LAS VEGAS — Telehealth was supposed to be a game-changer for care delivery, but adoption has been slow and only in niche specialties. Still, company backers and optimists say tailwinds will spur the technology's uptake in a traditionally conservative industry across myriad use cases, from follow-up visits to post-acute care.
"I think we're past the tipping point of where virtual care becomes expected or embedded," virtual care vendor Teladoc COO David Sides told Healthcare Dive on the sidelines of the HLTH conference in Las Vegas this week. "I don't think you can put the genie back in the bottle."
The industry has seen an increasing emphasis on low-acuity urgent care as a crop of symptom checkers and digitally-enabled health apps like four-year-old 98point6 and three-year-old K Health have entered the market.
But executives in the virtual care space say there's a lot of white space to expand, including follow-up after high-acuity care like surgeries or chemotherapy, for example.
"There's a very, very rich world that's used for things beyond the flu or the rash," Roy Schoenberg, CEO of privately-held telehealth vendor American Well, told Healthcare Dive. "The thirst on the side of the health system to tie these technologies together into complex care is insatiable."
Earlier this year, American Well launched an acute care telehealth cart to allow hospital patients and their care teams to connect to remote specialists for use cases like ICU consults.
Virtual care is "an efficiency mechanism," Sides said. Teladoc, which went public in 2015, plans to move more into primary care within the health system by using remote patient monitoring, digital therapeutics and other tools, and bring a pilot to market next year.
Both American Well and Teladoc have are moving deeper into primary care — specifically for specialty, complex and high-cost cases.
Last week, Teladoc launched Teladoc Medical Experts, a service pairing patients with high-cost, chronic needs with a doctor to help them navigate virtual and in-person care options. CEO Jason Gorevic said on the company's third quarter earnings call Thursday the service enrolled 100,000 employees from Nationwide Insurance and UPS so far.
Just two days prior to the launch of Medical Experts, American Well created a new company called The Clinic in tandem with The Cleveland Clinic. The joint venture provides virtual access to Cleveland Clinic's medical specialists for patients with complex conditions.
"Imagine for a second that, through technology, when that patient goes home, their home is essentially the ward of the oncology department," Schoenberg said. "If you can be with them every day in their home and converse with them, you're going to change people's ability to fight cancer."
Regulatory barriers slowly ebb
The requirement that physicians get licensed for each state or jurisdiction where they plan to practice medicine has stymied adoption of virtual care nationwide.
"What we didn't think about it, with the arrival of telehealth, if you're a complex cancer patient in North Dakota, you have a higher probability of getting treatment that's less advised than the treatment you'd get in one of the leading cancer centers in the country," Schoenberg said.
That's not to say the government is uninterested. In May 2018, the U.S. Department of Veteran's Affairs eliminated state licensure requirements for its physicians and saw a subsequent explosion in veteran's use of virtual care.
And CMS finalized a rule in April giving Medicare Advantage plans additional flexibility to offer telehealth benefits for people treated in their homes in 2020.
Teladoc, which has inked contracts with six insurers in MA, forecasts it's going to be a few more years before virtual care proves its ROI and is more widely adopted in the marketplace.
Eliminating state licensing could help, experts say. Schoenberg believes national licensing for physicians could come in the next decade if interest in virtual care continues to ramp up.
But national licensure would be a "very tough road to hoe," Ann Mond Johnson, CEO of the American Telemedicine Association, said. "Regulation and reimbursement has to support that effort."
Fee-for-service Medicare could also expand to cover telehealth, relaxing stringent and complicated coding requirements to promote telehealth parity, though historically the Congressional Budget Office has maintained there's no way to model the cost implications of that decision.
Indeed, evidence is still emerging about the potential for cost savings.
Injecting stronger economic incentives into the system would prompt a "real giant expansion in the delivery of remote care," David Ryan, general manager of health and life sciences at Intel, argued.
But broad government reimbursement support is likely years away and moving "criminally slow," according to Schoenberg. Some legislators want to move the needle. On Wednesday, a bipartisan group of lawmakers in the U.S. House of Representatives and Senate introduced the CONNECT for Health Act, which would remove geographic restrictions for emergency and mental health virtual care and in federally-qualified health centers' and rural clinics' use of telehealth.
However, the Trump administration is currently "kicking the can," Schoenberg said, by stretching the risk contracts to give payers and providers the ability to provide telehealth as long as they're taking on risk. "I think that's chickening out."
But that's not a simple ask, administration officials said. The federal government has 15 different codified definitions of telehealth across its disparate agencies — five within HHS alone — and there are 26 different offices that have accountability or authority around the service, said Ed Simcox, CTO and active CIO of HHS.
"We're not singing across the same sheet of music," Simcox said. "It's a messy situation."
And then there is Amazon
However, the free market may soon spur the government to take a renewed interest in loosening strictures on telehealth. E-commerce giant Amazon elbowed into virtual care for the first time in September with Amazon Care, a telehealth pilot for Seattle-area employees.
Fay Rotenberg Bush, president of virtual primary care company Firefly Health, called that and an "exciting accelerant" for the market.
The service includes in-app telemedicine visits with doctors and nurses provided by a Washington state clinic for urgent or preventive care, in-person follow-up visits at an employee's home or office and at-home prescription drug delivery.
A potential commercial launch is likely years away, but if successful, Amazon has indicated it would be looking at multiple pathways to scale — and there's room for it, given current telehealth vendors aren't meeting all clients' virtual care needs, according to KLAS Research.
Experts expect the e-commerce behemoth to shop for clinician and telehealth vendor partnerships if it grows the new offering, in lieu of running an expensive provider network itself. But "on-site clinics are not new. Telehealth is not new," Peter Flesichut, SVP and CTO of NewYork-Presbyterian Hospital, said. "What is interesting is that they're creating their own technology."
American Well's Schoenberg also called out Amazon's creating of its own platform, calling it a "bold step" to recognize the technology is foundational to managing the care of its employees.
American Well may face little threat if Amazon stepped more firmly into the market. The vendor contracts directly with health insurers and health systems like Cleveland Clinic and Anthem Blue Cross.
Purchase, New York-based rival Teladoc, however, is different. The 17-year-old company relies heavily on subscriptions paid out by insurers (accounting for revenue of almost $120 million in the third quarter) over visit fee revenue paid either by insurers or directly by patients ($18 million). Many of its clients are employers, including more than 40% of the Fortune 500.