While everyone is doing telehealth, most are not happy with the experience for three key reasons:
- Not profitable
- No clinical impact
- No way to measure ROI and get actionable data
This is the first in a series of three articles discussing each of these telehealth frustrations.
Today we’ll talk about the number one frustration for providers: telehealth is not profitable. This is because they are losing revenue, losing clinical time, and increasing non-clinical tasks in order to do telehealth visits.
Payment Parity Concerns
The good news is that according to CMS live interactive audio or video visits (including E/M visits) are considered the same as in-person visits and are paid at the same rate for the duration of the COVID public health emergency. While most private payers have been following suit, there are always some exceptions and Medicaid (which isn’t worth the hassle for many doctors to bill) varies from state to state.
Probably the biggest concern regarding telehealth reimbursement is whether CMS and private payers will continue to pay for audio-only telehealth visits at the same rate after the public health emergency. California’s governor Gavin Newsome has been decried for proposing a 65% reimbursement rate for audio-only telehealth. Many advocates cite disparity concerns for vulnerable, tech-challenged populations. (A JAMA study of 41 California safety-net institutions found 48.5% of visits were conducted over audio-only compared to 48.1% in-person and 3.4% video.) Non-supporters are concerned about unnecessary overuse and quality of care.
Procedures That Can’t Be Done Via Telehealth
While there are ways to facilitate physical exams over telehealth, some physicians are losing payment on procedures that aren’t easily done over telehealth. In a MedPage Today article, endocrinologist Arthur Guerrero, MD notes that when patients don’t come in they can’t charge for retinal scans which his practice would typically perform for diabetics. On the other hand, some physicians like ENT specialist Marc Dean, MD were able to take advantage of their telehealth platforms to completely convert to a virtual practice, including physical exams. By having patients purchase an affordable device before the appointment and using a platform that could stream medical devices during a video visit, he was able to continue performing the necessary physical exams remotely.
Lost Clinical Time
Another way providers are losing revenue is the increased time spent on non-clinical activities in order to make telehealth work. This is because they may lack the virtual tools and skills to efficiently coordinate many of their pre- and post-visit processes. Video conference technology like Zoom, MS Team, and Google Meet do not have an efficient way to do front desk transfers between staff. This means administrative tasks like waiting for no-shows and IT support may end up falling on the doctor’s shoulders. For example, if a patient is late or no show for a video appointment, how long should a doctor wait before moving to the next patient?
Another physician mentioned in the MedPage Today article, Todd J. Maltese, DO who runs a neurology and sleep practice said that it typically takes his patients an average of 10 minutes to get set up for a telehealth visit. In addition, he has had to personally spend half-an-hour on multiple occasions to help clients with tech issues before he could actually start the appointment. Doctors doing AV support is not reimbursable time (this is also clearly stated in the 2021 E/M rules). Those could have been a 20-29 minute E/M visit that reimburses at $84 to $119 (non-facility).
In our own experience, we’ve had providers using Zoom and MS Team tell us that it can take them an extra 5 to 10 minutes to get a video call going because the patient loses or never received their video link, so they have to get on the phone to call the patient and then manually re-send the link again to enter; or the patient has audio or video issues and the doctor becomes the AV support staff.
We can get a feel for the value of this time using some calculations based on this AAFP blog. Let’s say a physician makes $2.17/minute (based on a 250K salary working 48 weeks a year, 5 days a week, 40 hours a day). She sees 18 patients a day where 30% (6 visits) are telehealth. That’s 6 visits a day that are losing 5 to 10 minutes on tech troubleshooting and inefficient prep. That totals to losing 30-60 min each day on telehealth troubleshooting which multiplied by $2.17/minute is a loss of $15,624-$31,248 a year ($23,436 average) . If a physician is spending 20 minutes per patient that’s 1 to 3 additional patients that could be seen each day!
Needs More Staffing Resources
While telehealth has been successfully launched for most practices, one of the concerns is its sustainability as in-person visits become available. Overhead costs (facility, supplies, staffing, technology, insurance) are typically 60% of practice revenue with facilities, supplies and staffing taking up the largest chunk. Adam Licurse, MD, Director of Telehealth at Brigham and Women’s pointed out in a recent webinar that they are now essentially having to run two practices with different processes and protocols, but with the same staffing resources. For many practices they can’t afford to hire more staff to manage their telehealth practice. One way to make it work is to leverage the right technology to automate and streamline front desk and compliance overheads like telemedicine consent, eligibility checking, self-scheduling, copay collection, state and specialty matching, IT troubleshooting and patient transfer.
According to practice owner K. Michael Rodriguez, MD, an important part of this is using a telehealth platform that enables them to easily mimic their already efficient office workflows. This reduces the burden of training their front desk and physicians, and it allows them to effectively incorporate telehealth into their existing routine.
Arrowhead Regional Medical Center (ARMC), for one, was able to use the VSee platform to replicate their existing hospital workflows and maximize their MA time. VSee allowed them to set up multiple specialty waiting rooms that funnel patients into a single queue. A single MA can monitor and prep patients for multiple departments and specialty physicians. On the physicians side, they will only see relevant patients that have been automatically matched to their specialty in the queue. They can easily “pick up” the patients that are tagged “Ready” from the queue, so they don’t spend time troubleshooting technical issues. At the end of the visit, the patient may be transferred back to the front desk for further education and to schedule any necessary follow-up visits.
Providers using general video conference tools are also more likely to leak copays with telehealth visits because they don’t automatically capture credit card information and collect copays at the time of the telehealth visit. This leads to patients getting paper invoices for copays weeks and months later when they’ve already forgotten about the visit and are too busy to pay the bill. Missed copays can mean only getting paid 80-90% of visit fees. If 30% of your visits are telehealth and a third of those copays (10%) go missing that would be a $2500K to $5000K loss in copays ($3750 average, assuming every visit has a copay of 10-20% at $250K salary x a third of all telehealth visits at 10%)
Less Efficient Use of Time
Doctors are unable to leverage the power of telehealth to be more efficient with their time. Video conference solutions aren’t designed with the flexibility to see patients out of order depending on the urgency of their case. There is no way to jump to another patient if a visit ends early or runs late. Once a patient is scheduled for their 15-minute slot, there is little flexibility for managing the time around that visit. However, the right telehealth tool offers patient tagging, queue prioritization, and automated routing and walk-in dispatching, so doctors can see more patients than in-person.
No Remote Patient Monitoring Tools
Finally, there are a lot of potential remote monitoring services that can be additional revenue for practices – continuous glucose monitoring, time spent on device instruction and setup, time spent reviewing RPM data, time spent discussing results with patients. The problem is videoconference solutions do not have capability to capture, manage, and bill for remote patient monitoring services. The right telehealth platform allows you to capture these opportunities without the overhead of learning, and maintaining a separate video visit technology.
In the next article of this series, we will further discuss Remote Patient Monitoring’s potential and whether telehealth is making a clinical impact.