While the COVID-19 public health emergency accelerated connected health via telemedicine, remote patient monitoring (RPM), virtual care, and other digital health technologies, we're now in the phase of facing the longstanding barriers to connected care that existed before the pandemic.
The first article in this series focused on defining connected care and how it can help achieve the Quadruple (even Quintuple) Aim. Now, let's look at the barriers to digital connected care and what's being done to solidify its position and accelerate further adoption.
Providers and patients want more digital connected healthcare
Various research projects and surveys have revealed that many clinicians and their patients appreciate the value of connected care. Both parties want to see it scale:
- 79% of patients were very satisfied with the care received during their last telehealth visit (AMA).
- 41% of patients would have chosen telehealth over an in-person appointment for their last visit, even if both required a copay (AMA).
- 87% of primary care providers believe connected care can improve diagnoses (PCP Survey 2021).
- 82% of providers believe connected care can detect healthcare issues earlier (PCP Survey 2021).
- 80% of consumers felt that connected care enables more direct patient-doctor communication (PCP Survey 2021).
Despite positive opinions around the benefits delivered by connected care, several challenges may slow the full assimilation into everyday healthcare. These challenges may disproportionally affect historically underserved populations, rural communities, senior adults, and those with documented health inequities.
“Technologies that are integral parts of digital connected care can flourish with the right policies, regulations, laws, collaborative agreements and workflows." (HIMSS22)
Digital connected care adoption by providers and patients
Adoption of digital connected healthcare is the top-line impediment that all others impact. Patients and providers want connected healthcare, yet adoption is moving slower than market excitement and venture funding activity.
- 73% of healthcare consumers say anytime, anywhere access is essential to improve moving ahead. 56% of primary care providers agree.
- 51% of patients surveyed were interested in using digital technology to track health information and share the data with their doctors.
- 30 million U.S. patients, or 11.2% of the population, are estimated to use RPM tools by 2024. This represents 28.2% growth, up from 23.4 million patients in 2020.
A post-pandemic approach to connected care is shaping up as health systems, value-based care, and health plan contracts determine their hybrid health strategies and solutions to combine virtual care with in-person delivery options. However, accelerating adoption requires wide-scale solutions to three pressing barriers.
What are the most pressing barriers to accelerating the adoption of digital connected care?
Barrier one: Broadband access
A 2020 article in the Journal of Medicine, Law, and Ethics called broadband access a public health issue and the “super-determinant" of health. “Unfortunately, the rural and underserved populations who stand to benefit the most from telehealth approaches are also the least likely to have access to broadband or high-speed Internet — a necessary prerequisite to these promising approaches." Approximately 24 million people in the U.S. live in digital deserts without broadband access. This includes 19 million people in rural communities and 1.4 million living on Tribal lands.
Many digital health and connected care initiatives have access to technology, staff, and processes but cannot achieve their goals without high-speed Internet access. One example cited was an expectant mother in the upper delta of Arkansas who was diagnosed with preeclampsia and given a blood pressure cuff, a weight scale, and connected devices to remotely send blood pressure and weight data to her medical team. Because this woman did not have broadband access, she regularly had to drive a mile to access a wireless signal to send the data.
What's being done?
In 2019, the Federal Communications Commission (FCC) approved $100M for a three-year connected care pilot to benefit low-income patients and veterans with telehealth and RPM services. As of March 2022, 107 applications had been approved across 40-plus states, allocating over $98M.
At the end of 2021, the FCC's Emergency Broadband Benefit Program will transition into the Affordable Connectivity Program. It's a $14B long-term benefit for consumers to receive a monthly amount to offset the cost of Internet service.
The Connect American Fund, also under the FCC and known formally as the Universal Service Program for High-Cost Areas, is a federal universal service high-cost program designed to ensure that consumers in rural, insular, and high-cost areas have access to modern communications networks. These networks need to be capable of providing voice and broadband service, both fixed and mobile, at rates that are reasonably comparable to those in urban areas. The program fulfills this universal service goal by allowing eligible carriers who serve these areas to recover some of their costs from the federal Universal Service Fund.
Other FCC programs include the Global Health Worker initiative, the Rural Health Care Program, which provides funding to eligible health care providers for telecommunications and broadband services necessary for the provision of health care. There's also the COVID-19 Telehealth Program, which has provided two rounds of $200M in funding as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, to help health care providers provide connected care services to patients at their homes or mobile locations in response to the COVID-19 pandemic.
Barrier two: Reimbursement
CMS reimbursement decisions have a ripple effect across commercial and self-funded employer health plans. During the beginning of the public health emergency (PHE), reimbursements for telehealth emerged and continue to evolve. The federal government, state Medicaid programs, and private health plans expanded their coverage for virtual healthcare services in response to the need for care at a distance. However, it's unclear how long reimbursement will continue and for what types of care once the PHE ends.
Beyond telemedicine, there is a misalignment between reimbursement and coverage policies, prevention goals, and the inclusion of other connected health technologies like digital health and RPM. Critics say that payers should go beyond the clinic or hospital settings to cover digitally-enabled prevention and that Medicare should broaden reimbursement when digital therapeutics are evidence-based.
What's being done to help reimburse for connected care services?
In 2021, CMS proposed expanding telehealth reimbursement for mental health to include certain behavioral health services delivered to patients via audio-only telehealth calls or as part of opioid treatment. For the 2023 Medicare Physician Fee Schedule (PFS) rule, CMS proposes significant changes. These include three new permanent telehealth codes for prolonged Evaluation and Management (E/M) services, discontinuing reimbursement of audio-only E/M services, and discontinuing coverage for virtual direct supervision. Additionally, if passed by congress, the rule would postpone the effective date of the telemental health six-month rule until 151 days after the PHE ends and extend coverage of the temporary telehealth codes until 151 days after the PHE ends.
The proposal also requests coverage change on 54 service codes, moving them to CMS' Category 3 telehealth list. These services could provide clinical benefits but lack sufficient evidence to justify permanent coverage as a telehealth benefit.
As of August 2022, the Federation of State Medical Boards (FSMB), 10 U.S. states still have waivers, 38 states (plus Washington, DC) have an expired or no waiver, and 20 states/territories have long-term or permanent interstate telemedicine waivers. These waivers allow licensure exceptions to out-of-state physicians, preexisting provider-patient relationships, and when audio-only use meets specific requirements. An example of one such waiver update from California states, “[1/7/22 Update] re: interstate telemedicine - Physicians using telehealth technologies to provide care to patients located in California must be licensed in California."
Current law says that Medicare may cover a broad scope of services via telehealth without restrictions, but this coverage is mostly temporary. Some estimate that the PHE may end summer of 2023, which could extend coverage until the end of 2023 unless additional services are deemed necessary or evidence-based to deliver value as a permanent benefit.
Barrier three: Real-world evidence of connected care benefits
In healthcare, federal policy and reimbursement are critical drivers of adoption, along with evidence of efficacy and positive impact. Real-world evidence (RWE) demonstrating the value of digital connected care is vital to integrating with standards of care, clinical pathways, or program workflows. However, many published authors point to a lack of evidence around the most important issues to patients and providers.
Connected care pilots and initiatives face adoption roadblocks when plans, implementation, and reporting efforts fall short of achieving stakeholder goals. Why would patients or clinicians use a tool or technology? How can it benefit their prioritized outcomes like health, efficiency, and quality? What do patients and providers need to experience to adopt, adapt, and engage deeply? A HIMSS21 session blog shared a poignant view, “As long as pilots, studies, and professional standards of care seldom provide the information or analysis needed to navigate the use of connected care for patients or providers, we should expect slow adoption."
In essence, a digital health tool or connected care therapy must fulfill four requirements:
- Fill an unmet need with patients
- Integrate seamlessly among provider systems and workflows
- Demonstrate equal or better outcomes than traditional therapies
- Offer a calculable return on investment to payers.
What's being done?
Most research relates to telehealth shared by organizations like the Alliance for Connected Care and the American Telemedicine Association. The Agency for Healthcare Research and Quality (AHRQ) digital healthcare research program has some of the most robust collections of research. Their database includes over 700 AHRQ-funded projects related to digital and connected healthcare.
In relation to digital connected care adoption, AHRQ has taken a position that stakeholders who can benefit from these tools and technologies need more of “an understanding of how these resources can be best delivered and used to enhance clinical workflow, information flow, and outcomes." They advocate and represent a collaborative approach to clinical evidence development, particularly as it relates to how digital connected care not only impacts outcomes like health and quality of life but also ease of use and integration with a person's or clinician's workflow. They call out that research must better document which intervention modalities or digital tools most effectively deliver the service or step as part of a standard of care.
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