The Feds Are Supporting Telemedicine

This post was originally featured on EMRandHIPAA.

The Federation of State Medical Boards (FSMB) recently passed a model telehealth policy that promotes virtual visits for first-time encounter. This is notable for 2 reasons: first, many state medical boards liberally borrow from the federal boards, and second, this marks a shift from the old model in which patients were encouraged to see providers in person before engaging in telemedicine consults.

It’s encouraging to see the old, arbitrarily restrictive model fade, in favor of one where patients can begin building a relationship with their physician without travel. Indeed, people meet on the internet all the time; why can’t patients meet their care providers the same way?

The old model was arbitrarily limiting access to care, and thus driving up costs and driving down quality. Under the new model, patients should finally be able to login to a web service and be connected directly to a qualified physician that payers will cover. For telemedicine companies like American Well, Doctor on Demand, and others, this is a major coup.

This combination of technology and new guidelines will reduce ER visits, improve access, and ultimately reduce costs. Once it’s easy to get access to preventative medicine, patients will actually partake in preventative care. As a simple example to illustrate this, let’s examine my wellness check up habits.

I’m a healthy young male. I haven’t been to the doctor for a check up in close to a decade and have no intention of going. The process of booking an appointment, leaving my job that I love, and sitting in a waiting room are enough to deter me from ever going to the doctor. But if I could step into a private space and consult with a physician via a video consult for 15 minutes, I might actually get an annual check up. If the physician discovered something concerning and asked me to come, I would actually come in. But I would never come in for an in person visit without an explicit reason to. It’s not worth the pain and headache of going into the doctor’s office unless I have a reason to; the only way to achieve preventive medicine at scale is to make it easy for patients and providers alike.

Ambulances, ERs, and urgent care centers should expect a similar change in their operations. In these environments, specialists can now be reimbursed for first time consults with patients across a range of devices – iPhones, iPads, Androids, Macs, PCs, and even Google Glass. Neurologists can beam into ambulances for strokes, cardiologists for cardiac resuscitations, and trauma specialists for trauma cases. The opportunities are really endless, and my company, Pristine, is proud to lead the way in these new hyper-mobile telemedicine environments.

On the other hand, the new guidelines set forth by the FSMB aren’t all positive. Perhaps most perplexing, the FSMB did  not classify messaging and audio-only phone calls as telemedicine. They didn’t strictly forbid either activity, but they made it clear to payers and providers that live, synchronous video is necessary for reimbursement. In light of the shift to ACOs and value based models, this is perplexing. It’s been suggested that Kaiser Permanente and Group Health physicians reportedly spend up to 2 hours per day interacting with patients through asynchronous messaging.

Despite some setbacks in the new standards set forth by the FSMB, I’m incredibly excited about the future of telehealth across the continuum of care. The new model put forth by the FSMB is just the first of many steps toward a healthcare delivery system in which telemedicine powers the majority of care delivery across the country.

What Is The Cost Of Fraud Prevention In Healthcare?

This post was originally featured on EMRandHIPAA.

Among other things, credit card companies prevent enormous volumes of fraud. In exchange for their services, credit card companies typically charge about 2.5% of merchant revenue. The cost of fraud prevention for most merchants is no more than 2.5% of revenues.

But healthcare is rarely paid for by credit card. The vast majority of payments are directly transferred from payers to providers.

So what is the cost of fraud prevention in healthcare?

If providers were angels and never frauded payers, then the entire claims system would have no reason to exist. In this utopian world, providers would simply bill payers accurately and payers would gladly pay knowing that the claims were honest.

But that’s unrealistic. Payers are extremely skeptical of providers. There is an enormous amount of friction between payers and providers to ensure that providers aren’t overpaid: the technology vendors at every layer of the stack (provider, clearing house, payer), the billers, coders, claims departments, prior authorization departments, insurance agents, AR departments, etc. All of these people, processes, and technologies exist to ensure that providers aren’t overpaid.

Although I cannot find any explicit numbers, it’s not unreasonable that the sheer administrative costs of the claim system is greater than 10% of all healthcare costs.

In addition to compliance costs, actual Medicare Fraud is estimated at about $50B, which is about 9% of all Medicare payments.

The takeaway of the story is that providers can’t seem to stop frauding Medicare. The irony is that physicians – who are generally respected by the public – are those whom the system works most diligently to ensure aren’t overpaid.

Welcome To Telehealth Through Google Contacts

A few months ago, Google announced that they are developing contact lenses that can measure glucose levels present in one's tears. For diabetics accustomed to poking themselves multiple times per days, these contacts present an incredible opportunity to improve quality of life.

Now, Google has filed a patent for what I'll call "Google Contacts," which feature tiny cameras embedded in the contact lenses. 

At Pristine, the moment we saw Google Contacts, we began dreaming. Compared to a contact lens, Glass is a primitive tool. Because the screen is removed from one's direct line of site, Glass isn't a practical augmented reality device. Rather, Glass is just a passive device, described by Google as: "there when you need it, and out of sight when you don't."

Google Contacts will open an incredible wave of opportunities in augmented reality and human-computer interaction. With the ability to layer or remove any data from one's visual field, the lines between reality and virtual reality begin to blur.

Google Contacts will also create incredible new opportunities in telehealth. By embedding cameras in contact lenses, Google Contacts will overcome one of the greatest limitations of Glass: the fact that the camera can't mirror movements of the eye. 

Imagine an emergency room physician or nurse, sending the visual product of an exam to a neurologist or other specialists for an immediate consult. The specialist could "draw" on the screen on which s/he is viewing the video stream, and the person wearing the contacts could literally see what the consultant is drawing. The opportunities for telepresence and collaboration are incredible.

Or imagine an emergency responder who, by closely examining an injured or ill person, will automatically beam back detailed visual information to a physician back at the hospital. Or a military medic, beaming back details of an injured soldier from the battlefield to doc based in the rear.

Coupled with breakthroughs in augmented reality, the future for Google Contacts looks incredibly promising.

Why Is It So Difficult To Reduce The Cost Of Care?

This post was originally featured on EMRandHIPAA.

By refusing to pay for readmissions within 30 days of discharge from a hospital, Medicare has sent a strong message across the healthcare industry: < 30 day readmissions should be avoided at all costs. As a result, providers and vendors are doing everything in their power to avoid < 30 day readmissions.

This seems like a simple way to reduce costs, right? Well, not quite…

The vast majority of costs of care delivery are fixed: capital expenditures, facilities and diagnostics, 24/7 staffing, administrative overhead, etc. In other words, it’s extremely expensive just to “keep the lights on.” There are some variable costs in healthcare delivery – such as medications and unnecessary tests – but the marginal costs of diagnostics and treatments are small relative to the enormous fixed costs of delivering care.

Thus, Medicare’s < 30 day readmission policy doesn’t really address the fundamental cost problem in healthcare. If costs were linearly bound by resource utilization, than reducing readmissions (and thus utilization) should lead to meaningful cost reduction. But given the reality of enormous fixed costs, it’s extremely difficult to move down the cost curve. To visualize:

Medicare’s < 30 day readmission policy is a bandaid – not a cure – to the underlying cost problem. The policy, however, reduces Medicare’s outlays to providers. Rather than reduce (or expand, depending on your point of view) the size of the pie, Medicare has simply dictated that it will keep a larger share of the metaphorical pie for itself. Medicare is simply squeezing providers. One could argue that providers are bloated and that Medicare needs to squeeze providers to drive down costs. But this is intrinsically a superficial strategy, not a strategy that addresses the underlying cost problems in healthcare delivery.

So how can we actually address the fixed-cost problem of healthcare? Please leave a comment. Input is welcome.

Why Telehealth?

Telehealth, aka telemedicine, is one of the most important trends shaping the future of healthcare. It is one of the most effective and direct ways to achieve the triple aim of cost, quality, and access.

This blog post will attempt to explain the underlying problems in the healthcare delivery system that telehealth addresses. As a result of solving these problems, telehealth creates value along all dimensions of the triple aim.

Healthcare delivery is fragmented across medical discipline, location, and time. In a given location, it can be difficult to get the right specialist to a patient in need. Specialists are busy and have full schedules in their clinics everyday. Specialists don't want to leave their clinics and patients don't want to go to the specialists' clinics. The cost of travel - time, cost, and distance - is significant for all parties. Neither party wants to travel to see the other.

Within a given location, there is almost always significant supply and demand imbalances for healthcare services. Telemedicine addresses the supply and demand problem by making location irrelevant. In a world in which telehealth is the norm instead of the exception, a patient in need should be able to access a qualified specialist from a much larger pool than in the analog era of healthcare delivery. Solving the access problem by increasing supply in every location also addresses cost and quality problems. Telemedicine addresses cost problems by forcing providers to compete to provide the best care at the lowest price. Telemedicine addresses quality problems by reducing the time to care, which can meaningfully impact outcomes.

At Pristine, we're proud to pioneer a new avenue of telehealth. Our telehealth solutions are by far the lightest-weight and easiest to use in both physical and virtual terms. Are clients don't need any physical infrastructure or local servers at their local sites. In fact, our clients don't even need to install software on their Macs and PCs. Everything runs natively in the web browser in beautiful HD.

Our clients - UC Irvine, Brown, and soon to be several more - are using our solutions every day to address the supply-demand challenge of healthcare delivery, and as a result, are working towards the triple aim.

Onwards and upwards!