2016: will telehealth catch on or stagnate, due to factors out of control?

click to enlargeUpdated. Reviewing the Robert Graham Center study summarized by Editor Chrys last week, René Quashie of Epstein Becker Green, perhaps the leading law firm in the health tech area, opines that despite the great progress made by telehealth (telemedicine/virtual consults, but also remote patient monitoring), “state legal and regulatory issues, reimbursement, and provider training and education continue to be serious barriers to wider adoption of telehealth. And until the landscape evolves to address these barriers, telehealth adoption is likely to stagnate despite the great promise of telehealth holds as a tool to improve quality and access.” Yes, that old FBQ* (actually the top two) continues to be as true now as five years ago. While in closing Mr Quashie puts his trust in the ‘pull’ factor of consumers and patients “who will continue to demand better access and more innovative delivery models outside the conventional office visit,” this Editor is far less sanguine, despite having used a virtual consult app recently. It was turned to more out of sheer frustration–time pressure (work, travel), being unable to secure a timely visit with a specialist (no one seems to be taking new patients!) despite good (non-Obamacare) medical coverage, and a condition which was eminently photographable (plus $40 at hand). National Law Review  * The Five Big Questions (FBQs)–who pays, how much, who’s looking at the data, who’s actioning it, how data is integrated into patient records.

Then again, if you read Health Populi and believe Gallup’s polling (based on a slightly skewed question), a majority of Americans aren’t thinking about delivery models or telehealth at all. They’re unhappy, and would like to hand the whole hot mess over to the government when asked if “government is responsible for ensuring that people have health insurance.” Yet the Affordable Care Act, now two years in, was supposed to do exactly that by forcing everyone to pay for a healthcare policy or else pay a punitive tax. Too many did the math; the tax penalty was cheaper, especially for those Young ‘n’ Healthy Invincibles with slim purses and other things to spend on. They were the ones who were expected to pony up premiums, use few services and generally prop up the system.

click to enlargeNow the American populace are shocked, shocked to find that out-of-pocket costs are way up and access is down. The same Health Populi article cites Fair Health’s spring 2015 consumer survey, finding that 33 percent of American patients felt that their out-of-pocket costs were ‘much more than expected’, with an additional 17 percent in the ‘somewhat’ category–a total of 50 percent. The contradiction of government control versus spending (and actuarial) reality is, in this Editor’s opinion, not going to be solved easily or well.

As to the wisdom of government involvement, there’s another developing and embarrassing ACA Big Fail12 of the 23 ‘CO-OPs’ (Consumer Operated & Oriented Plans) formed in 2014 as non-profit, thus Good Guy consumer alternatives to traditional Bad Guy insurers, have failed within two years. They’ve failed in small and large states: examples are New York (the largest plan), Arizona, Iowa, Nevada and Colorado. Their purpose was to ensure a low cost alternative to for-profit insurer exchange plans for low-income (but non-Medicaid) people not covered by employer plans, despite having to offer the same ‘Christmas tree’ benefits as those and ACA exchange plans. By being non-profit, CO-OPs were supposed to subtract the Big Profits, Big Salaries and return them to policyholders in lower premiums. Ultimately that same government cut the CO-OP subsidies that in reality made those low premiums and good service levels possible–then actuarial reality got the better of them in short order, right into insolvency. The remaining CO-OPs are staggering, not paying back their loans and in fact are receiving further bailouts. Scratch an estimated $876 million in startup loans that were supposed to last for 15 years and be paid back! (We are Pondering the Squandering, indeed.)

The model doesn’t work.

Who is left holding the proverbial bag?

One, doctors and hospitals. The Wall Street Journal profiled in its local section over this US holiday weekend the lurch that the New York CO-OP, Health Republic, left both doctors and policyholders in. According to trade association GNYHA, hospitals alone are owed over $165 million. A practice in tony Mount Kisco, NY, which had 13,000 patients covered by Health Republic, is owed millions. The damage is concentrated in the NYC metro area, where most policyholders live–and an area rated as most expensive by insurers. And the guarantor in most states of insurance failure doesn’t cover losses in NY State based on a loophole in the law.

Doctors and hospitals in the other two Health Republic states, New Jersey and Oregon, are waiting for the other shoe to fall, although Health Republic has maintained that these plans are sound. Their NY losses were $52.7 million in the first six months of 2015, and $77.5 million in 2014.

Two, those policyholders. 500,000 or more nationwide are now searching for (more expensive) coverage, and that estimate is likely low as there are 215,000 in NY alone (updated per WSJ). Yet on PBS (a network paid for largely by the American taxpayer!), these low-income, borderline Medicaid (US low-income state program) people, who are just trying to get by, are told by an HHS spokesperso to essentially pound sand, be grateful for the ACA, and spend the little money they have to pay premiums. There has to be a better way! MedCityNews, PBS, Forbes, Daily Caller

To put a fine point on this, the outlook for telehealth, telemedicine and telecare in the US, while brighter, still face a maximum uphill battle with reimbursement and inclusion in insurance plans. While the healthy payers consolidate, the landscape is littered with the debris of failed insurers and a failing, by slow measures, of the ACA-mandated individual insurance exchange filled with costly ‘Christmas tree’ policies–exactly the opposite of affordable, less expensively-delivered care.

Editor’s Note: If the WSJ articles are paywalled, search on the article title and often, but not always, the paywall will be down.

Related: An optimistic view of 2016 and telehealth/telemedicine in Drive to ACOs and value-based care may make 2016 The Year of Telehealth (US)

Categories: Latest News, Opinion, and Soapbox.

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