- We're gonna change gears quite a bit, and switch to something, the topic of telemedicine. What I'm gonna hope to do over the about twenty minutes or so is give you a brief snapshot of where we stand on this topic area. Mark said he wanted to end on a note of optimism, I'm gonna start with pessimism because when... We all have heard all the, how telemedecine's gonna change the world, and it's gonna be the great innovation, it's gonna be a way to increase access to care for the underserved in rural communities, and yet when I speak to employers, when I speak to health plans, they say, "how's that whole telemedicine thing going?" I go like, "Oh man, it's been a bust. "You know, we offer it to our employees or enrollees, "and no one's really taking it up." And so what I wanted to do today was to tell you kind of where do we stand in 2019 with the use of telemedicine and then return back to that question of whether, where are we headed here and what do we need to do about it. So, this idea has been echoed throughout why has telemedicine been such a bust so far, from CNBC. Forbes has talked about that telehealth has an awareness problem and how very few people are using it. So echoing the ideas that I've heard from others. Now, specifically, this has garnered a lot of policy interest so you hear, here in Massachusetts, but nationally, where people are saying what we need to do is we need to increase the coverage for telemedicine. It's a payment problem, so they're at health plans, they're at the state legislature saying we need telemedicine parity laws that every telemedicine visit must be covered. This is also gotten something on the national scale where a number of our presidential candidates have said, Pete Buttigieg and others have all, in their rural health plans, introduced that telemedicine, we need to increase dollars. Okay, so what is it actually, where do things actually stand? I'm gonna give you a snapshot of a couple of different places where telemedicine is being offered. I'm gonna show you some numbers, and we'll come back to what your assessment is at the end. So we'll start with Medicare. For those of you unfamiliar, Medicare has been covering telemedicine for over a decade. They've actually covered most types of outpatient visits, but they're very restrictive in some ways. So they'll cover pretty much anything, but it has to be a person in a rural area. So it can't be here in Boston. And also very importantly, the person can't have that telemedicine visit from their home. They have to go to a local clinic and just really concretely what that's like, you go to your community mental health center, you go to your primary care clinic, a federally-qualified health center, they have a back room where they have a setup, and the computer system setup and the camera, and from there they get the telemedicine visit as opposed to their home. There are several exceptions. More recent legislation passed by congress has expanded telemedicine to urban areas and for substance use treatment in the patient's home, but those are rare exceptions. So what numbers are we seeing? What we see is we're about up to just over 400,000 visits in the Medicare program annually, and the rate of growth is about 30 to 40 percent per year. Vast majority of these visits are for the treatment of mental health conditions. We see, while you can - I often joke, you can put the word "tele" in front of almost anything out there. You've seen some paper, but the vast majority 75 to 80 percent of these visits are all for the treatment of mental health conditions. What we see in terms of rates of use, it varies quite a bit in terms of who you're talking about. If we look at all enrollees, we see about five visits per 100 rural Medicare enrollees in the United States. If we take those with a mental health diagnoses, it's almost 20. For those who are with serious mental illness, schizophrenia, bipolar disease, there we see rates that are about 60 visits per 100 rural enrollees in the United States. So you can tell me whether that's a lot or a little, we'll get back to that in a moment. One thing that's very clear is that this is not spread evenly throughout the United States. This is a piece where we're showing a map of the United States, obviously. And we're showing what fraction of the psychiatrists in each of these states has provided a telemedicine visit in the Medicare program. Here, Massachusets on the west coast, it's very small percentages. You probably, you meet a psychiatrist on the street, they're very unlikely to have provided a telemedicine visit, but one goes to the mountain states, south states, the southern states, we'll see in Texas 14 percent. Up in Wyoming, we have 20 percent and in North Dakota, almost a quarter of all psychiatrists have provided a telemedicine visit. And this is consistent with use rates we're seeing, both within the Medicare population and elsewhere. So this is, on the coasts we see very little telemedicine use but again in the mountain states, in the South, and a little bit into the Midwest, we're seeing much greater use among our rural enrollees. How about in the commercial side? In a partnership with OptumLabs, we've been the using the Optum data. Also to kinda see, where is it among this large national insurer in the use of telemedicine in terms of its growth. Now when we talk to telemedicine companies, when it comes to commercial insurers, it's complicated in terms of what is covered. Because it's a combination both of what the insurer's policy is, but also each employer is also making a decision about whether to offer telemedicine to their employees as a covered benefit. So it's not clear, and also each health plan seems to have a slightly different way of getting reimbursed. So this has been much more complicated for the actual telemedicine companies in terms of getting coverage. They like Medicare 'cause it's pretty simple for them in that way. And they also have to navigate a number of state regulations that have emerged over time. And actually, interestingly, when I speak to telemedicine companies, these regulations that are actually sometimes more problematic for them in terms of offering the service than the reimbursement issues. Nonetheless, with those barriers, we are seeing relatively rapid growth. We're seeing almost 600,000 visits in the Optum population for different forms of telemedicine and a faster growth rate than we're seeing in the Medicare population. In terms of what it's for, here we see a slightly different picture. I told you in the Medicare population, almost all the visits were for mental health conditions. Here, a very common condition being treated is for mental health, or tele mental health, but by far, the now dominant form of telemedicine that we're seeing, at least in the Optum population, is for what's been termed direct-to-consumer telemedicine. What is that? These are companies such as American Well, Teladoc and others who are offering, we would call it, almost an urgent care. You can go there, you can get a visit, you'll use your app or your home computer, again this is now in the home now, and you'll put in some information about what's going on with you, and then within 15 minutes, 24 hours a day, 7 days a week, a physician will come on the other side and you can get your problem addressed. And again, while the use rate as I'll show you in a moment in a population level are low, as a growth rate, we're seeing pretty rapid growth in this form of telemedicine. One thing that's been argued is that a lot of people come to me and say, "you know what, we're gonna use this." I'll talk to an employer, and they say, "we wanna offer this service 'cause we have so many "employees who live in rural areas "or who have-- lack access to a provider, "and that's who we're really targeting with this service." We don't see that in the data. We find that those who use this telemedicine are just as likely to live in an urban area or live in a rural area, the nearest travel time to the nearest doctor, the travel time to the nearest hospital is about the same as what we see of those who don't use telemedicine. So in other words, framing this differently, the vast majority of telemedicine users for the direct-to-consumer side are mostly folks who live in urban areas, they also tend to be higher educated, higher income, slightly less healthier. So not who the employers have said that they wanna target, but I don't wanna deny it's a pain in the butt to see a doctor. And so, you know, here in Boston where we have more doctors per capita, it's still very painful to get into a primary care visit. So these patients do have access issues, but they're not the disadvantaged in the way that I think a lot of the policy debate is going on. And in terms of use rates, we're seeing that as I've mentioned before, among Medicare, all rural enrollees, we're seeing about five visits per hundred rural enrollees. But among the commercial population, about less than half of that. So those are areas that we're seeing both on the Medicare side, as well as, on the commercial side. I also wanted to give you a picture what it's like on the more acute care side, and in emergency departments, and specifically the use of telestroke. For those of you unfamiliar, telestroke has been a little bit more of the more common form of telemedicine that's been used. What will happen, the idea here is that the patient in particular, maybe in a rural community, will go to an emergency room with potential stroke symptoms. The treatment of stroke has gotten complicated in the last couple of years because of very good reasons. We have more therapies that are available to those patients, both tPA and thrombectomies. And so this has made both a lot of treatment availability for them, but also made it more complicated. So the average emergency medicine physician often struggles to know, "okay, is this the patient I should do x with, or y with?" So telestroke has emerged as a possibility for them. So a patient will come to a rural emergency department with a potential stroke, they'll push the button on the wall, a camera will turn on, a neurologist, ideally a vascular neurologist who has telestroke expertise will come in, help the physician who's at the bedside, help do an exam, interpret the imaging, the CAT scan that hopefully is done very very quickly and they can guide that physician in terms of determining what is the right therapy for that patient. For telestroke, it's interesting, we talk so much about the payment rates. The way it's actually emerged out there on the landscape is that hospitals in rural areas have decided to just to put this in, and they're contracting with the telestroke providers independent of the billing system. So we see very, very few reimbursements or bills for these, and so they've just been paying a monthly fee, a yearly fee to have this service available to their patients. And the people who are providing this service, it's interesting, it's either big academic centers, for example, Mass General over there has a big telestroke network, but we're also seeing here that large private companies who can serve hundreds of hospitals around the nation are providing this telestroke service. In terms of numbers, it's about 1300 now, hospitals nationally. And these data we've obtained from actually going to each of these telestroke networks, asking them who is within their network. So interesting, about 25 percent of all hospitals in the nation have this, this capacity now. In terms of total number of patients, so this is now using Medicare data where there are roughly 350,000 patients a year, who unfortunately have a stroke. Among these, about 200,000 of those, roughly, go to a big academic center, or a center that has a primary stroke center that has neurologist on site. But among those community hospitals where telestroke could have real advantage and provide care, we're now seeing about 30 percent of patients in the US of the community hospital group, 30 percent of them are going to a hospital with this new capacity. Who are these hospitals who have telestroke capacity? Interestingly, and despite the policy debate, they're less likely to be in a rural community, unfortunately. They're more likely, less likely to be a small hospital and they're less likely to be one of our critical access hospitals in the United States. So, not exactly how it has, people have hoped. People hoped it would be focused more on the rural areas in terms of which hospitals will take this up. So to summarize some of this work and going back to where I started the talk, is that when I speak to people about telemedicine, again a lot of pessimism. Why is the growth rate not been high enough? What I'm seeing in our data across a couple of these different areas, is relatively rapid growth in telemedicine, maybe it's not as fast as the proponents have hoped, but I would note that given the growth rates we're observing, and compound interest, we are actually going to see, if these growth rates continue, within the next 5 to 10 years, we're gonna see it really becoming much more the norm as it is already in some of the states like North Dakota, etc., where we're seeing the greatest use of this. Depending on the form of telemedicine, we're seeing whether it is reaching those disadvantaged populations. In the Medicare population, I think the answer is yes. We are seeing that telemedicine is being most commonly used by rural, I didn't show the data, poor and disable enrollees who really are in need of care. However, in the direct-to-consumer telemedicine, as well as to some degree, telestroke, in some ways, the telemedicine is not reaching the-- preferentially reaching those disadvantaged populations. Thank you.
