AMGA CAO/COO Council: Telehealth

AMGA COVID-19 Resources

Presentation Summary
June 9, 2020

This summary on the use of telehealth in response to the COVID-19 pandemic is based on a presentation via AMGA’s Chief Administrative Officer/Chief Operating Officer Council listserv on June 9, 2020. For more information about the CAO/COO Council, please click here.
Thalia Baker, FACMPE, Associate Vice President, University of Alabama Medicine (UAM)

  • UAM is a large campus (mostly downtown Birmingham, AL).
  • UAM had the American Well Platform to provide specialty care to remote, rural areas. When COVID hit, they shifted primary care over to this virtual platform. It took four days to get everyone trained and functioning on the platform, but once done, they quickly recovered and are currently at about 88% of pre-COVID volume (not revenue).
  • UAM monitors volume across the entire primary care network (80 providers) and has an automated dashboard that updates the mix of patients and types of visits across the entire system (about 2,000 providers) on a daily basis. Sites vary significantly in how many patients are being seen by video and telehealth.   
  • The same modeling used to monitor volume is also being used to make revenue projections. After pulling capitated plans out of the mix, fee-for-service revenue is averaging about $127.84 per visit. This is a 23% reduction in revenue per visit compared to pre-COVID levels.
  • UAM is using the model to project revenue based on different mixes and types of visits. They want to move closer to the 50/50 mark for in-person and virtual visits. They also plan to use the model to estimate shortfalls in specialty use of virtual medicine.
Angie Kuhn, Chief Operating Officer, SIMEDHealth, LLC
  • SIMED is 30 years old and includes 115 providers (physicians and/or ACPs) in a multispecialty “super group” (smaller groups under one umbrella maintaining independence and governance structure).
  • SIMED’s service area covers north-central Florida; the main hub is in Gainesville.
  • SIMED’s electronic health record (EHR) is Intergy, a Greenway product. They use a third-party vendor, Phreesia, to assist with patient check-in (process and complete forms) prior to patient visits.
  • SIMED had no telehealth before the pandemic. They quickly purchased equipment, laptops, tablets, etc. to support EHR software and telehealth video.
  • The first video conferencing platform they used was Free Conference Call. It had challenges. Employees called patients offering a virtual visit and patients who agreed received a call a day before their visit to talk through downloading the app, logging in, and connecting to the physician. (SIMED set up a 10-person call team to help patients navigate this process.) When it was time for the visit, a medical assistant (MA) called the patient to set things up and place the patient in the waiting room. The process was cumbersome and not very effective in the long term.
  • Some physicians started using doximity, which worked for them. But the software with the best operational workflow was, which streamlined processes and enabled SIMED to eliminate their 10-person call center. Now all physicians are using the business health care portion of Phreesia has been integrated and will send reminders to patients 15 minutes before visits.
  • SIMED went from no telehealth to weekly utilization of 43% in primary care, 45% in medical specialties, 20% in surgical specialties, and 35% organizationally. They are considering how to reallocate space to create permanent telehealth service, since physicians are using exam rooms for telehealth now.
  • Virtual medicine challenges include:
    • Trying to help 100+ providers transition to electronic care
    • Training all providers and staff on how to use the software
    • Getting providers to use the same platform
    • Assisting patients and helping them change how they receive care (some have embraced telehealth, but others are not as excited about it)
    • Retraining front staff to collect copays, including creating small, fun competitions to achieve improvements
    • Coding changes surrounding telehealth—including place of service, payers not sure how to code, and changed codes mid-stream—meant reeducating everyone
    • Expanding Internet infrastructure capacity to ensure more bandwidth.
  • Benefits of virtual medicine include:
    • Carriers and payers have been paying for virtual medicine, and payments have not been delayed (big question is: will they continue to pay, and at what level?)
    • More providers are staying on time with appointments
    • Providers are learning other ways to provide care that may help them in the long run
    • Parking shortages at the main campus were eliminated
    • Fewer no-shows since patients are in communication throughout the process
    • Increased access for more patients.
  • Overall, SIMED has experienced a decrease of about 35% in average charges since COVID-19 and conversion to telehealth.
Jim Demopoulos, M.H.A., Senior Vice President and Chief Operating Officer, Lehigh Valley Physician Group (LVPG)
  • The network includes 1,700 providers in roughly 300 practices with 2.5 million annual visits and a patient population of about 550,000. LVPG is in Lehigh Valley, PA, about 90 minutes west of New York City.
  • LVPG is taking learnings from virtual care and “reimagining and reinventing” the workforce to better utilize the virtual space in practice. Since virtual care doesn’t currently generate RVUs, LVPG needed a new workforce model as work shifted to virtual care.
  • A lot depends on reimbursement. Some payers may keep video visits on par with face-to-face visits, some may reduce reimbursements dramatically, while others may not cover virtual care at all.
  • LVPG is leveraging technology and regionalization to expand beyond pre-COVID volumes, make up for economic losses from COVID, and eliminate future shortfalls. The model takes into account ratios for virtual visits, face-to-face encounters, telephone visits, and e-visits and is being beta-tested within family medicine.
  • A major focus of the redesign is more efficient use of technology by patients. Roles have changed for some staff who perform outreach to patients before video visits to make sure they can connect and make sure they are active in the patient portal.
  • LVPG has virtual check-in and check-out processes, patients can self-schedule their health maintenance, and LVPG is able to capture e-vitals. Patients can tell LVPG when they have taken medications via the patient portal. LVPG can even help with medication costs through a function within their Epic EHR that captures this and other social determinants of health.
  • LVPG is taking advantage of economies of scale by regionalizing telehealth functions and adding tools such as “auto-arrive” to help patients guide their online navigation. Currently only 15 % of patients are utilizing virtual scheduling services; LVPG wants to expand this to a majority of patients.
  • In LVPG’s survey of patients on their telehealth experience, 55% said they would be more likely to have a face-to-face encounter if they were able to “e-check-in.” LVPG’s e-check-in captures demographics and insurance information, allows patients to update their medications and allergies, and lets them give the reason for their visit. They can also complete a clinical questionnaire as well e-sign documents in advance (e.g., consent to treat). A study in Epic of patients using e-check-in shows an average time savings of 10-15 minutes per visit compared to those who don’t. If you multiply this by 2+ million ambulatory visits annually, the time and effort savings for the workforce are considerable.
  • LVPG is encouraging patients, regardless of the type of visit, to complete patient-entered questionnaires. Clinical leaders from all specialties worked together to design clinically based scheduling questionnaires (built into the Epic EHR) based on the reason for the referral/visit. The questionnaires enable patients to directly schedule an appointment with the right type of provider in the right practice by answering a handful of clinical questions. The questionnaires have been implemented in many specialties, but LVPG is encouring their use more widely to enable staff to focus on the visit and save time and effort for the clinical team.
  • LVPG is expanding the scope and utilization of direct scheduling, making it possible for patients (and colleagues across the network’s care continuum) to schedule any type of visit at any practice. LVPG has these capabilities built in, but hasn’t sufficiently scaled them across the network/group practice.
  • LVPG is not necessarily trying to reduce FTEs, but seeks to repurpose staff so they can leverage the virtual space, connect with patients more often, and deliver on the promise of same-day access and population health. The time saved in scheduling and intake can be shifted to tasks that expand virtual care and dive more deeply into patient panels for proactive treatment of patients to move care into the realm of population health—that is the silver lining of this pandemic.

Questions and Answers

What has the impact [of COVID-19] been on ancillary revenue?
  • UAM’s ancillary revenue was devastated. Specialists are back and ancillaries are starting to pick up. UAM set up curbside service (e.g., big injection clinics) in tents, outside major locations. This service worked so well that patients are concerned it will be dismantled. UAM is considering whether to keep it as a permanent service.
  • SIMED’s ancillary volume also went down significantly to about 20% of pre-COVID levels. SIMED provided curbside services, and they are looking to reconfigure space so they can keep this service long term.
  • LVPG’s face-to-face ancillaries plummeted: volume fell to about 20% in April from historical levels. LVPG’s practice accounts for about 90% of health network’s clinical activity, and levels are only now starting to rebound.
What do you have in place to help patients minimize the chances of a technical problem?
  • UAM contacts patients with appointments and offers to “convert” them to a video visit (1st choice) and phone visit (last choice—due to very low reimbursement). A team calls the patient, helps them download the AW touchpoint app, and tests it with them to make sure patients can use it before the visit.
  • SIMED had a call team that helped every patient. Although they still have a help line, the transition to has significantly reduced the need for patient assistance.
  • LVPG repurposed staff to serve as “access coordinators,” who reached out to patients prior to video visits and made sure patients have the latest patient portal app downloaded and to help them connect. If a virtual visit doesn’t work, it is converted to a phone visit.
Are you investigating in-home patient monitoring or testing devices?
  • UAM is looking to expand home monitoring. They are already doing it for a large subset of patients in rural areas (e.g., discharges coming out on blood thinners [Warfarin] receive home monitoring).
  • LVPG started remote patient monitoring for CHF patients before the pandemic using a tool called Care Companion. Patients receive Bluetooth-enabled blood pressure cuffs and scales, and fill out a brief set of clinical questions every day.  LVPG also is planning to push education out to patients about their conditions. They plan to scale up use of this technology considerably.
With the advent of tele-video, how does your group envision work needed from clinical support staff like MAs in the future?
  • For UAM, the big issue is whether providers can blend their sessions and do face-to-face and virtual visits together or whether they keep them separated. If they are separate, there could be huge staff and space savings. But physicians don’t like that option. UAM may be forced, for financial reasons, to ask physicians to separate virtual and video care.
  • SIMED has been piloting telehealth shifts at a small primary care division for about two weeks. One shift runs from 8 a.m. to 10 a.m. and another from 10 a.m. to 12 p.m. If workflow goes as expected, they may be able to reduce staff.
  • LVPG extended video visits for providers interacting with the patient, which includes medical assistants and nurses, within the workflow (typical work and other additional responsibilities). In after-hour, virtual blocks, only the provider interacts with the patient.
Are you finding tele-visits take longer than in-person visits, about the same or less?
  • UAM visits are running about 20 minutes in length.
  • SIMED providers who normally run behind are finishing on time, but SIMED is are not sure if this is due to patients or providers.
  • LVPG visits take less time, but a majority of patients feel the interaction with the provider is more focused during video or phone encounters. LVPG doesn’t yet know whether this is just perception or a reality.
What are you seeing with payers in terms of virtual reimbursement?
  • For the UAM market, Blue Cross is planning to stop reimbursements for telehealth at the end of June, claiming it will create overutilization. UAM is pushing hard to continue the reimbursement.
  • SIMED is monitoring the situation, payers all have different end dates. Right now, they are paying, although a couple have changed reimbursement midstream. The question is: how long they will continue to get reimbursed at the same levels for telehealth?
Are you seeing payment at the same rate as in-person visits?
  • UAM is seeing different rates from commercial payers, especially for phone visits, which is why they are discouraging phone visits unless there is no other option. Medicare products in the UAM market have done well, as have capitated plans.
  • For LVPG, most payers reimburse the same amount for video visits as for face-to-face encounters, but those rates are set to expire. LVPG is in talks with payers, urging them to recognize and continue to reimburse this important space in health care. They expect the majority of payers to continue reimbursements for virtual care, but again, don’t know at what rate.
Can you describe the training your providers received and what you think might be needed going forward to optimize virtual visits?
  • UAM conducted a quick face-to-face team training for everyone in 50-minute increments. Each physician would train together with their CMA on how to do the visits as a team.
  • The SIMED team conducted one-on-one trainings. Training is ongoing for physicians who struggle with the virtual format. For them, they are providing continued face-to-face training, as well as tips to help.
  • LVPG developed a virtual learning platform, which they sent to providers along with tip sheets, and a centralized area for questions/troubleshooting.
Can SIMED talk about the competition you have for collecting the co-pays?
  • Collection of co-pays fell by about 40% in April, so SIMED set a goal for front-end staff. If they meet 100% copay collection and 80% on any outstanding balances, they get a “goody bag” reward for meeting that goal. In May, three clinics met these goals, groups got to decide what they wanted (e.g., pizza, donuts, etc.). It’s not cash-based, but something small to incentivize staff and say “thank you.”
How long are you scheduling virtual sessions, the normal length of time, or are you under/over scheduling?
  • UAM made a decision not to “tinker” with their templates for now, so schedules are the same.
  • SIMED is continuing a normal schedule although physicians with several telehealth visits in a row get through them quicker, still no adjustments have been made.
  • LVPG’s only primary change to their scheduling template has been to extend hours earlier in the morning and later in the afternoon and evening.
Have you faced pushback from physicians in the older demographic when it comes to telehealth?
  • UAM and SIMED both have experienced pushback from this demographic. At this point, UAM is only gradually reopening their clinics, limiting the number of patients physicians can see face-to-face, which has compelled more of the reluctant physicians to start utilizing the video component.
  • At SIMED, this was the last group to receive training in order to get the “easy ones” done first. But even this group has adapted after they completed a few virtual visits. SIMED also showed them their financials, which helped to incentivize them.
Is anyone running into challenges staffing screening stations at clinic entrances?
  • SIMED utilized staff who would have been furloughed or had their hours reduced. As they see increases in volume, they anticipate entrance screening will become more of a problem and they are developing permanent job descriptions with a plan to hire screeners (MAs and front staff are doing screenings now).
  • LVPG, too, accessed colleagues on furlough for entrance screening. LVPG has incorporated screening questions into appointment confirmations and questionnaires prior to visits. As they bring people back from furlough, it has become a challenge to continue screening at entrances. Now on-site screenings are being conducted at the practice and no longer at the entrances, which has been approved by clinical staff.