is a potentially inexpensive method (although not without costs given the required manpower) to help fill the massive need for additional caregivers while simultaneously addressing the rising unemployment burden in the greater economy.37
The COVID-19 pandemic is testing the American health care system and highlighting major gaps in care, such as health care underutilization. The systemic response to the pandemic presents an opportunity to address these same gaps while combating the pandemic itself. The explosion of telehealth and RPM has the potential to improve health care underutilization and strengthen established community health care networks, thereby improving chronic disease care and improving patient outcomes through established cost-effective strategies. As CMS will continue to reimburse for telehealth equally with in-person visits until the Public Health Emergency ends, it would be advantageous to streamline these methods quickly to provide additional care during the pandemic and retain these well-established systems for long-term coordination.38 The COVID-19 pandemic has removed barriers that previously inhibited the success of remote health care. Recent policy encouragement has increased patient engagement in chronic care management through telehealth, RPM, and CHWs. By fortifying these essential avenues of care, we have the ability to help patients, hospitals, and the overall American health system—an opportunity we cannot afford to ignore.
Author Affiliations: Icahn Mount Sinai Hospital (CAB, AR), New York, NY; New York University School of Medicine (MN), New York, NY.
Source of Funding: None.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (CAB, MN, AR); analysis and interpretation of data (MN); drafting of the manuscript (CAB, MN, AR); and critical revision of the manuscript for important intellectual content (CAB, MN, AR).
Address Correspondence to: Chip A. Bowman, MD, MPH, Icahn Mount Sinai Hospital, 1 Gustave L. Levy Pl, New York, NY 10029. Email: firstname.lastname@example.org.
1. Kaufman HW, Chen Z, Niles J, Fesko Y. Changes in the number of US patients with newly identified cancer before and during the coronavirus disease 2019 (COVID-19) pandemic. JAMA Netw Open. 2020;3(8):e2017267. doi:10.1001/jamanetworkopen.2020.17267
2. Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. The National Academies Press; 2010.
3. Levine S, Malone E, Lekiachvili A, Briss P. Health care industry insights: why the use of preventive services is still low. Prev Chronic Dis. 2019;16:E30. doi:10.5888/pcd16.180625
4. Dabestani NM, Leidner AJ, Seiber EE, et al. A review of the cost-effectiveness of adult influenza vaccination and other preventive services. Prev Med. 2019;126:105734. doi:10.1016/j.ypmed.2019.05.022
5. Ament A, Baltussen R, Duru G, et al. Cost-effectiveness of pneumococcal vaccination of older people: a study in 5 western European countries. Clin Infect Dis. 2000;31(2):444-450. doi:10.1086/313977
6. Ran T, Cheng CY, Misselwitz B, Brenner H, Ubels J, Schlander M. Cost-effectiveness of colorectal cancer screening strategies—a systematic review. Clin Gastroenterol Hepatol. 2019;17(10):1969-1981.e15. doi:10.1016/j.cgh.2019.01.014
7. Appleby J. What is happening to non-COVID deaths? BMJ. 2020;369:m1607. doi:10.1136/bmj.m1607
8. Hurdle J. Fear of COVID-19 infection is keeping many other patients away from hospitals, officials say. NJ Spotlight News. May 4, 2020. Accessed August 11, 2020. https://www.njspotlight.com/2020/05/fear-of-covid-19-infection-is-keeping-many-other-patients-away-from-hospitals-officials-say/
9. Kretchy IA, Asiedu-Danso M, Kretchy JP. Medication management and adherence during the COVID-19 pandemic: perspectives and experiences from low- and middle-income countries. Res Soc Adm Pharm. Published online April 15, 2020. doi:10.1016/j.sapharm.2020.04.007
10. Maheu MM, Whitten P, Allen A. E-Health, Telehealth, and Telemedicine: A Guide to Startup and Success. Jossey-Bass; 2001.
11. Turner Lee N, Karsten J, Roberts J. Removing regulatory barriers to telehealth before and after COVID-19. Brookings. May 6, 2020. Accessed August 11, 2020. https://www.brookings.edu/research/removing-regulatory-barriers-to-telehealth-before-and-after-covid-19/
12. Portnoy J, Waller M, Elliott T. Telemedicine in the era of COVID-19. J Allergy Clin Immunol Pract. 2020;8(5):1489-1491. doi:10.1016/j.jaip.2020.03.008
13. Bashshur R, Doarn CR, Frenk JM, Kvedar JC, Woolliscroft JO. Telemedicine and the COVID-19 pandemic, lessons for the future. Telemed J E Health. 2020;26(5):571-573. doi:10.1089/tmj.2020.29040.rb
14. Medicare telemedicine health care provider fact sheet. CMS. March 17, 2020. Accessed August 11, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
15. Landi H. Half of physicians now using telehealth as COVID-19 changes practice operations. Fierce Healthcare.April 23, 2020. Accessed August 11, 2020. https://www.fiercehealthcare.com/practices/half-physicians-now-using-telehealth-as-covid-changes-practice-operations
16. Associates MSFP. Leadership Interview. 2020. August 11, 2020.
17. Polisena J, Coyle D, Coyle K, McGill S. Home telehealth for chronic disease management: a systematic review and an analysis of economic evaluations. Int J Technol Assess Health Care. 2009;25(3):339-349. doi:10.1017/S0266462309990201
18. Emanuel EJ. The real cost of the US health care system. JAMA. 2018;319(10):983-985. doi:10.1001/jama.2018.1151
19. Field MJ, Grigsby J. Telemedicine and remote patient monitoring. JAMA. 2002;288(4):423-425. doi:10.1001/jama.288.4.423
20. Blazey-Martin D, Barnhart E, Gillis J Jr, Vazquez GA. Primary care population management for COVID-19 patients. J Gen Intern Med. 2020;35(10):3077-3080. doi:10.1007/s11606-020-05981-1
21. Lee SI, Ghasemzadeh H, Mortazavi B, et al. Remote patient monitoring: what impact can data analytics have on cost? Paper presented at: 4th Conference on Wireless Health; November 1-3, 2013; Baltimore, MD. Accessed April 18, 2020. https://people.cs.umass.edu/~silee/pub/C8.pdf
22. Hambelton K. How does multichannel marketing promote patient engagement? Becker’s Hospital Review. October 13, 2016. Accessed April 18, 2020. https://www.beckershospitalreview.com/finance/how-does-multichannel-marketing-promote-patient-engagement.html
23. Bratan T, Clarke M. Optimum design of remote patient monitoring systems. Paper presented at: 2006 International Conference of the IEEE Engineering in Medicine and Biology Society; August 30-September 3, 2006; New York, NY. Accessed April 18, 2020. https://ieeexplore.ieee.org/document/4463292
24. CMS, HHS. Medicare and Medicaid programs; policy and regulatory revisions in response to the COVID-19 public health emergency. Fed Regist. 2020;85(66):19230-19292.
25. Soza H, Yermilov I. Increase revenue, improve patient care with mobile-enabled remote patient monitoring. Medical Economics®. September 26, 2018. Accessed April 18, 2020. https://www.medicaleconomics.com/view/increase-revenue-improve-patient-care-mobile-enabled-remote-patient-monitoring
26. Levey NN. Widening coronavirus crisis threatens to shutter doctors’ offices nationwide. Los Angeles Times. March 24, 2020. Accessed August 17, 2020. https://www.latimes.com/politics/story/2020-03-24/coronavirus-outbreak-primary-care-doctors
27. Gregg A, Tutek J, Leatherwood MD, et al. Systematic review of community paramedicine and EMS mobile integrated health care interventions in the United States. Popul Health Manag. 2019;22(3):213-222. doi:10.1089/pop.2018.0114
28. Role of community health workers. National Heart, Lung, and Blood Institute. June 2014. Accessed August 17, 2020. https://www.nhlbi.nih.gov/health/educational/healthdisp/role-of-community-health-workers.htm
29. Taylor EF, Machta RM, Meyers DS, Genevro J, Peikes DN. Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers. Ann Fam Med. 2013;11(1):80-83. doi:10.1370/afm.1462
30. Khullar D, Chokshi DA. Can better care coordination lower health care costs? JAMA Netw Open. 2018;1(7):e184295. doi:10.1001/jamanetworkopen.2018.4295
31. Jack HE, Arabadjis SD, Sun L, Sullivan EE, Phillips RS. Impact of community health workers on use of healthcare services in the United States: a systematic review. J Gen Intern Med. 2017;32(3):325-344. doi:10.1007/s11606-016-3922-9
32. Kangovi S, Mitra N, Grande D, Huo H, Smith RA, Long JA. Community health worker support for disadvantaged patients with multiple chronic diseases: a randomized clinical trial. Am J Public Health. 2017;107(10):1660-1667. doi:10.2105/AJPH.2017.303985
33. Hiss RG, Armbruster BA, Gillard ML, McClure LA. Nurse care manager collaboration with community-based physicians providing diabetes care a randomized controlled trial. Diabetes Educ. 2007;33(3):493-502. doi:10.1177/0145721707301349
34. Elliott G, Smith AC, Bensink ME, et al. The feasibility of a community-based mobile telehealth screening service for Aboriginal and Torres Strait Islander children in Australia. Telemed J E Health. 2010;16(9):950-956. doi:10.1089/tmj.2010.0045
35. Vaughan EM, Naik AD, Lewis CM, Foreyt JP, Samson SL, Hyman DJ. Telemedicine training and support for community health workers: improving knowledge of diabetes. Telemed J E Health. 2020;26(2):244-250. doi:10.1089/tmj.2018.0313
36. Goldfield NI, Crittenden R, Fox D, McDonough J, Nichols L, Rosenthal EL. COVID-19 crisis creates opportunities for community-centered population health: community health workers at the center. J Ambul Care Manage. 2020;43(3):184-190. doi:10.1097/JAC.0000000000000337
37. Waters R. Community workers lend human connection to COVID-19 response. Health Aff (Millwood). 2020;39(7):1112-1117. doi:10.1377/hlthaff.2020.00836
38. COVID-19 frequently asked questions (FAQs) on Medicare fee-for-service (FFS) billing. CMS. 2020. Accessed August 17, 2020. https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf