MODERNIZING THE CARE DELIVERY PARADIGM WITH VALUE TOP-OF-MIND

By Dr. Oren Mechanic, MD, Chief Clinical Officer, eMed

The value proposition in healthcare is a combined function of patient outcomes, safety, quality, access, and equity as a total function of cost. US healthcare costs have been on the rise, with the latest estimates indicating that they are nearing $4.3 trillion (~20%) per year. With stagnant patient outcomes and ever-apparent inequitable care, along with persistently increasing costs, the value of the US healthcare system may have plateaued. It’s time to shift the focus and re-evaluate this value proposition by modernizing the efforts of the numerator. I hope we can reflect on and appreciate the value of telehealth for our healthcare system.

The year 2020 was a turning point for healthcare delivery as clinics shifted to virtual visits. Telehealth became a necessary tool in reducing the spread of COVID while treating and preventing multiple conditions through virtual care. The growth of telehealth services provided a unique opportunity to study the value of healthcare. Several distinct growth areas were identified; quality and safety, access and equity, patient navigator systems, to name a few

The dramatic expansion of healthcare into a virtual space posed a myriad of challenges and questions about the quality of care and patient safety. Such telehealth standards were a regular discussion by clinicians – we often contemplated care escalation, secure screen sharing (such as for genetic counselors and orthopedics), and evaluation of sensitive body regions via telehealth. A multi-disciplinary Virtual Care Task Force was created by CRICO (an academic medical center patient safety organization – AMC PSO – affiliated with Harvard physicians) to establish a Patient Safety Guide for the Virtual Visit for new delivery solutions with patient safety vulnerabilities in mind. We established an aim to make telehealth quality on-par with in-person. 

In addition to quality and safety, equitable healthcare is an essential component of value driven care. A system that only provides at-par care to the top 5% (when compared to European affluent nations) poses a lot of questions about how the other 95% is treated in the country. We need to ensure that as many people have the opportunity to receive timely healthcare, and telehealth affords us just that. The pandemic revved up telehealth use, and hopefully, significant comfort with technology. We studied an ambulatory care clinic and found that nearly 58% of all visits were telehealth visits at the onset of the pandemic. Importantly, although there were opportunities for improvement in equity, the implementation of telehealth didn’t follow prior patterns of disparities of in-person care. Previously marginalized populations were accessing healthcare more than prior (including older adults!). Access is a clear vehicle to improve equity and may be an equalizer. 

With an eye on improved access to telehealth, some clinics introduced patient navigators to their telehealth offerings. A patient navigator system is a healthcare support program that helps patients navigate a complex healthcare system. They include trained professionals who can provide guidance to access healthcare services. These patient-centered services may include scheduling appointments, assisting with insurance issues, and connecting patients with community resources – effectively reducing barriers to telehealth. I was part of a team that evaluated such a program, and we saw improved access and equity, all while no-shows and cancellations decreased. The healthcare value proposition was improved on the numerator and denominator.

Telehealth isn’t going anywhere, and it shouldn’t. The shift to protect and increase the value of healthcare needs to be top-of-mind; how do we leverage technology to bring more timely, accessible, quality-driven, and equitable care while mitigating health costs? We haven’t touched on remote patient monitoring, at-home test-to-treat programs, and hospital-at-home. These initiatives can improve patient outcomes or reduce healthcare costs, thus improving the value of healthcare. 

Some other questions remain. With Medicare reimbursement for some telehealth services fading, how do we maintain adequate technological infrastructure? How can we utilize at-home diagnostics and care to improve accessibility? Are there opportunities out there that seek to alleviate fragmented care and resurrect the ‘medical home’, such as bridging episodic virtual care with primary care?  These questions, and many more, shape the future of telehealth and, ultimately, the future of value in the modernized US healthcare paradigm. 

Referenced Above:

Mirror, Mirror 2021: Reflecting Poorly. Health Care in the U.S. Compared to Other High-Income Countries. The Commonwealth Fund. Fund Reports. August 4, 2021

Patient Safety Guidance for the Virtual Visit Report: Managing Risk in a new Care Setting. CRICO. 2021. Accessed at: 

https://www.rmf.harvard.edu/Risk-Prevention-and-Education/Guidelines-and-Algorithms-Catalog-Page/Guidelines-Algorithms/2021/Patient-Safety-Guidance-for-the-Virtual-Visit-AMC-PSO

Emanuel, Ezekiel J., et al. “Comparing health outcomes of privileged US citizens with those of average residents of other developed countries.” JAMA internal medicine 181.3 (2021): 339-344.

Mehrotra, Ateev, et al. “Rapidly converting to “virtual practices”: outpatient care in the era of Covid-19.” NEJM catalyst innovations in care delivery 1.2 (2020).

Mechanic, Oren J., et al. “Evaluation of Telehealth Visit Attendance After Implementation of a Patient Navigator Program.” JAMA Network Open 5.12 (2022): e2245615-e2245615.

About the Author
Dr. Oren Mechanic is the Chief Clinical Officer at eMed Digital Healthcare. In addition to this role, he is an Affiliate Associate Professor at the University of Miami Miller School of Medicine and an emergency medicine physician at Mount Sinai Medical Center in Miami Beach, Florida.