No Easy Answers in Bioethics Podcast
Insight into the Telehealth Landscape: Bogdan-Lovis and Pletcher - Episode 24
April 15, 2021
In this episode, Senior Academic Specialist Libby Bogdan-Lovis is joined by Dr. Sarah Pletcher, Vice President and Executive Medical Director of Virtual Care at Houston Methodist. Dr. Pletcher shares her telehealth expertise in a conversation that explores the benefits of telehealth for patients and providers, the influence of the COVID-19 pandemic on telehealth adoption, reimbursement models, the future of telehealth, and more.
Recorded March 5, 2021
This episode was produced and edited by Liz McDaniel in the Center for Bioethics and Social Justice. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.
- American Telemedicine Association
- Center for Telehealth and e-Health Law
- National Consortium of Telehealth Resource Centers
Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Bioethics and Social Justice at the Michigan State University College of Human Medicine. This episode features a discussion on telehealth that explores the benefits for patients and providers, reimbursement models, the influence of the COVID-19 pandemic, and more. Center senior academic specialist Libby Bogdan-Lovis is joined by Dr. Sarah Pletcher, a telehealth expert and a College of Human Medicine alumna. Listen on for insight into the current and future telehealth landscape.
Libby Bogdan-Lovis: Good afternoon. This is Libby Bogdan-Lovis. I am a senior academic specialist at Michigan State University, College of Human Medicine, in the Center for Ethics and Humanities in the Life Sciences.
Sarah Pletcher: Hi, good afternoon. I’m Sarah Pletcher. My current role is Vice President and Executive Medical Director at Houston Methodist Health System in Houston, Texas. I’m a 2005 Michigan State College of Human Medicine grad. And I spent time during master study there with the Center for Ethics team, and delighted to be rejoining y’all today.
LBL: Thanks, Sarah. It’s my understanding that in your role at Houston Methodist, you lead the health system on strategies, processes, practices, and education around system-wide virtual care and digital health program across the organization. So that’s what I want to talk to you about today. And, I’m going to start with a basic question. Oftentimes the terms telehealth and telemedicine are used interchangeably, and among the lay audience as well as medical audiences. Can you explain what you see as distinctions, the relevant distinctions between telehealth and telemedicine?
SP: Sure. You know, I honestly don’t think there’s, there’s any relevant distinction left. I mean, there was a time when telemedicine was meant to refer more to clinical care delivered over those technologies. And telehealth was a little bit more broad, and might include, you know, professionals collaborating, or education between providers. But I think over the years any distinction was lost and people use the terms completely interchangeably. And we have this whole new crop of other terms like connected care, connected health, virtual care, virtual health, smart health, e-health, mobile health. And in general, those, those are all alternately umbrella-ed and bucketed and tiered, and have become largely interchangeable. So at this point, I don’t see a lot of distinction left between telehealth and telemedicine.
LBL: Okay. That’s interesting to know. You know, with this past year, and with COVID-19, it seems like everyone has concluded that it let the genie out of the bottle with telemedicine. But maybe. You know, reimbursement issues are always there. What do you see as key factors for the stakeholders that prompted the telehealth reimbursement decisions that came along with COVID-19?
SP: Yeah. And, I mean, certainly the pandemic gave us a huge shot in the arm in terms of easing and enabling not just reimbursement, but legal regulatory freedom to do more. But telemedicine has been around for a long time, and telemedicine reimbursement’s been around for a long time, albeit in a bit of a patchwork quilt where you had to navigate state-by-state, whether all of the third-party private payers were reimbursing, and, you know, where and when Medicare reimbursement was available. You know, sometimes based on address and zip code. You know, some states had Medicaid, but it depended on specialties. But I think the point I would make is that we had plenty of telemedicine reimbursement before COVID. But COVID certainly reset the playing board in terms of the scope of availability of reimbursement. And, you know, really every payer coming to the table to participate, which, which was great.
LBL: So what are the regulatory changes that happened?
SP: Oh, we need a whole podcast for that, a separate podcast. But they had to do with licensing, credentialing, privileging. Some of the regulatory considerations around prescribing. You know, some states had rules before where you had to see a patient in person first before you could see them over telemedicine. So those are some of the areas where, you know, those are still considerations, but where there was some easement during the pandemic and we hope much of that will remain. That gave us a little bit more latitude. And again, even before the pandemic, there had been a lot of efforts to advance that landscape, you know, but certainly COVID helped, helped move the boulder up the hill quite a bit faster.
LBL: So, are some of those regulatory changes national? Do they apply across states?
SP: Some of them do, yes, and some of them are sort of emergency pandemic temporary. And others are, you know, we’re going to improve this now going forward. And, you know, I think there’s always been that balance between things that are federal and things that are, you know, state and even regional. You know, and then of course, every health system and payer sets their own standard for what, what they want to get up to. You know, and some health systems, look after patients in multiple states and therefore have to navigate. So it’s, it’s a complicated tapestry. But, you know, again, the pandemic certainly shed a light on why those barriers need, need easing and hopeful that will retain a lot of those, a lot of that progress.
LBL: And then currently is there a national body working on that?
SP: There are many and have been many. You know, too numerous to name, but certainly the American Telemedicine Association has been active for many, many years. The Center for [Telehealth] and [e-Health] Law is another advocacy and education group. There’s also a National Telehealth Resource Network where grant funded, there’s resource centers really serving every state. And they’re active sort of at the state level. And then of course you have the health systems and the insurance companies and the vendors out there, you know, all wading in as well. But those are sort of some of the ones that come to mind.
LBL: Okay. That’s helpful. So then following up on that, is it true that CMS sets the threshold for telemedicine reimbursement?
SP: I would say that CMS sets the threshold in the same way that they do for every other sort of reimbursement. I don’t see a special link with telemedicine. I mean, CMS, like the private payers, has had to wrestle with and develop new codes, or modifiers for their codes. And some insurance companies are able to recognize a role for telemedicine and create their own codes that, you know, are well beyond what CMS is doing. So I, I guess I see them as they’ve all got their sleeves rolled up trying to work out what makes most sense for their patients, and for their bottom line, and ultimately for delivering high value care. But I don’t, I don’t see one as being the, you know, the leader. I think it’s a roundtable, at least in my, my esteem.
LBL: Okay. So what's in it for other third-party payers beyond Center for Medicaid and Medicare services, like insurance companies?
SP: Yeah. I mean, I think it kinda comes down to access to expertise. And with telemedicine facilitating access, whether that’s specialty into a small rural hospital, or giving a patient convenient access on their phone to stay connected to their care team. Or a fragile patient who’s gone home from the hospital to be monitored and avoid going back to the hospital. You know, I think if it’s used in ways that create access, and, you know, more, not just high tech but high touch for the patient, you know, that leads to better outcomes, and avoidance of hospital stays, and avoidance of transfers, and avoidance of unnecessary diagnostics and care. So, I think if the insurance companies continue to recognize that creating access to expertise leads to better quality and lower cost, that’s, that’s the primary driver behind why they would support it.
LBL: Okay. So, for the novice, explain how telemedicine can be high touch.
SP: So if the, if and the non-telemedicine model, let’s just say you live in rural Michigan, you know, where I grew up. And your specialist is four hours drive away. And so the only time, as an asthmatic, you go to see your specialist is once a year when your parents drive you to the specialist four hours away. But now with telemedicine, you can have check-ins without that windshield time. You’re able to manage your condition with more insight from that specialist, you know, so that’s where the high touch comes in. The, you are touching, not physically, but you are touching your health care team more frequently, yet without having to the transportation, and they don’t all have to be, you know, standard 30 minute long visits because that’s how the codes work. It can be more flexible. A phone call, a video chat. You know, it can be a three-way conversation between your primary care and your specialist to come up with a solution, or tweak your regimen without having the old school constraints of, you know, I only get that expertise when I make an appointment and drive somewhere to a clinic.
LBL: Right. Okay, I see. So, you mentioned earlier large healthcare systems, and certainly we’re in the period of very active mergers and acquisitions.
LBL: To create your healthcare systems.
LBL: Are there any telehealth complexities related to those large healthcare mergers?
SP: I mean, sure. I don’t know that they differ that much from all the other complexities of the large system merger, right? Like there’s, there’s, you have to integrate staffing, and technology platforms, and electronic medical records, and your workflows, how you do billing and coding, you know, sort of aligning your contracts. Obviously there’s redundancy when mergers happen. You know, systems may have a very different appetite for legal and regulatory innovation. So that needs to be aligned. But again, I don’t think that’s, that’s too different than what they contend with already.
LBL: Okay. Yeah. See how that would be.
SP: But the benefit of course is that they’re often attaining scale.
SP: Where, you know, now maybe they have 35 small rural community hospitals where it now makes a lot more sense for them to invest in, into telemedicine where they can use a hub and spoke model to look after and load level resources across a larger system. So certainly the scale that comes with, and efficiency that can come with a merger can be beneficial.
LBL: Yeah, the hub and spoke model does seem to be, that there’s a lot of wisdom behind that. And I think again of Michigan.
LBL: Yeah. How, so, the other thing that, that we’re moving into very quickly, or immersed in, is value-based healthcare.
LBL: How does telehealth articulate, or not, with value-based healthcare, that future?
SP: Yeah. And I think, I think the important thing to remember is that when you talk about telehealth, you know, it really is a whole suite and approach of platforms that allow you to wrap around medical care. But it still comes down to what medical care are you delivering. You know, it’s not as if it’s a magic, you turn it on and you have… You know, so you have to decide how you’re going to use it. But it’s certainly a powerful tool in, again, advancing that high touch, low-cost convenience access. Reaching underserved patients, better looking after those fragile, you know, chronic condition, dual diagnosis patients. So, many of the challenges that face a value-based healthcare approach, those patients that really need access to care, it can be a very powerful tool if you set it up with that orientation in line.
LBL: Okay. I understand. So, this past year, I like many, and my partner like many, we both had a telehealth visit for an annual exam.
LBL: Yeah. [Laughs] It did help not having to go into an office. But I’ve heard that in general, about 80 percent of a diagnosis is drawn from the medical history, and 20 percent is based on the physical exam. Now in our case, we could provide our care providers with information about our blood pressure and temperature, etc. Some of the vitals stuff. But what strategies can make up for that 20 percent in-person?
SP: Yeah, and I, I would, I would first say, when you talk about a diagnosis, you know, that’s different than an established patient whose diagnoses are known to you, and where you’re managing, you’re managing their disease. I, you know, so I think part of the question is, when do you need the extra 20 percent physical exam? And then what elements of it do you need? There’s a lot of information that you can draw from a video encounter. You know, how well, you know, what’s their skin tone look like? How’s their circulation look? Do they look like they’re making an extra effort to breathe? Have they lost weight? Do they have a tremor in their hand? You know, how’s, how’s the tone of their hair? I mean, just casual stuff you can, you can observe during a visit. And you can also ask the patient to show you a rash, or show you something they’re concerned about in the context of that visit.
SP: And there are devices, peripheral devices, that, for patients where it makes sense, you can deploy that will allow you to listen to their heart and lungs, to look in their ears and nose, and throat and eyes. You know, so it doesn’t make sense to put those kind of devices in every single patient’s home that you have. But if you truly have a patient that you know you’re going to need that additional information more frequently, that investment might make sense.
SP: You know, the other thing I just like to point out from time to time is that there’s so much information you get when you’re able to see a patient in their home environment.
SP: Which we don’t ordinarily see. You know, you get a sense of living condition, and what’s happening in the background, and who else is in the space with the patient, and what’s the dynamic that you can observe between the patient and some of those other people who they might share a household with. Very rich information that you can observe. And also just building relationship with the patient. You know, oh, I see a Christmas tree in the background, you know, just being able to kinda share in their life in a different way. So I think that any information that we aren’t able to get, we have to address. And if at the end of the day, if you need to do an exam, you gotta tell the patient, hey, I’m sorry, but I’m going to need to have you come into the office to further evaluate this issue that you’re having. But on balance, there’s so much information we can glean.
LBL: Yeah, I can see how there would be real gains with being able to see into the home, and looking at some of the interpersonal dynamics. So who would pick up the cost of some of those auxiliary devices, measurement devices? Insurance companies?
SP: It depends, right? In some cases it’s the insurance company, who’s like, hey, this is a great solution for my patient to have better care. If it’s a health system that’s participating in risk or value-based structures, the health system might provide that to their patients. In some cases it’s the employer, right? The employer’s like, hey, I don’t want you to miss work, so I’m going to invest in you having this gadget so that if you need to have a urgent care visit, you can be seen and have it be less disruptive to your, you know, your work-life. And we have plenty of patients now who are saying, hey, I’m going to go to Best Buy and drop, you know, 300 bucks so that I can travel around and be in my, you know, vacation house far from COVID risk and still know that I can check in and be seen. You know, we have concierge patients who choose to have that model. So, you know, anyone can write the check, it just depends on the structure of the care relationship. Who’s most likely to be the person to make that investment.
LBL: Right, or capacity to pay out of pocket for those sorts of things.
LBL: So, as you know, we work in a medical school here.
SP: Yes, I am aware. Having attended said institution.
LBL: Yeah. So how, you know, we’re always working at tweaking the curriculum, and the clinical experiences. How might we best future prepare our medical students for the telehealth of today and tomorrow. I imagine your vision about what’s coming down the pike is pretty broad.
SP: Yeah, and I think, you know, just as Michigan State was very forward thinking in looking over their entire curriculum to find ways to make it more relevant to all different patient populations. Similarly, you’d look in all corners of the curriculum to, to virtually enrich it. So, whether that’s having patients, I think Michigan State had that longitudinal patient-centered experience where the students went out to the homes. Great. Keep that going, but maybe instead of once a month, it’s they go for the visit the house twice, but they check in with the patient for a video chat once a week in addition to that. And it’s, again, higher touch but less windshield time for the students. You know, so I think things like that. Or when you’re doing the, you’re learning how to do a physical exam. You know, you do a couple in-person and then you learn how to do visits remotely. How can you evaluate and have someone at the bedside assist in being your hands, and boots on the ground as you’re doing a remote exam?
SP: You know, virtual technologies also allow the instructors and the educators to participate, right? So if you’re a medical student doing an exam or a resident, and you look in the ear and think, huh, I don’t know what I’m seeing, the technologies now allow you to bring that attending or professor, you know, in so that you’re looking at the same thing at the same time.
SP: Even if you’re not in the same place. So, I think really looking at the curriculum and overhauling it. You know, keeping all the great aspects to it, but look at like, well, how would we, how would we update this to be a little more future-looking?
LBL: Yeah, good suggestions. I’ll share them. Are there any relevant lifecycle or age distinctions regarding the efficacy of telehealth, like pediatric populations versus the elderly? And, and I know you mentioned earlier, you, with telehealth, you get insight into the home. And, and again, that’s arguably a real advantage, especially with pediatric and elderly populations. Anything beyond that?
SP: No, I mean, telehealth has been, has been demonstrated with a mountain of studies and data to have efficacy at every age, and really across every specialty. You know, there are certain conditions that just don’t lend themselves well to a telehealth exam. You know, where you, obviously you can’t deliver a baby. [Laughs] Um, you know, there’s certain things that you just can’t, can’t do. But, the efficacy does not have any lifecycle or age distinctions. I think there are differences in, you know, utilization and adoption and access, just based on, you know, what technologies they have at hand and are comfortable using. You know, but there again I think COVID has, has really facilitated folks having to try things they might not have before to gain a little bit more comfort. And it’s kind of funny for me to see. You know, whereas few years ago you couldn’t convince that 85-year-old grandmother to do a visit over the computer, now good luck getting her to come in because I just want to see the doctor on my iPad.
SP: So the adoption has, has really begun to cross over into all age categories, which has been really great to see.
LBL: Yeah, it has been interesting transition. And, and in many ways I keep thinking, there’s no going back. But you mentioned can’t deliver a baby. Which leads into the discussion of reproductive health. And what influences shape telehealth’s future for those politically sensitive reproductive health needs, such as oral contraceptives, medical, abortion, those kinds of things.
SP: Yeah, and I, it was funny as I said that, I began to regret my comment, because we actually have helped deliver babies over telehealth. We’ve had several occasions in some of our rural critical access hospitals or frontier clinic locations where, you know, they don’t have any OB coverage whatsoever, and many of them don’t have physicians in the hospital at night, and a patient comes in. And where our docs have come on over video and talked the person at the bedside through what to do. So, even as I said that I thought, well, they don’t actually [laughs] use their hands, but our docs have actually remotely assisted with delivery. But to answer your question, you know, at the end of the day, I keep coming back to the same theme. Telehealth enables access, and it enables convenience. And when you have access and convenience, you are removing barriers that we know are, are often there for patients. And some of those barriers are, are not accidental. And so if you disrupt them, you know, you’re going to tangle with both sides of that equation. And that can sometimes lead to telehealth being targeted because the technology does enable bypassing or, or navigating some of those barriers in a different way. You know, but at the end of the day, it’s about access, from my perspective.
LBL: Yeah. That was very diplomatic answer, yes, and useful. So what are relevant infrastructure needs to ensure telehealth data privacy protection? And this is something the bioethicists talk about quite a bit, right?
SP: Yes. That is, that is very, very relevant. And many of us in the telehealth space joke that the privacy people care way more about privacy than any patient we’ve ever met. But, I would say, you know, the relevant needs are really no different than they would in a non-telehealth medical encounter, right? You have to make sure that the setting of care offers security and privacy. Whether that’s a technology platform or an in-person setting. Your electronic medical record or your charting processes need to be secure, and you need to have policies and procedures for your staff and your team around how you share data. So it isn’t, it isn’t different whether it’s in person or over tele. You know, we do have to think through the security of the technology platforms that we use.
SP: You know, but that’s sort of par for the course really.
LBL: Yeah. And that is going to be ongoing, right?
SP: Of course.
LBL: Yeah. There’s going to be a lot of, there are challenges now, there’s lots more in the future. I just, yeah. So, I’m going to wrap this up with a provocative question. I saw this past week an announcement for a job posting for a bioethicist, actually two bioethics positions, with Google Health.
LBL: And, so I Googled Google Health [laughs] to see what’s going on there. And what I wondered is if you can address any possible, well, articulation or tension between a commercial corporate market like that, and more of our standard health care delivery. What do you see happening with that?
SP: There, there again, you know, that would be a probably a whole other podcast series. You know, but the large-scale disrupters, the Googles, the Amazons, the Walmarts, you know, there are several others in there. You know, they have the capacity to really change the game and create access and connections in ways we never imagined. And that will, of course, bring with it ethical considerations. You know, so I’m not surprised that they’re considering that, and, you know, I think it’s great that there’s integration of all areas of expertise, whether they’re traditional medical or ethical or public health or social work or anthropology or community and social resources. You know, you gotta think through that whole environment that ought to wrap around healthcare. You know, it’s a sacred practice and needs to be stewarded carefully.
LBL: Yeah. Thank you very much. That’s a wonderful way to end up. We really appreciate your time, Sarah.
SP: Well, thank you so much for having me. It’s great to reconnect with my Michigan roots, and sending you guys some warm weather from, from the South.
LBL: Thank you. And we’ll keep our cold weather up here this time.
SP: If you wouldn’t mind, that would be much appreciated.
LBL: Okay. Take care.
SP: Bye guys.
LBL: Bye bye.
Liz McDaniel: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at bioethics.msu.edu for full episode transcripts and other resources related to this episode. A special thank you to H-Net: Humanities and Social Sciences Online for hosting this series. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel in the Center for Bioethics and Social Justice. Music is by Antony Raijekov via Free Music Archive.