By Mary Witkowski, Susanna Gallani, and David N. Bernstein
As the economy reopens, a debate has emerged about whether to continue supporting telehealth and digital practices, or whether to return to pre-pandemic practices, practically relegating telehealth solutions and digital interactions to lower-value exceptions to traditional medical care.
The next set of regulatory and payment policies will likely set the trajectory for how digital health is integrated into the overall care model. We suggest that rather than making these policy decisions based on incremental thinking relative to historical pricing of in-person care, they ought to be based on an assessment of how they generate value for patients.
For the purpose of our exposition, we define digital health care as including videocall-enabled outpatient clinic appointments, home health care (including “hospital at home” solutions), remote monitoring, and digitally enabled multi-disciplinary multi-site teams. Among many benefits, digital health care allows for remote primary care and specialty follow-up visits, enhances aspects of preventative medicine via targeted digital messaging, and increases monitoring functions via digital devices for chronic care patients.
Out of necessity, during the pandemic, these care delivery innovations were brought to scale. The U.S. government and several commercial payers supported this transition by reimbursing telehealth at similar rates to equivalent in-person visits, effectively treating them as substitutes. The implications of this telehealth boom for patient outcomes, cost of care, and health equity are only now being fully analyzed and appreciated.
By removing the physical co-location requirement for a patient-physician interaction, digital health care reduces the impact of transportation barriers and time constraints for patients, thereby increasing the convenience of some health care services. Further supported by digital devices recording routine health data for patients at home, digital health care enables timely interventions that often contribute to enhanced chronic care management. For patients who may feel intimidated by the sterile clinic environment, connecting to a physician while in a familiar setting can foster a greater level of comfort to discuss sensitive topics or ask questions. Physicians may gain valuable inputs to the design of a care plan from a better understanding of the patient’s home environment and social support.
Digitally enabled stand-alone interactions, however, also inhibit the establishment of a close connection, warm hand-offs to another care provider (e.g., social work) or same-visit follow up diagnostics (e.g., labs, simple imaging), and the ability to physically examine the patient.
Additionally, digital health can affect health care delivery at the regional level. Recently established centers of excellence (COEs), which can leverage economies of scale arising from high patient volumes, robust multi-disciplinary teams, and integrated care models centered on medical conditions or patient populations, have contributed to greater value for patients. However, COEs are often geographically located in dense urban centers. Digital health care could enable more dynamic and consistent teaming between local clinical sites and COEs. Patients would benefit from tighter coordination between clinical specialty hubs and local providers, which would allow patients to limit their direct interactions with the COE to certain steps in their care plan (e.g., initial diagnosis, treatment planning, major surgeries) while receiving ongoing treatment (e.g., recovery, rehabilitation, routine management and surveillance) at locations closer to home.
At this time, the overall impact of digital health care on patient outcomes is still largely unmeasured. It is necessary to perform a systematic analysis of when and how virtual care improves outcomes for different conditions and patient populations, and how a combination of in-person and virtual care can be most effectively combined during the overall longitudinal course of care.
In addition, a pervasive use of technology impacts the cost structure of delivering care. Digital health is largely assumed to be a source of cost savings by reducing the need for clinical space and ancillary staff (e.g., check-in personnel) or investments in new clinical space. Existing facilities may be made available for alternate utilization.
However, shifting the clinician’s workflow toward digital settings can also give rise to higher costs, either directly or indirectly. Often, in telehealth visits, physicians perform more of the process at a much higher cost per minute compared to ancillary staff (in the U.S., it is not unusual to observe a 6:1 rate between the cost per minute of physicians and ancillary staff).
Additionally, digital health may exacerbate known drivers of burnout, such as lower personal engagement with patients or time spent interacting with digital systems and electronic health record systems, compounded by new IT-related issues and glitches, which can cause inefficiencies and frustration.
The overall impact of digital health care on access and health equity is also relatively unknown at this point. Overcoming logistical barriers by increasing the mobility of health care improves penetration in rural areas and facilitates access for patients who suffer limited transportation options, cannot easily be absent from work, or have difficulties in securing care for their loved ones (e.g., young children, vulnerable family members, etc.). However, the populations that may benefit the most from these advantages are often precisely those for which access to reliable connectivity, appropriate devices, and digital literacy are low. Therefore, without significant investments in digital infrastructure and digital education, digital health might exacerbate disparities in access and reduce health equity.
The role of telehealth and digital health in the post-pandemic “new normal” is yet to be determined. Policy and regulation will play a significant role in determining whether these modalities are here to stay.
A return to pre-pandemic approaches and regulations on digital interactions could severely limit the options for innovation. However, too quick a move to swing the pendulum toward digital health could lead to suboptimal or worsening situations.
Regulators and payers need to inform their decisions with systematic assessments of actual or potential contributions of digital health to reducing costs, improving outcomes, and expanding access and equity. These evaluations will help define incentives for digital health not just in terms of how it compares to in-person care, but how it contributes to the overall value of integrated in-person and virtual care.
Mary Witkowski, MD, MBA is a fellow at the Harvard Business School working at the Institute for Strategy and Competitiveness on value-based care.
Susanna Gallani, PhD, MBA is an assistant professor of business administration at Harvard Business School whose research focuses on incentive and performance management systems.
David N. Bernstein, MD, MBA, MEI is a clinical fellow in orthopaedic surgery at Harvard Medical School and an orthopaedic surgery resident physician at Massachusetts General Hospital.