THE RED-HOT TELE-VISIT MARKET NEEDS TO TURN GREY . . . WHY SENIORS MUST BE A NEW FOCUS FOR TELEHEAL

Tele-visits are one of today’s hottest healthcare technologies. Tele-visits here refer to the direct provision of care by a clinician via video, phone, or other real-time synchronous technology. In 2016, over $280M in venture capital was invested in telemedicine, a significant part of which went into tele-visits.[i] 52% of hospitals use three or more connected health technologies, which include tele-visit capabilities.[ii] Further, a majority of large employers now offer some form of tele-visit health benefits.[iii] Such enthusiasm is unsurprising. Tele-visits are a seemingly obvious innovation. They have the potential to increase access to care and patient choice. Patients are starting to respond to this investment. There were conservatively more than 1 million tele-visits in the past year.[iv] Although impressive, it is only a small fraction of the 880 million office visits that occurred during the same period.[v] (By comparison, there are over 10 million retail care clinic visits,[vi] a similar albeit more mature care innovation.) Thus, for tele-visits to truly fulfill their promise, more patients must embrace the technology and use it appropriately. Many health systems, health plans, and employers are doing great work building consumer interest either on their own or in partnership with their tele-visit vendors. However, they have been less successful in getting older Americans to use the technology. Patients over 65 represent a small fraction of the tele-visit landscape. This is uncaptured demand in a population that can uniquely benefit from the technology. Just as importantly, by creating offerings to serve seniors, tele-visit providers will undoubtedly improve the tele-visit experience for the entire market.

The power of healthcare digital marketplaces

Outside of healthcare, the creation of digital marketplaces for goods and services has been transformative. Many innovators have become household names: Airbnb for lodging, Uber and Lyft for taxi services, eBay for shopping, and so on. By allowing consumers and producers to convene online, these markets free up underused and misused assets, better match buyers and sellers, simplify transactions, and make life easier for everyone. The impact of such markets can be profound. Consider that in April 2016 there were 17 million taxi rides in New York City. Of those 17 million, 5.9 million of them involved the ride sharing services Uber, Lyft, and Via.[vii] New York’s iconic yellow taxis had already forfeited more than a third of the market.

Tele-visits—and the digital healthcare marketplaces they enable—offer similar potential for disruption. Making healthcare providers easily available on demand can in principle reduce unneeded emergency department visits, expand the physician workforce, improve access to behavioral health and ancillary care providers, and eliminate key barriers to effective chronic illness management. A meaningful subset of providers, for the right incentives, are willing to participate. Informal exploration of many healthcare digital marketplaces, including Live Health Online®, AmWell®, MDLive®, TelaDoc®, and JeffConnect®, advertise seemingly robust provider networks.[viii] The groundwork for true disruption is certainly set.

More than one million online visits, but only a handful of seniors

65-and-older people are major users of healthcare services. Seniors make up 15% of the US population.[ix] However, their increased need for care and their above-average insurance coverage means seniors account for 27% of all physician office visits.[x] Further, they account for 35% of hospitalizations.[xi] However, seniors appear to be only a small part of tele-visit users. A 2016 presentation on Mayo Clinic’s eVisits for a minor acute illnesses pilot showed that only 6% of the volume was from patients over 60 years of age.[xii] TelaDoc, the largest eVisit service in the United States, says 65-and-over patients represent about 1–2% of its volume.[xiii]

Tele-visits are not the only area where older patients differ from their children. 40% of millennials (people aged 18 to 34) own a health wearable. Only 10% of people over 55 do. Similarly, 48% of millennials go online to find a physician, versus 23% for the 55-plusers.[xiv] While these differences are striking, they show that meaningful segments of seniors will use health technology. If seniors use wearables and other health technology, and seniors need more office visits than the average consumer, then the obvious questions are why are they not using tele-visits today, and what can be done about it?

Barriers that are keeping seniors offline, at least for now

Agate Consulting has conducted no formal research on barriers to tele-visit adoption in senior populations. It will do so, and encourages others to as well. However, there are several likely explanations for seniors not using tele-visits. Some of the reasons are related to the health system’s structure, whereas some are driven by the tele-visit offerings themselves.

Structurally, the rapidly growing 1-million-plus-encounter tele-visit market is fueled primarily by employer investment. Employers offer tele-visit coverage via a tele-visit vendor or their insurance carrier. This coverage reduces the patient’s out-of-pocket costs. Just as important as coverage, employers actively promote the service to their employees. Employers, specifically self-insured employers, make these investments to move care to the lower-cost tele-visit setting, satisfy employees, and reduce the missed work associated with getting routine care. However, seniors, especially those over 65, typically get their insurance from Medicare rather than an employer. Roughly 70% of 65-and-older Americans get their insurance directly from Medicare. While face-to-face physician office visits are covered via Medicare Part B, there is no commensurate coverage for tele-visits.[xv] As a result, the patient will have to pay the full consultation fee, typically between $45 and $99, out of pocket. For the 30% of seniors who get their Medicare coverage through a private Medicare Advantage plan, tele-visits may be reimbursed. Several Medicare insurance carriers, including Anthem and Humana, are starting to cover the service as an “add-on benefit.” Add-on benefits are things above and beyond the core services covered under Medicare Part B.[xvi] Unfortunately, paying for add-on benefits is more challenging than paying for core services. Even when Medicare Advantage plans provide reimbursement for tele-visits, their promotional activities are typically less aggressive than employer-based programs. This is for many reasons. Insurers lack the multiple patient touch-points that employers have. Further, insurers do not directly benefit from the time savings and productivity gains that tele-visits create for the patient like employers do. All these dynamics result in many seniors having to pay the full cost of tele-visits should they want to engage—and should they happen to learn about the services.

In addition to the fact that seniors lag non-seniors in technology adoption and the insurance-related structural issues described above, there are likely other issues slowing seniors’ adoption of tele-visits. These include tactical product issues, the overall orientation of tele-visits vis-à-vis traditional care, and senior-specific clinical considerations.

Tactical product issues are the things within the tele-visit solutions that are uniquely challenging for seniors to use. Best practices for developing technology used by seniors consider age-related changes in vision, hearing loss, and reduced proprioception and coordination.[xvii] Font size, selection, and spacing; icon size and labeling; color contrast; and navigational metaphors all need to account for seniors’ unique needs. There have been mixed results among tele-visit vendors, although many of the ones evaluated seemed at least pretty good. Many solutions feature easy-to-read high contrast ratios, easy navigation, and clear and well-labeled iconography. However, few had large or adjustable font size, and many of the screens were crowded. (Virtuwell® stood out as demonstrating some best practices in terms of font readability and screen crowding.) Continued usability testing with seniors will undoubtedly improve the offerings greatly.

More problematic than user interface issues are the workflow differences between tele-visits and how people traditionally receive care. In his book, The Longevity Economy, Joseph Coughlin, director of MIT’s AgeLab, describes the challenges of getting seniors to embrace technologies that require dramatic changes in how they view the world.[xviii] The issue exists even when the innovation is beneficial to the user. For example, consider blind-spot detectors in automobiles. Senior drivers, often with decreased mobility, should appreciate not needing to strain their necks before crossing a dotted white line. However, if someone has been turning his or her head each time before changing lanes for forty years, modifying this behavior will not be easy. They will need to unlearn decades of positively reinforced behavior. More generally, blind-spot detectors require a change in the driver’s mental model of the activity of driving. Most, but not all, of the tele-visit platforms feel markedly different from a traditional physician’s office or urgent care center. Many of these differences may be good things in the long run. For example, maybe patients should get to pick which of the three doctors working in an emergency department should treat them (when practical). Maybe patients in a physician’s office should have the option to not fill out their health history and jump right into a visit. However, anything that can bridge the cognitive gap between traditional care models and tele-visits might help get more seniors engaged. Maybe a clipboard background icon? The one-click “Get an Uber” button is great for catching a cab because it effectively digitizes the hand signal to hail a passing taxi cab. Today, simply showing up a doctor’s office at 8 PM and saying, “you don’t know me but see me now” is not how seniors initiate treatment. As such, a “Speak to a Doctor Now” button on their phone may not be intuitive to older users.

Finally, tele-visits targeting seniors must account for the clinical differences these patients have versus middle-aged or younger cohorts. 80% of people 65-and-older have multiple chronic conditions, compared to 18% of those aged 18 to 44.[xix] Accordingly, they take more medications. 91% of seniors report taking a prescription drug in the past thirty days, versus 37% of those aged 18 to 44.[xx] Further, seniors are more likely to have a relationship with a primary care physician. Roughly 95% of those 65 and older have had contact with a healthcare provider in the past year, compared to 77% of those 18 to 44.[xxi] In total, seniors have a more complex medical history that complicates treatment even of routine illnesses. Further, 25% of those aged 65 to 74, and 50% of those 75-and-older have some level of hearing loss.[xxii] Treating them requires providers to speak louder and slower to deliver care, especially over a phone or computer. Lastly, seniors comfort with technology and/or reduced manual dexterity complicates their ability to use at-home medical devices (e.g., blood pressure cuffs, otoscopes) and sync data from their smartphones. Overcoming all these barriers is of course possible. However, it will likely require modifications to tele-visit preparation, tele-visit duration, and tele-visit reimbursement processes.

Some things that can be done to get seniors into tele-clinics

Driving greater use of tele-visits among seniors will require a multipronged strategy. First is increasing insurance coverage to reduce out-of-pocket costs. This must be quickly followed by extensive senior-focused targeted promotion. The marketing of tele-visits can be insurance led, affinity group driven (e.g., AARP), or provider initiated. The latter will be an especially important channel as CMS is aggressively encouraging provider risk arrangements under MACRA. While insurance coverage and promotion are necessary, they are likely not sufficient. Rather, the offerings themselves need to evolve in some of the following ways:

• Having their usability optimized for seniors’ needs. This is the obvious improvements—bigger fonts, more whitespace, high-contrast ratios, simple navigation, and so on. This is more than just changing the splash screen image of an attractive 30-year-old person to an attractive 60-year-old person. This is certainly hard to do, but it is certainly doable.

• Helping bridge the cognitive divide between brick-and-mortar care and tele-visits. This is harder. Modifying the products and workflows to help seniors be more comfortable using the new technology. This could include employing traditional imagery (e.g., clipboards, waiting room magazines, receptionists). It could be altering the tele-visit workflow to feel more familiar, e.g., more formal check-in and check-out processes. It could be employing more senior-specific health messaging and branding.

• Creating care models to meet seniors’ needs. This is even harder. Some ideas include expanding visit options beyond the commonly used one-size-fits-all fifteen-minute tele-visit. It is important to note that most brick-and-mortar doctors typically bill for at least six types of outpatient care encounters—level 3, 4, or 5 new patient visits, and level 3, 4, or 5 established patient visits. A variety of visit types may be needed for tele-visits as well, especially for seniors with their clinical complexity, sensory challenges, and technology discomfort. Many senior users are being actively managed for several health issues. Accordingly, better emphasis on care continuity and data exchange between tele-clinics and traditional primary care facilities is also key. Finally, and perhaps most important, using tele-visits for follow-up care, rather than new complaints, may markedly help seniors as well.

How seniors will make tele-visits a reality for all

Making products better for seniors often make products better for everyone. The now-ubiquitous OXO brand of kitchen appliances was designed by Sam Farber after he noticed his arthritic wife struggling with hard-to-grip kitchen utensils.[xxiii] OXO works great for 80-year-olds and 18-year-olds alike. If tele-visits become easier for seniors to use, they can become easier and thus more attractive to Gen-Xers and millennials. Beyond usability, the flexibility in care models that seniors require can be applied to the overall market. In the long run, the one-size-fits-all tele-visit model won’t scale in the under-65 market any more than it will with seniors. Finally, by pulling seniors into tele-visit marketplaces, the providers can effectively serve more of any individual doctor’s patient panel. Hence, providers will be more willing to invest in the technology because they can use it with all their patients, not just a portion of them.

Ultimately getting large numbers of seniors using tele-health requires building ecosystems, not merely apps. Such telehealth ecosystems connect all relevant parties. In doing so, they reinforce trust among patients, providers, and payers alike. Telehealth ecosystems will have tele-visit functionality embedded within EMRs. For patients, tele-visits and their associated payment processes will be included with leading mobile devices. Finally, more and more payers and providers will not merely participate in telehealth, but actively shape the deployment of tele-health offerings in the ecosystem. The American Well platform is an exciting example of such an emerging ecosystem. It features deep integrations with EMRs, native solutions for select Samsung mobile devices (and an Apple deal just announced), and active partnerships with both large payers and leading providers.

Truly great technology can be used by all ages and is useful to all ages. Examples range from the iPhone and Amazon Echo to the simple white Google search box. Online healthcare can also be applicable to all ages. These marketplaces can create huge cost efficiencies while improving health outcomes. Initial results are promising. True disruption, however, requires meeting the needs of the whole market, especially seniors, the highest healthcare using segment.

NOTES:

[i] 2016 Rock Health Funding Database.

[ii] 2016 HIMSS Connected Health Survey.

[iii] Beck M. How Telemedicine Is Transforming Health Care. WSJ. June 26, 2016.

[iv] Agate Consulting market analysis.

[v] CDC – National Center for Health Statistics website.

[vi] Bachrach D. et. al. The Value Proposition of Retail Clinics. RAND Institute. 2015.

[vii] Fortune. New York Taxis Are Still Dominating Uber. July 13, 2016.

[viii] Agate Consulting, Inc. “secret shopping” of select tele-visit offerings.

[ix] Mather M. Population Bulletin. Population Reference Bureau. Dec. 2015.

[x] Ashmam JJ and Hing E. Variation in physician office visits by patient characteristics and state, United States, 2012. CDC Presentation at the National Conference on Health Statistics, 2015.

[xi] Weiss AJ. Overview of Hospital Stays in the United States, 2012. AHRQ. Oct. 2014.

[xii] Penza K. eVisits for Minor Acute Illnesses. Mayo Clinic. 2016. Found online.

[xiii] TelaDOC. Telehealth: 1 million e-visits and 10 lessons learned. Feb. 24, 2016. Data visually estimated from the graph.

[xiv] Rock Health. Digital Health Consumer Adoption Survey, 2016.

[xv] Medicare Part B tele-visit reimbursement is generally limited to visits between two different physician offices, e.g., a patient at a primary care office tele-visiting with a specialist, and only when the patient is in a rural area.

[xvi] There is currently legislation being considered in the US House of Representatives to simplify this.

[xvii] Designing Apps for Elderly Smartphone Users. Clutch. April 27, 2017.

[xviii] Coughlin JF. The Longevity Economy: Unlocking the World's Fastest-Growing, Most Misunderstood Market. Hachette Book Group. 2017.

[xix] Gerteis J et. al. Multiple Chronic Conditions Chartbook. 2010. AHRQ.

[xx] CDC. Health, United States, 2016.

[xxi] CDC. Summary Health Statistics: National Health Interview Study, 2015.

[xxii] NIH - NIDCD. Quick Statistics About Hearing website.

[xxiii] Wikipedia. OXO (brand), referenced on 11/28/2017.