I believe there a large number of additional stakeholders (beyond consumers, providers and health plans) that have a key role. Employers can and should play a key role in promoting virtual care to their employees (and dependents on their plans) as it is critical for them to promote accessible care (to both increase more proactive preventive care and as a mechanism to reduce overutilization of more complex care downstream). I'd also say that "communities" have a role to play - schools promoting virtual health as a way to ensure that students get access to better care, non-profit groups/churches serving the underserved as a way to address health needs of those who are underserved, and local governments and other groups who are attempting to address health inequities.

A broad question that really starts with care delivery settings, be them physician or health system based. It requires embracing and integrating virtual care into care and revenue paradigms. That cannot be done without adequate payment for the care delivered virtually, so payers, both public and private, must support that care transition. Regulators at the local, state, and national level must make sure policies do not undermine progress and inhibit the innovation and evaluation of care and outcomes that need to evolve. HIT can be transformational but can also obstruct when we are challenged by lack of interoperability, proprietary exclusions, and cost. We need vehicles from which to evaluate data and experience and share through vetted outlets in the professional and lay media. And, of course, we need patients to embrace and access virtual care, hopefully within their medical home. That may require continuing efforts to improve broadband access, tech literacy, and access to personal device technology for all.

This must be a continuum, dynamic, creative,and patient centered. It has the potential to lead to higher quality care at lower cost and improve the health of the individual, community, and nation.

We all have witnessed rise and rise of digitally enabled care models and telehealth. There is no lack of studies and surveys pointing toward acceptability of such models but evidence around clinical, care model, modality appropriateness and effectiveness is sorely lacking. Stake holders such NIH and other funders need to fund research and RCT's to create the strong evidence base. Additionally we need to train next generation physicians and clinicians to lead the new frontier. Stacy here is the list of stakeholders that needs to be involved to force multiply adoption and build trust in digitally enabled care.
Providers
Clinicians
Payors
Employers
Research funding agencies
Educational institutions
Venture firms
start up firms
technology firms
Policy makers

My company, Eighteen Ventures, is working with two companies involving virtual care. Using virtual care as one way to increase healthcare services in underserved communities would have a significant impact on helping people receive the medical and healthcare attention they need. Research must focus on how healthcare institutions have to do a better, sustained, committed job reaching out and engaging these communities using this new service delivery model.

It is important to be methodical about Virtual Care implementations to capture which components truly add value. I see a similar trajectory to the EHR era - we first shared best practices for implementation. We now need best practices for optimization. Sharing these findings in the innovation sections of scholarly journals is important (like NEJM Catalyst, Telemedicine and e-Health, Telehealth and Medicine Today)
home.liebertpub.com/publicatio...
telehealthandmedicinetoday.com...
catalyst.nejm.org/

Great question, Stacy - I'm thinking that we should actually be thinking about question this way: what are all the different ways the industry could prove that telehealth CPTs should be reimbursed by insurers? We might want to come up with additional CPTs, elaborating modifiers, or coming up with other codes that would force insurers to reject the CPTs and have to answer for why they're not paying for certain services.

For example, we have 99421, 99422, 99423 which are tied to how much time is spent with a patient. But, what if industry could help refine CPTs that had even further detail and separation based on remote diagnostics, health at home, and all the other learnings from the past year?

My opinion is that if we do the benefits research from a reimbursement perspective we might be able to make progress faster.

We should focus on how many visits are conducted with previously established relationships vs how many are one offs...

Great question Stacy. Virtual care modalities, especially digitally-enabled care (hybrid in-person and virtual care) are relatively new. There is a lack of conclusive evidence regarding appropriate use, clinical efficacy, and effectiveness (clinical, operational, financial, equity etc.) of digitally enabled care.

Given the need and potential impact, a national virtual health research agenda should be considered focusing on digital transformation, improving care and outcomes across the health care continuum and disease states. Organizations, such as the NIH and its institutes, AHRQ, other funding agencies, and professional societies should consider funding research or undertaking effort to define the value of virtual care across a range of environmental contexts, use cases, operational, financial, and care models with a goal to generate and disseminate a robust evidence base for patient-centered, sustainable digitally-enabled models of care delivery.

Great question Meg. The pandemic public health emergency created circumstances, including consumer demand, that supported the rapid expansion of virtual health options. But post pandemic, several hurdles will need to be overcome to ensure that fully integrated care models survive and evolve:
- Payment models that fairly compensate providers for virtual care. Medicare, Medicaid and most payers have been reimbursing providers for virtual care during the pandemic. These payment practices must be made permenent.
- Geographic restrictions in provider licensing that were eased during the pandemic must be addressed to enable delivery of virtual care across state lines.
- Much work is needed to integrate virtual and in-person care in physician practice, outpatient and inpatient clinical care models. As with all innovation, achieving widespread adoption of new approaches to care will take time and effort.

That is a big question and there are many facets to consider. First is that doctors learn where and how to use virtual visits in their practice and specialty. We know our patients like it and appreciate its convenience and connection, but doctors aren't always used to the interface or its impact on routines and revenues. That is something they need to overcome and may find insights at the AMA and/or their specialty org.

We also know that the relief on regulatory and payment for care will change once the PHE is over. What that means and how it will support or inhibit care is yet to be seen and will likely vary by location and payer. We need advocacy and data to help us with payers and legislators/regulators. Our telemedicine platforms will also need to evolve so they comply with HIPAA and integrate with our EHR's. Hopefully we will also see intuitive evolutions that use voice recognition and AI to enhance the ease and utility of our patient encounters and condition specific remote technology. We need to evolve in our payment system as well, so the incorporation of virtual care enhances our quality, outcomes, and reduces cost. Prospective payment that recognizes and rewards high quality care needs to include the cost of technology and will allow physician practices to appropriately integrate TM into their care paradigms.

To state the obvious, interoperability remains a big challenge. Digitally enabled care helps us physicians connect with patients outside of the four walls of our clinic. Various digital solutions and devices are collecting potentially useful data that our patients may want to share with us, yet it remains a struggle to get that data back to physicians in a way that's easy to access and actionable. Relatedly, figuring out whether a digital solution is validated and reasonably evidence-based is tough for physicians. The market is awash with solutions and devices that purport to do all sorts of exciting-sounding things for physicians and patients, but it's tough to know what actually works. This is an important issue in AMA's blood pressure control work. That's why we support the U.S. Validated Device listing for BP measurement devices: validatebp.org/.

Since we have elaborated on some of the benefits, I'll address this questions by sharing an interesting challenge. Scheduling virtual and onsite appointments during the same clinic session (for some of our specialty ambulatory practices) is proving to be a significant hurdle. It's likely that the ideal hybrid virtual/onsite model for these practices looks like sessions (or fractions of a session) that are uniquely devoted to virtual or onsite care for a given provider. Otherwise, the transition back and forth between one modality and the other, and the downstream tasks that result from the visits and the different ways in which they're addressed (e.g. different team members, MA for in person and scheduler for virtual) can result in confusion and lower quality experience. Again though, this isn't a result of virtual care itself, as it's not a hurdle we're experiencing with the sessions are fully devoted to one modality, or to the other, by any given provider.
Another interesting point, which Meg mentioned below, that is particularly interesting is appropriateness. I sense we're just beginning to segment the populations and conditions that benefit the most from virtual care, and the times or contexts when they do.

This is one of the million dollar questions of the post-pandemic virtual care world. My sense is that the short honest answer is nobody knows for certain. We do however, know that reimbursement will not be rolled back to where it was pre-pandemic. Even at that time, the extent of reimbursement varied greatly among states, with a few states by and large guaranteeing telehealth reimbursement at the same level as in person care, with few restrictions. Post pandemic, some restrictions will be reinstated but a vast swath of the general population experienced telehealth during the pandemic and now expect it to be part of how they receive care. Health plans are having to consider these patient expectations, and the willingness of provider organizations and groups to meet them, in their decisions on the future of coverage and reimbursement.

I agree with Juan's assessment here. I think the biggest unanswered question is whether Congress will pass a federal law that removes the restrictions in Medicare around providing telehealth in a patients' home and outside of rural or health professional shortage areas. These restrictions are waived during the federal public health emergency but will be reinstated once that ends without Congressional action.

Let's start by acknowledging this is a work in progress, but virtual care can begin to address some of the disparities that do exist. This includes access to care both in terms of eliminating transportation issues but also time of day issues for those that work multiple or off hour jobs. Virtual care has the ability to provide more personalized care based on an individual's social circumstances and education, and can further provide prompts, reminders, and just in time education, and nudges. Moreover, virtual care can be asynchronous when needed and create pathways for improving patient activation and health literacy.

Telehealth should really be thought of as the great healthcare access equalizer. The invisible costs of healthcare are hard to quantify but typically impact patients with more challenging economic and social situations. These invisible costs tend to cause patients to deprioritize healthcare. Telehealth can eliminate many of these invisible costs (transportation, lost hourly wages, childcare, etc.). That is... if, the systems are designed in a way that afford opportunity to all patients in an equitable manner. How are healthcare systems assuring equitable design of their telehealth platforms? What should healthcare organizations role in improving digital literacy among their communities be? While adopting policy around the provision of broadband access to all citizens is crucial, it's a bit analogous to giving someone a car without teaching them how to drive. Healthcare orgs are uniquely positioned to start educating around digital literacy as this directly translates into health literacy, engagement in ones health, and access to care.

I totally agree about the importance of digital literacy. In addition, expanding access to high-speed wifi should be a priority, as well as making sure people have the devices they need to utilize telehealth. Virtual care has potential to be a great equalizer, but I think we need to provide some targeted help to underserved patients, communities, and medical practices before we can really say that it is.

Virtual healthcare has the potential to reduce disparities, but to make real progress on that front will require significant improvements in access to high speed internet service. In Baltimore, where I live, we have immense differences in both the availability and affordability of high speed data service based on where one resides. High speed internet service should be considered a public utility, and not dependent on the willingness of service providers to develop infrastructure in economically disadvantage neighborhoods.

I think it is critical to acknowledge that virtual care does not necessarily mean digital care. Remember that during COVID, for Seniors, a very large % of the visits that were defined as "telehealth visits" where done by telephone (voice driven). My challenge would be to the innovators - look for ways to reach people in the way they want to be reached and are able to be reached. That does not necessarily mean digitally, through an app, on a smart phone. Greater equity can be achieved by not dictating the channel in which care is delivered.

as long as those modalities are still reimbursed... There is legislation being voted on in most states that get at this once the PHE has been declared "over". Many states medicaid programs will stop reimbursing for telephone visits at that time and move back to systems that don't even reimburse for video visits at parity to face to face. State legislators need to start placing and understanding the value of quick touch bases and audio only visits with patients.

Great point Marcus. In addition to improving access and allowing telephone calls as a care modality, the focus should be on measuring and monitoring outcomes to ensure patients are getting the right care, at the right time, in the right setting. When done in the wrong setting, context, and use cases, phone calls can jeopardize patient's safety.

Virtual care, like any discussion of value has many facets and components beyond the "dollars and cents" aspects. While a financial determination is a component of determining value, other factors such as access, outcomes, satisfaction (patient, community and clinician) and quality of care are also important factors to consider. And while this is certainly not an exhaustive list of factors - it is important to understand that the measure of value is more than just dollars and cents.

In the end, value almost always come down to dollars and cents, to someone. But there are many aspects of virtual care value that go far beyond the cost or price of the care. For example, virtual mental health services for people living in smaller or rural communities without easy direct access to mental health professionals can mean the difference between receiving and not receiving care. Virtual consult services can provide hospitalized patients with access to specialty and subspecialty medical services that might not be readily available in person. Hospital-at-home services can provide acute level care to patients in the comfort of familiar surroundings while reducing the risk of nosocomial infection.

From a clinical perspective, we can measure value in terms of clinical outcomes and patient satisfaction. In chronic disease care for instance, we have shown statistically significant improvements in disease control, hospitalizations, cost of care and patient satisfaction when compared to standard of care. So value can incorporate all of these facets.

Please correct me if my understanding would be incorrect. For me the value of Virtual Care is to reduce inefficiencies in health care, improve access, reduce costs, increase quality of life and focused attention on the patient and make more personalized and precision medicine. We notice that the advances in recent technologies, such as: Big Data, AI, sequencing of the humans genome, wearable and implantable sensors for the continuous collection of patient data and their treatments. The new Health Centered Patient has brought the opportunity to use all these technological tools to obtain genome data information, through of analysis tools based on AI and may even get to print personalized drugs for targeted therapy, thus transforming health nowadays.