Episode 7
Navigating Telehealth with Dr. Jonathan Neufeld
In this episode,
Cam talks to Dr. Jonathan Neufeld to talk a bit about Navigating Telehealth. Tune in to hear about telehealth advancement, how telehealth improves the quality of care, the reimbursement landscape, and the ideal mix of telehealth and in-person care.
“I think that what we're finding with regard to quality, is that yes, there are things you can't do in a telemedicine encounter. But, you can do more than you think. And if you use telemedicine to do the things that you can do, you end up getting an awful lot of care, taken care of for way lower cost and with way more convenience.”
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Transcript:
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Transcript
I think that what we're finding with regard to quality,
Dr. Jonathan Neufeld:is that yes, there are things you can't do in a telemedicine encounter.
Dr. Jonathan Neufeld:But, you can do more than you think.
Dr. Jonathan Neufeld:And if you use telemedicine to do the things that you can do, you
Dr. Jonathan Neufeld:end up getting an awful lot of care, taken care of for way lower
Dr. Jonathan Neufeld:cost and with way more convenience
Triston Yoder:welcome to a virtual view where we talk about telehealth,
Triston Yoder:healthcare and everything in between.
Cameron Hilt:Today we have Dr.
Cameron Hilt:Jonathan Neufeld, who is a clinical psychologist and integrated primary.
Cameron Hilt:Or the pre and post doctoral training at the VA Southern Arizona health care
Cameron Hilt:system and university of California Davis, the latter institution where he
Cameron Hilt:worked with several tele-health pioneers.
Cameron Hilt:He's a senior research associate at the Institute for health informatics
Cameron Hilt:at the university of Minnesota and the program director for the great Plains
Cameron Hilt:tele-health resource and assistance center, which is part of the national
Cameron Hilt:consortium of telehealth resource centers.
Cameron Hilt:Dr.
Cameron Hilt:Neufeld.
Cameron Hilt:Thanks so much for joining us today.
Cameron Hilt:It's a pleasure to have you on a virtual view.
Dr. Jonathan Neufeld:Great.
Dr. Jonathan Neufeld:Thank you, Cam.
Dr. Jonathan Neufeld:Call me Jonathan.
Cameron Hilt:Thank you, Jonathan.
Cameron Hilt:We're really excited to be able to have you be a part of the show today.
Cameron Hilt:It's a rare occasion that we actually get to have someone who has been a
Cameron Hilt:part of the UMTRC before in the past.
Cameron Hilt:Jonathan, do you mind telling us a little bit about some of your
Cameron Hilt:past history with the UMTRC.
Dr. Jonathan Neufeld:sure.
Dr. Jonathan Neufeld:Boy, it goes back a ways and I'll probably get the dates a little mixed up, but we,
Dr. Jonathan Neufeld:I know that we first wrote, I joined.
Dr. Jonathan Neufeld:I was in Indiana at the time, still live in Indiana, but connected with the folks
Dr. Jonathan Neufeld:at Indiana rural health association for some grant related work I've been
Dr. Jonathan Neufeld:doing tele-health I know that Don Kelso at the time and others on staff
Dr. Jonathan Neufeld:were interested in tele-health work.
Dr. Jonathan Neufeld:And so I wrote a grant and evidence-based telebehavioral health network
Dr. Jonathan Neufeld:grant with Matt and he was there.
Dr. Jonathan Neufeld:And we did that for three years.
Dr. Jonathan Neufeld:And toward the end, we saw the announcement for the.
Dr. Jonathan Neufeld:Telehealth resource center grant come out.
Dr. Jonathan Neufeld:And we saw that Ohio and Indiana and Michigan and Illinois weren't covered yet.
Dr. Jonathan Neufeld:The tele-health resource centers grew one section at a time.
Dr. Jonathan Neufeld:And those four states just hadn't been claimed.
Dr. Jonathan Neufeld:So Matt, I.
Dr. Jonathan Neufeld:That grant to for the UMTRC originally.
Dr. Jonathan Neufeld:And then I was the clinical director while Matt was on staff and he was the titular
Dr. Jonathan Neufeld:director of the UMTRC for the beginning.
Dr. Jonathan Neufeld:And then after Matt left, Becky took over and we worked together for a while
Dr. Jonathan Neufeld:until I left for Oaklawn Indiana.
Cameron Hilt:It's great to be able to have someone that, really
Cameron Hilt:understands the history of the UMTRC on our podcast years later.
Cameron Hilt:And.
Cameron Hilt:tell us a little bit about so now you work at, one of our sister
Cameron Hilt:tele-health resource centers GP track.
Cameron Hilt:Tell us a little bit about your journey to becoming the program director at GP Track.
Dr. Jonathan Neufeld:So after I left UMTRC and you may
Dr. Jonathan Neufeld:have heard this from others.
Dr. Jonathan Neufeld:It's a wonderful community of people.
Dr. Jonathan Neufeld:Wonderful set of grantees.
Dr. Jonathan Neufeld:I think we're somewhat unique if you can be somewhat unique, but I think
Dr. Jonathan Neufeld:we're unique among grantee programs, at least at HERSA, just because
Dr. Jonathan Neufeld:we're collaborative and congenial.
Dr. Jonathan Neufeld:So it was a really tight organization when I left UMTRC I still had some sort
Dr. Jonathan Neufeld:of pending obligations to attend some meetings and help do some trainings.
Dr. Jonathan Neufeld:And my new CEO said, yeah, great.
Dr. Jonathan Neufeld:Go ahead and do that.
Dr. Jonathan Neufeld:Stay connected because it was one of the things that.
Dr. Jonathan Neufeld:That I brought to Oaklawn was this connection to the world of
Dr. Jonathan Neufeld:telehealth as well as expertise in it.
Dr. Jonathan Neufeld:I continued to be in touch with the TRCs and the former principal
Dr. Jonathan Neufeld:investigator and director.
Dr. Jonathan Neufeld:At GP track Stuart speedy decided to retire.
Dr. Jonathan Neufeld:He had been at university of Minnesota for a long time, was
Dr. Jonathan Neufeld:very instrumental in the growth and development of the informatics program
Dr. Jonathan Neufeld:at Minnesota, which is 50 years old.
Dr. Jonathan Neufeld:And it's an amazing program.
Dr. Jonathan Neufeld:And Stuart was retiring from IHI Institute for health informatics.
Dr. Jonathan Neufeld:And he knew me from UMTRC days and just kinda tap me on the shoulder and actually
Dr. Jonathan Neufeld:with some help from others around the TRC community, who said, Hey Stewart.
Dr. Jonathan Neufeld:Yeah, you gotta see if you felt interested.
Dr. Jonathan Neufeld:So that one thing led to another until I came to the university
Dr. Jonathan Neufeld:of Minnesota virtually, I still live in Indiana, but took over.
Dr. Jonathan Neufeld:After Stewart retired as director of the great Plains tele-health resource and
Dr. Jonathan Neufeld:assistance center with and kept a fabulous staff there who are still with us now.
Cameron Hilt:Yeah, I can reiterate, it's a very close-knit community
Cameron Hilt:amongst the tele-health resource centers, both nationally and regionally.
Cameron Hilt:And it's cool to see, those connections that you were able to make just by
Cameron Hilt:working on another TRC, even being able to make that connection and just
Cameron Hilt:moving over to a different region.
Cameron Hilt:I was curious your background is as a clinical psychologist.
Cameron Hilt:So how did you first get introduced to telehealth and what really drew you into
Cameron Hilt:actually wanting to pursue, full-time work focusing specifically on telehealth.
Dr. Jonathan Neufeld:So when I.
Dr. Jonathan Neufeld:Did my post-doc at UC Davis medical center, which is in Sacramento, just
Dr. Jonathan Neufeld:a few miles up the road from Davis.
Dr. Jonathan Neufeld:I was in the department of family and community medicine.
Dr. Jonathan Neufeld:And.
Dr. Jonathan Neufeld:Just, it just so happened that the postdoc position that they that I applied
Dr. Jonathan Neufeld:to and that they provided there, was supervised by a man named ed Callahan.
Dr. Jonathan Neufeld:Also a psychologist who was in family medicine at UC Davis.
Dr. Jonathan Neufeld:And ed had had worked with a number of other researchers at the university
Dr. Jonathan Neufeld:and the department of psychiatry who.
Dr. Jonathan Neufeld:Some early, early is relative in tele-health right.
Dr. Jonathan Neufeld:This was late nineties.
Dr. Jonathan Neufeld:So Medicare had passed its rules and UC Davis had an active
Dr. Jonathan Neufeld:telemedicine program with folks like.
Dr. Jonathan Neufeld:Don Hilti, who is a widely published psychiatrist in the tele-health world,
Dr. Jonathan Neufeld:actually, while I was there, Peter, who's a former president of ATA joined
Dr. Jonathan Neufeld:UC Davis faculty, and he's still there.
Dr. Jonathan Neufeld:And it just so just in my work with Ed and said, Hey, there's these guys doing
Dr. Jonathan Neufeld:this interesting stuff over in psychiatry, are you interested in working with them?
Dr. Jonathan Neufeld:And so I got connected there and when I joined the faculty,
Dr. Jonathan Neufeld:then after my post-doc.
Dr. Jonathan Neufeld:I actually joined first, as an analyst in psychiatry, they had a behavioral
Dr. Jonathan Neufeld:health capitated plan that they ran out of the department of psychiatry
Dr. Jonathan Neufeld:and they brought me on as an analyst for that plan while I was finishing.
Dr. Jonathan Neufeld:Doctoral hours licensure hours in the family medicine clinic.
Dr. Jonathan Neufeld:And then after I finished and was licensed, then they brought
Dr. Jonathan Neufeld:me in, on faculty at UC Davis in the department of psychiatry.
Dr. Jonathan Neufeld:And I got to work with Peter and Don and Jim Marson from emergency medicine.
Dr. Jonathan Neufeld:You still around quite a bit.
Dr. Jonathan Neufeld:And A lot of just got a lot of exposure.
Dr. Jonathan Neufeld:They had the first tele-health learning center I think Kathy was
Dr. Jonathan Neufeld:involved at the time there.
Dr. Jonathan Neufeld:And just was, became immersed in that work that they were doing there.
Dr. Jonathan Neufeld:So then when I left UC Davis and came to Indiana, it was one of the things that
Dr. Jonathan Neufeld:I just wanted to stay in touch with.
Dr. Jonathan Neufeld:I wanted to keep finding out what was going on in tele-health in Indiana.
Dr. Jonathan Neufeld:So I made a lot of cold calls, met some people through the folks in California
Dr. Jonathan Neufeld:because Greg Beck, who had been working for children's in Indianapolis
Dr. Jonathan Neufeld:Had been trained at UC Davis and was doing a telehealth program down there.
Dr. Jonathan Neufeld:So I called him up and met him.
Dr. Jonathan Neufeld:We hit it off.
Dr. Jonathan Neufeld:And then a group just started meeting and talking about telehealth
Dr. Jonathan Neufeld:in Indiana for a number of.
Dr. Jonathan Neufeld:And that led to meeting Matt, writing the grant with Indiana rural health
Dr. Jonathan Neufeld:association and et cetera, et cetera.
Dr. Jonathan Neufeld:I was always interested in the technology.
Dr. Jonathan Neufeld:I was interested in tech stuff.
Dr. Jonathan Neufeld:One of my first projects at UC Davis was working.
Dr. Jonathan Neufeld:Palm pilot the precursor of the cell phone, or the, of the,
Dr. Jonathan Neufeld:yeah, the little handheld device, their personal digital assistant.
Dr. Jonathan Neufeld:And so I wanted to stay involved in technology and I just had some great
Dr. Jonathan Neufeld:opportunities there at UC Davis to do that and ended up hanging on to
Dr. Jonathan Neufeld:it had ended up having some great opportunities in Indiana to continue.
Cameron Hilt:No, that's great.
Cameron Hilt:It sounds like early in your career, you had seeds.
Cameron Hilt:Different ways that you can get plugged into tele-health where you
Cameron Hilt:know, that interest grew over time.
Cameron Hilt:And as you got involved to really leading you where you are now and you
Cameron Hilt:gave a little bit of background of how you seen, tele-health kind of grow and
Cameron Hilt:change over the course of your career.
Cameron Hilt:So you know, what have been some of the biggest changes
Cameron Hilt:that you've seen in telehealth?
Cameron Hilt:Over the past few years,
Dr. Jonathan Neufeld:The biggest changes that have driven it
Dr. Jonathan Neufeld:are in the mid nineties when Medicare started paying for it.
Dr. Jonathan Neufeld:And actually it really didn't hit its stride until about 2000.
Dr. Jonathan Neufeld:When Medicare finally decided to pay for both intakes and
Dr. Jonathan Neufeld:therapy in behavioral health.
Dr. Jonathan Neufeld:And since that time, behavioral health has been the majority of what Medicare
Dr. Jonathan Neufeld:pays for in telehealth until Covid.
Dr. Jonathan Neufeld:But still the largest single specialty, the longer largest
Dr. Jonathan Neufeld:single lump of encounters that Medicare pays for telehealth.
Dr. Jonathan Neufeld:But the biggest things besides that reimbursement in the technology
Dr. Jonathan Neufeld:world are first of all, the public internet when I started, we were paying
Dr. Jonathan Neufeld:multiple ISDN lines or multiple DSL.
Dr. Jonathan Neufeld:Lines to various sites or there's another acronym I'm
Dr. Jonathan Neufeld:forgetting now with gang lines.
Dr. Jonathan Neufeld:But anyway, UC Davis is paying a dollar a minute for connectivity.
Dr. Jonathan Neufeld:So you can imagine what it would take to make a telehealth program
Dr. Jonathan Neufeld:sustainable when every hour it's 60 bucks.
Dr. Jonathan Neufeld:Your first 60 bucks just goes for the connectivity.
Dr. Jonathan Neufeld:Not to mention the little set top boxes from Tanberg and poly-com that.
Dr. Jonathan Neufeld:Upwards of three, four, $5,000 to plug them into , your ISDN lines.
Dr. Jonathan Neufeld:The fact that you could get to the point where, your connectivity was basically,
Dr. Jonathan Neufeld:a hundred bucks a month or 200 bucks a month, whatever it was when we first
Dr. Jonathan Neufeld:started getting a more ubiquitous internet, that was a huge change in how
Dr. Jonathan Neufeld:those expenses impacted tele-health.
Dr. Jonathan Neufeld:The other thing is just.
Dr. Jonathan Neufeld:Just the rapid transformation or the rapid advances in video compression
Dr. Jonathan Neufeld:and transmission technology.
Dr. Jonathan Neufeld:When you first started to be able to run, video calls on a
Dr. Jonathan Neufeld:generic computer running software.
Dr. Jonathan Neufeld:Polycomm had software for awhile that was H.323 compliant.
Dr. Jonathan Neufeld:But it was clunky and it was hard to use.
Dr. Jonathan Neufeld:And web based video platforms really changed all that.
Dr. Jonathan Neufeld:And I really have to say, I have to emphasize that even the
Dr. Jonathan Neufeld:algorithms and code that we had zoom coming onto the scene, zoom.
Dr. Jonathan Neufeld:Change generationally before COVID zoom was around before
Dr. Jonathan Neufeld:COVID, several years before COVID.
Dr. Jonathan Neufeld:But when zoom came on the scene, their video algorithms were just a generation
Dr. Jonathan Neufeld:ahead of what else was available.
Dr. Jonathan Neufeld:The age the H.264 advanced video codec had come out, but zoom really took
Dr. Jonathan Neufeld:that and ran with it and provided a markedly better throughput markedly,
Dr. Jonathan Neufeld:better video markedly, more adaptable.
Dr. Jonathan Neufeld:It was just a real game changer in a lot of ways.
Dr. Jonathan Neufeld:And everybody has caught up or a lot of people have caught
Dr. Jonathan Neufeld:up to a certain extent.
Dr. Jonathan Neufeld:But those things made it possible to really do high quality ubiquitous,
Dr. Jonathan Neufeld:just kinda click a button and there you go, kind of video.
Dr. Jonathan Neufeld:And that really has changed the world of telehealth.
Dr. Jonathan Neufeld:And then,
Dr. Jonathan Neufeld:you can't underestimate the impact, that COVID-19 had on it because we had a
Dr. Jonathan Neufeld:solution there waiting, and then all of a sudden, boom, national, international
Dr. Jonathan Neufeld:situation where we needed tele-health.
Cameron Hilt:Absolutely.
Cameron Hilt:yeah.
Cameron Hilt:Before the pandemic.
Cameron Hilt:How many people knew and utilize telehealth services.
Cameron Hilt:I was just on a student panel this week and I had a student who asked me
Cameron Hilt:did telehealth exist prior to COVID-19 and yes, it's had a very vast history.
Cameron Hilt:The father of telemedicine can be traced back to the seventies.
Cameron Hilt:People really didn't know that the services were being utilized and in
Cameron Hilt:what ways they're being utilized.
Cameron Hilt:But now it's commonplace.
Dr. Jonathan Neufeld:I've said in other settings too that most, of
Dr. Jonathan Neufeld:course most people's view of telehealth is telehealth since March of 2020.
Dr. Jonathan Neufeld:And it, and most people think of it as, live video to your home.
Dr. Jonathan Neufeld:And in fact, before March of 2020, almost none of it was live video to your home.
Dr. Jonathan Neufeld:And we could do that, the technology existed, but you couldn't get
Dr. Jonathan Neufeld:paid for it most of the time.
Dr. Jonathan Neufeld:Just the year prior to that, I think it was Medicare started paying for
Dr. Jonathan Neufeld:mental health services to the home.
Dr. Jonathan Neufeld:Other than that Medicare didn't pay for it.
Dr. Jonathan Neufeld:And most commercial payers, didn't either, there's some dabbling here
Dr. Jonathan Neufeld:and there, and some Medicaid payers that were pretty progressive did.
Dr. Jonathan Neufeld:But you were going into an office somewhere to do a live video
Dr. Jonathan Neufeld:telehealth call until mostly until COVID-19 until the pandemic.
Dr. Jonathan Neufeld:And then all of a sudden, everybody realized, oh, this is telehealth.
Dr. Jonathan Neufeld:This is where my doctor sees me at home, sitting on my couch
Dr. Jonathan Neufeld:with my cell phone, it's wow.
Dr. Jonathan Neufeld:Yeah, that's cool, but we couldn't do that a month ago or, whatever.
Dr. Jonathan Neufeld:The other interesting thing that I think even folks in the field don't
Dr. Jonathan Neufeld:realize is that most of the telehealth that has happened since the beginning
Dr. Jonathan Neufeld:of the pandemic would not have been reimbursed before the pandemic
Dr. Jonathan Neufeld:would not have existed without the flexibilities during the pandemic.
Dr. Jonathan Neufeld:And it's why there's such pressure to make those changes permanent,
Dr. Jonathan Neufeld:because I we know what it's like to operate with one hand and one arm
Dr. Jonathan Neufeld:and one leg tied behind our back.
Dr. Jonathan Neufeld:It's okay, we can go back to that.
Dr. Jonathan Neufeld:But nobody wants to do that, but that's, those are the permanent laws.
Dr. Jonathan Neufeld:They're still on the books, when we go back from the COVID-19 relaxation.
Dr. Jonathan Neufeld:So yeah, it really is critical that we examine those rules and think
Dr. Jonathan Neufeld:about, okay, how do we want to support virtual care going forward,
Dr. Jonathan Neufeld:both as a policy decision, but also reimbursement at whatever payer levels.
Cameron Hilt:Yeah.
Cameron Hilt:And I'm glad you brought that up, especially with, the most recent
Cameron Hilt:edition that we had of the physician fee schedule from Medicare.
Cameron Hilt:One of the big wins that we've seen through the course of the pandemic is,
Cameron Hilt:the lifting of geographic restrictions when it comes to telebehavioral health.
Cameron Hilt:But to your point, there's still lots of other specialties that
Cameron Hilt:we have a lot of evidence-based.
Cameron Hilt:So their effectiveness of being able to offer it through, Modality, but still,
Cameron Hilt:there are some of those restrictions that are in place that it makes it
Cameron Hilt:hard for a lot of healthcare providers who did all this work to implement
Cameron Hilt:this new service, potentially hired staff, got the technology on board.
Cameron Hilt:And now all of a sudden they're in this weird limbo I've done all this investment.
Cameron Hilt:Our patients want it now, our providers enjoy, providing this service, but
Cameron Hilt:now I don't know if I'm going to be able to get reimbursed for it.
Cameron Hilt:Long-term.
Dr. Jonathan Neufeld:Yeah.
Dr. Jonathan Neufeld:Yeah, there, there is a lot of movement there.
Dr. Jonathan Neufeld:And I think that pressure is being felt.
Dr. Jonathan Neufeld:And to the extent that anything gets through Congress, this
Dr. Jonathan Neufeld:is definitely up there as one of the things that's critical.
Dr. Jonathan Neufeld:Telehealth has always been a remarkably bipartisan issue at the federal level.
Dr. Jonathan Neufeld:So to the extent that, anything can get done, both sides want it to happen.
Dr. Jonathan Neufeld:But, it doesn't guarantee anything.
Dr. Jonathan Neufeld:It still has to be acting, be passed as a piece of legislation that somebody is
Dr. Jonathan Neufeld:supporting and somebody is offering and somebody is going to get credit for that.
Dr. Jonathan Neufeld:And if we just keep wrangling about who's going to get credit for it,
Dr. Jonathan Neufeld:then, and it doesn't get done.
Dr. Jonathan Neufeld:So yeah, it's a, it can be a challenge, but I suspect.
Dr. Jonathan Neufeld:We're going to see that change happen this year.
Cameron Hilt:Yeah.
Cameron Hilt:absolutely.
Cameron Hilt:And I think, especially if you can see some of those changes from the
Cameron Hilt:federal level, I know here in the Midwest, we tend to see a lot of our
Cameron Hilt:Medicaid's tend to mirror Medicare.
Cameron Hilt:After they've made some decisions.
Cameron Hilt:And especially if we can see some of those changes at a federal level, even
Cameron Hilt:if it may not be instantly at a state level hopefully we can see, some of
Cameron Hilt:those state changes in Medicaid as well.
Cameron Hilt:Cause I know that can be a huge barrier, especially if your main
Cameron Hilt:patient base is Medicaid to be able to have the same reimbursement
Cameron Hilt:that you may have through Medicare.
Dr. Jonathan Neufeld:Yeah.
Dr. Jonathan Neufeld:Yeah.
Dr. Jonathan Neufeld:I've been very impressed with Medicare for the most part, actually CMS, I mean,
Dr. Jonathan Neufeld:they're aware they know the situation.
Dr. Jonathan Neufeld:They are a bit restricted because the original Medicare statute is in statute.
Dr. Jonathan Neufeld:If the original telehealth payment is in statute.
Dr. Jonathan Neufeld:And so CMS, can't just say we're not going to do it that way.
Dr. Jonathan Neufeld:Congress has to say, or at least give the administrator of
Dr. Jonathan Neufeld:CMS, the authority to do that.
Dr. Jonathan Neufeld:It is a pretty hard limitation, but CMS has been remarkably creative in
Dr. Jonathan Neufeld:wiggling around those restrictions or at least I don't want to make it sound
Dr. Jonathan Neufeld:nefarious, but they have figured out how to support an awful lot of virtual.
Dr. Jonathan Neufeld:In spite of the fact that an awful lot of it is restricted in the
Dr. Jonathan Neufeld:original legislation When the first Medicare coverage was put into place.
Dr. Jonathan Neufeld:One of the, in that 1996, 1997 act I don't know if you've heard the story of
Dr. Jonathan Neufeld:how OMB scored telemedicine and I don't know the numbers, but I definitely have
Dr. Jonathan Neufeld:the impression OMB scored it it's just, this was just going to be a bank Buster.
Dr. Jonathan Neufeld:If we let people from all over the country, see their doctor
Dr. Jonathan Neufeld:by telemedicine, this is just gonna put Medicare in the red.
Dr. Jonathan Neufeld:So they were very restrictive in what they allowed.
Dr. Jonathan Neufeld:And since then I did an analysis a while back.
Dr. Jonathan Neufeld:Since then Medicare, despite growing by double digit percentage, and in
Dr. Jonathan Neufeld:fact up until 2020 was growing at about a 30% or more per year rate.
Dr. Jonathan Neufeld:And so he had this logarithmic growth, but even so the peak of it was still
Dr. Jonathan Neufeld:less than 1%, less than a 10th of a percent of Medicare beneficiaries.
Dr. Jonathan Neufeld:Had any kind of a telehealth encounter.
Dr. Jonathan Neufeld:So it was really just a tiny trickle tiny rounding error at the bottom.
Dr. Jonathan Neufeld:And so those predictions about busting the bank never really came to fruition.
Dr. Jonathan Neufeld:I did, an interesting kind of comparison when I did some of that analysis.
Dr. Jonathan Neufeld:I wanted to find something to compare telemedicine to all of telemedicine
Dr. Jonathan Neufeld:in 2019, with Medicare, Medicare spent less on all of telemedicine in
Dr. Jonathan Neufeld:2019 that it spent on Holter monitors.
Dr. Jonathan Neufeld:There's cardiac monitor.
Dr. Jonathan Neufeld:You take home.
Dr. Jonathan Neufeld:It comes in a box.
Dr. Jonathan Neufeld:You'd wrap it up, put it on for a few hours, it sends a reading to your doctor.
Dr. Jonathan Neufeld:We spend more on that than telehealth and the whole country
Dr. Jonathan Neufeld:we being CMS and Medicare.
Dr. Jonathan Neufeld:So at the time when I wrote the article, I said, the Medicare telemedicine program is
Dr. Jonathan Neufeld:really nothing more than a pilot program.
Dr. Jonathan Neufeld:A couple of people pointed that out and said, Ooh, that's pretty strong
Dr. Jonathan Neufeld:statement, how do you, less than one 10th of a percent, how do you
Dr. Jonathan Neufeld:call that, real, a real program?
Dr. Jonathan Neufeld:Nobody wanted the pandemic to come that's for sure.
Dr. Jonathan Neufeld:But but it certainly has changed that, especially in
Dr. Jonathan Neufeld:the world of behavioral health,
Cameron Hilt:Yeah.
Cameron Hilt:we now suddenly have, some of the biggest use cases that we've ever had
Cameron Hilt:for telehealth with what you just quoted with Medicare and seeing, after we've
Cameron Hilt:had these big peaks and now that we've seen tele-health utilization still remain
Cameron Hilt:significantly higher than it was prior to the pandemic we're really looking at that
Cameron Hilt:and seeing what the actual outcomes are.
Cameron Hilt:What does some of the emerging research coming out of the pandemic look like?
Cameron Hilt:When it comes to tele-health.
Cameron Hilt:And I think that will be a really fascinating thing to monitor over the
Cameron Hilt:next few years and just look back at moments like you just mentioned and
Cameron Hilt:just Based off of what we found, that seems just real far off the mark.
Dr. Jonathan Neufeld:When the pandemic first started, a few months in 3,
Dr. Jonathan Neufeld:4, 6 months in everybody was taking a breath and realizing, okay We had
Dr. Jonathan Neufeld:done, we started doing telemedicine, just tons of telemedicine all over the
Dr. Jonathan Neufeld:country, a number of researchers and regulators and payers and others were
Dr. Jonathan Neufeld:starting to say, okay, great people are being seen, offices are operating.
Dr. Jonathan Neufeld:We're all doing telemedicine, but the big concern was, what about quality?
Dr. Jonathan Neufeld:Is all of this tele-health is going on.
Dr. Jonathan Neufeld:Is it, has it significant, significantly damaged the
Dr. Jonathan Neufeld:overall quality of medical care.
Dr. Jonathan Neufeld:And we worried about that for awhile.
Dr. Jonathan Neufeld:And a number of studies have tried to look at that.
Dr. Jonathan Neufeld:The challenge in my mind about that is that number one, we don't measure
Dr. Jonathan Neufeld:the quality of healthcare very well.
Dr. Jonathan Neufeld:Anyway, so it's hard to do a better job of measuring quality and tele-health,
Dr. Jonathan Neufeld:and we do measuring health care.
Dr. Jonathan Neufeld:Generally, you don't have a comparison an AB a legitimate comparison there.
Dr. Jonathan Neufeld:The other thing is that there's this sort of implication in that
Dr. Jonathan Neufeld:question that, yeah, we shouldn't do tele-health it's not as good a quality.
Dr. Jonathan Neufeld:We should just go into the doctor in person.
Dr. Jonathan Neufeld:Like we have been doing well when that's not possible anymore.
Dr. Jonathan Neufeld:And in the old days, it wasn't possible for other reasons, it's not that
Dr. Jonathan Neufeld:you just couldn't drive across town.
Dr. Jonathan Neufeld:It's like you couldn't get to a doctor.
Dr. Jonathan Neufeld:There was none in your region.
Dr. Jonathan Neufeld:The comparison is not, we should just fall back to in person, the
Dr. Jonathan Neufeld:comparison is we should do nothing.
Dr. Jonathan Neufeld:We should not see the doctor.
Dr. Jonathan Neufeld:And when you compare it to that, we haven't had to make that
Dr. Jonathan Neufeld:comparison for a while now.
Dr. Jonathan Neufeld:We've moved past that.
Dr. Jonathan Neufeld:It's a measure of how far we've moved past it but tele-health
Dr. Jonathan Neufeld:definitely beats nothing whether it's pandemic or it's just, far distance
Dr. Jonathan Neufeld:I think that what we're finding with regard to quality, at
Dr. Jonathan Neufeld:least where the world is.
Dr. Jonathan Neufeld:It's sorting itself out now is that yes, there are things you can't
Dr. Jonathan Neufeld:do in a telemedicine encounter.
Dr. Jonathan Neufeld:And there are especially things you can't do on a phone call with a
Dr. Jonathan Neufeld:patient, but you can do some things and those things that you can do;
Dr. Jonathan Neufeld:A, you can do more than you think.
Dr. Jonathan Neufeld:And B if you use telemedicine to do the things that you can do, you end up getting
Dr. Jonathan Neufeld:an awful lot of care, taken care of for way lower cost and way more convenient
Dr. Jonathan Neufeld:and great satisfaction because the patient is satisfied, with the convenience.
Dr. Jonathan Neufeld:They're satisfied with the care of course that they got care.
Dr. Jonathan Neufeld:But the thing that really kicks it up is that I didn't
Dr. Jonathan Neufeld:have to, take a day off work.
Dr. Jonathan Neufeld:I didn't have to drive across town.
Dr. Jonathan Neufeld:I didn't have to arrange for childcare.
Dr. Jonathan Neufeld:I didn't have to do all those other things that, that telemedicine
Dr. Jonathan Neufeld:makes it possible to avoid.
Cameron Hilt:Yeah.
Cameron Hilt:And that's an interesting point.
Cameron Hilt:And I think a lot of times you hear this all or nothing approach, it's either
Cameron Hilt:all telemedicine or it's all in-person.
Cameron Hilt:There are certain specialties where it might make complete sense
Cameron Hilt:to do it all on telemedicine.
Cameron Hilt:There might be others that make complete sense to do it all.
Cameron Hilt:In the office and like thinking of.
Cameron Hilt:Certain scenarios where it makes more sense to provide that type of service.
Cameron Hilt:I'm thinking of, telestroke services in particular, a lot of times that has
Cameron Hilt:the most benefit and rural areas where patients don't have easy access to the
Cameron Hilt:neurologists, those hospitals may have difficulty recruiting and not to say
Cameron Hilt:that those don't have a place in an urban setting either, that tends to be
Cameron Hilt:the most common place that you find it.
Cameron Hilt:Because perhaps if you live in an urban center, you might have more
Cameron Hilt:access to a neurologist and be able to actually see that individual in person.
Cameron Hilt:Really being able to understand and know when are the times that this patient
Cameron Hilt:needs to come in person and what are times where this can be done over
Cameron Hilt:telemedicine and really understanding should it be a hybrid approach or
Cameron Hilt:should it be an all or nothing, but it doesn't have to just be all or nothing.
Dr. Jonathan Neufeld:And because telemedicine in primary care specifically
Dr. Jonathan Neufeld:primary care, has been what we have come to see now in the pandemic.
Dr. Jonathan Neufeld:The thing that really happened that hadn't been happening before
Dr. Jonathan Neufeld:is telemedicine for primary care.
Dr. Jonathan Neufeld:Obviously we had other specialties too, and all of healthcare moved there
Dr. Jonathan Neufeld:but we tend to think now in terms of primary care and there's questions about
Dr. Jonathan Neufeld:how much telemedicine should there be versus in-person, what's the ideal mix.
Dr. Jonathan Neufeld:And I have some comments about that too, but.
Dr. Jonathan Neufeld:When you look at more historical or you go back a few years and
Dr. Jonathan Neufeld:you think about what are the real successes before the pandemic?
Dr. Jonathan Neufeld:You mentioned telescope, which is definitely one of them.
Dr. Jonathan Neufeld:And the fact is that without telestroke, without some rational and even aggressive
Dr. Jonathan Neufeld:application of telestroke care, there is no way that we're going to have stroke
Dr. Jonathan Neufeld:outcomes at every hospital in the country.
Dr. Jonathan Neufeld:That meet the standard of care.
Dr. Jonathan Neufeld:Physically, it could happen, but we have to train an awful lot of neurologists
Dr. Jonathan Neufeld:and an awful lot of them would have to be sitting around on their hands
Dr. Jonathan Neufeld:for an awful lot of their time.
Dr. Jonathan Neufeld:And that it's just not going to economically or professionally
Dr. Jonathan Neufeld:make any sense at all.
Dr. Jonathan Neufeld:There aren't enough stroke cases to use somebody like
Dr. Jonathan Neufeld:that full time in a rural area.
Dr. Jonathan Neufeld:And so you have to, one of the things telemedicine is
Dr. Jonathan Neufeld:great at aggregating demand.
Dr. Jonathan Neufeld:You have to aggregate the demand.
Dr. Jonathan Neufeld:To the point where that one neurologist or that team of neurologists can be
Dr. Jonathan Neufeld:serving a much larger geographic area or multiple centers in an urban area,
Dr. Jonathan Neufeld:whatever it takes to aggregate demand to the point where you can then staff
Dr. Jonathan Neufeld:24/7 neurology and have somebody calling and have those people busy 24/7 whatever
Dr. Jonathan Neufeld:it takes to make it a viable service.
Dr. Jonathan Neufeld:That aggregation of demand is another part of tele-health.
Dr. Jonathan Neufeld:It doesn't get talked about a lot.
Dr. Jonathan Neufeld:We talk about aggregating geographically, but also over time and, making it possible
Dr. Jonathan Neufeld:to sustain a practice for a sub-specialty and allow that sub specialist to, then
Dr. Jonathan Neufeld:they can actually start to migrate out of the urban areas because they can
Dr. Jonathan Neufeld:draw a map on, draw a line on the map and say, okay, that's my service area.
Dr. Jonathan Neufeld:And I'm going to virtually connect to all.
Dr. Jonathan Neufeld:I don't have to live in an area where there are enough
Dr. Jonathan Neufeld:patients to support my practice.
Dr. Jonathan Neufeld:I can live anywhere and just find a geographic area that
Dr. Jonathan Neufeld:will support my practice.
Dr. Jonathan Neufeld:And I'm personalizing it, but it's more, we do it more realistically in
Dr. Jonathan Neufeld:groups, but still that aggregation of demand is a huge benefit for those
Dr. Jonathan Neufeld:subspecialty practices like tele-stroke.
Dr. Jonathan Neufeld:That were, the rockstars before the pandemic and had been
Dr. Jonathan Neufeld:showing us an absolutely critical area that we need to move in.
Dr. Jonathan Neufeld:Even before the pandemic
Cameron Hilt:being able to capture and serve a larger area through the
Cameron Hilt:utilization of telehealth and, see that in variety of different disciplines.
Cameron Hilt:And, even with, within the context of Indiana, we have several mental
Cameron Hilt:health, professional shortage areas.
Cameron Hilt:And we have a few behavioral health providers that cover big chunks of
Cameron Hilt:Indiana, even though they don't live in those areas, but because they're
Cameron Hilt:offering it through tele-health, they can have that larger service area versus
Cameron Hilt:just being restricted to the one city that they're geographically located at.
Cameron Hilt:Even with that, being able to serve a larger patient population, but also for
Cameron Hilt:that hospital or clinic that's providing the services, opening up the number of
Cameron Hilt:patients that they can bring in for even their own business our own sustainability
Cameron Hilt:of their programs, which is huge as well.
Cameron Hilt:But with that, for some of our listeners that are just curious with tele-health, we
Cameron Hilt:talked about a few different disciplines, but just, in general, what are some
Cameron Hilt:of, The we've already talked about strengths, but what are maybe some of the
Cameron Hilt:weaknesses or limitations of telehealth.
Dr. Jonathan Neufeld:The biggest challenges I think that telehealth
Dr. Jonathan Neufeld:faces, and this is this is a, it's not really a weakness of telehealth per se.
Dr. Jonathan Neufeld:But one of the biggest challenges is, to do what you're already doing, or just
Dr. Jonathan Neufeld:mimic what you're already doing virtually.
Dr. Jonathan Neufeld:Some of the more progressive organizations and providers are starting
Dr. Jonathan Neufeld:to bump into this and realizing, we gotta take this to another level.
Dr. Jonathan Neufeld:Telehealth doesn't just enable us to replicate the in-person encounter
Dr. Jonathan Neufeld:virtually and doing it at a distance.
Dr. Jonathan Neufeld:It does do that, but if we do that, then we're leaving an awful
Dr. Jonathan Neufeld:lot of the value on the table.
Dr. Jonathan Neufeld:Tele-health doesn't really come into its own until you start doing what
Dr. Jonathan Neufeld:I call refactoring the encounter or refactoring the contact between
Dr. Jonathan Neufeld:the provider and the patient.
Dr. Jonathan Neufeld:And I don't mean just an individual provider, but in
Dr. Jonathan Neufeld:the clinic and the patient or between the group and the patient.
Dr. Jonathan Neufeld:So that patient can get various components of the services they
Dr. Jonathan Neufeld:need through various modalities.
Dr. Jonathan Neufeld:So if all you need is lab results, you get a phone call about that,
Dr. Jonathan Neufeld:or you go online and you check that asynchronously, or you get a message.
Dr. Jonathan Neufeld:Hey, your results are available.
Dr. Jonathan Neufeld:You can check now.
Dr. Jonathan Neufeld:And if what you need is a followup or you need some sort of an intake and we
Dr. Jonathan Neufeld:just need to exchange some information, we can do that online with a video.
Dr. Jonathan Neufeld:We can do an awful lot virtually.
Dr. Jonathan Neufeld:And then when it comes to the point where we need to see you to take your
Dr. Jonathan Neufeld:appendix out, or to provide that in a injection or do whatever we have
Dr. Jonathan Neufeld:to do physically, then you come in and you, and we do that physically.
Dr. Jonathan Neufeld:It's a variation of the old stepped care type of idea where you want
Dr. Jonathan Neufeld:to engage at the least restrictive.
Dr. Jonathan Neufeld:And I would add most cost-effective level.
Dr. Jonathan Neufeld:Possible for every service that has to happen.
Dr. Jonathan Neufeld:Now, if the service is an in-person encounter and you don't differentiate
Dr. Jonathan Neufeld:it any further than that, then yeah.
Dr. Jonathan Neufeld:You're going to be limited that you have to do a lot of those
Dr. Jonathan Neufeld:in person, but if you can.
Dr. Jonathan Neufeld:Break down that encounter breakdown, that level of service into a few of its
Dr. Jonathan Neufeld:components, like teaching and information exchange and lab results, explanation.
Dr. Jonathan Neufeld:And there are a lot of those things that don't have to happen
Dr. Jonathan Neufeld:in person at the doctor's office.
Dr. Jonathan Neufeld:The weakness of tele-health is using it to do what we've always done by video.
Dr. Jonathan Neufeld:The strength is when we start to rethink what we're doing by video, and what
Dr. Jonathan Neufeld:we're doing to deliver care, what it takes to deliver care and using the
Dr. Jonathan Neufeld:virtual channels that we have to do the things that they do well, and then use
Dr. Jonathan Neufeld:the in-person channels that we have to do the things that are necessary to do,
Cameron Hilt:That's a great point.
Cameron Hilt:Using tele-health is going against the status quo of the way that healthcare has
Cameron Hilt:been done and delivered for centuries.
Cameron Hilt:So really being able to think of now that we have this new way,
Cameron Hilt:that we can deliver this care.
Cameron Hilt:Are we actually thinking of it as a unique offering?
Cameron Hilt:Or are we just trying to do just like you said, are we just trying
Cameron Hilt:to provide the same service now it's just on video and not in person.
Cameron Hilt:Versus really trying to think through how does us offering this service
Cameron Hilt:through tele-health make this unique, how can we make this service better?
Cameron Hilt:Because we're providing it through tele-health or better fit
Cameron Hilt:for the patient or the provider versus, Kind of checking my box.
Cameron Hilt:I did my visit.
Cameron Hilt:I'm good to go.
Cameron Hilt:It's the same.
Cameron Hilt:And so really challenging some of that status quo.
Cameron Hilt:But because it's new for a lot of people the tendency is
Cameron Hilt:just to follow what you know.
Cameron Hilt:So if that's how you've provided care for your entire career, and now all of
Cameron Hilt:a sudden you have to learn how to do it over a tele-health platform, there's
Cameron Hilt:a learning curve attached to that.
Dr. Jonathan Neufeld:Yeah.
Dr. Jonathan Neufeld:There's a lot of change and it is not simple.
Dr. Jonathan Neufeld:I don't ever want to give the impression that, oh, all we have to do is X.
Dr. Jonathan Neufeld:And then, that'll solve problems.
Dr. Jonathan Neufeld:Healthcare is complicated and delivering individualized healthcare is challenging.
Dr. Jonathan Neufeld:Even in the best of circumstances, we've developed our skillsets
Dr. Jonathan Neufeld:and our ways of providing care.
Dr. Jonathan Neufeld:Just on the assumption that the patient is here.
Dr. Jonathan Neufeld:And it will take a while to Recode reorient to the ways that we can provide
Dr. Jonathan Neufeld:health care if the patient isn't here.
Dr. Jonathan Neufeld:It's also important to underscore the fact that.
Dr. Jonathan Neufeld:Healthcare also develops according to what's reimbursable because
Dr. Jonathan Neufeld:ultimately, you can provide an awful lot of healthcare, but if
Dr. Jonathan Neufeld:you don't get paid for it, you're not going to be doing it for long.
Dr. Jonathan Neufeld:And so telehealth has this, like any, I think probably any part of
Dr. Jonathan Neufeld:healthcare, it's absolutely dependent on the circulatory system that runs
Dr. Jonathan Neufeld:underneath it, that the infrastructure underneath it is the payment system.
Dr. Jonathan Neufeld:And if that in-person encounter is what has been conceptualized as this
Dr. Jonathan Neufeld:is what we pay then you have to kind of stuck trying to replicate the
Dr. Jonathan Neufeld:in-person encounter to get paid.
Dr. Jonathan Neufeld:So it's going to take some creativity on the part of payers as well, or
Dr. Jonathan Neufeld:some more vertically integrated capitation and quality-based payment
Dr. Jonathan Neufeld:arrangements that allow providers and organizations to be a lot more creative
Dr. Jonathan Neufeld:about how they provide services.
Cameron Hilt:Yeah.
Cameron Hilt:And I'm just gonna take a second, just for some of our listeners who may not
Cameron Hilt:know some of those innovative or different kind of value-based care payment models.
Cameron Hilt:Tell us a little bit about capitation payments and what that model looks
Cameron Hilt:like in a healthcare practice.
Dr. Jonathan Neufeld:Yeah.
Dr. Jonathan Neufeld:So a capitation payment is just a per member per month amount
Dr. Jonathan Neufeld:that a provider gets to provide a certain range of services.
Dr. Jonathan Neufeld:It could be, any healthcare they need all the way up to and including hospital care,
Dr. Jonathan Neufeld:but usually it's broken into outpatient and then other services, inpatient and
Dr. Jonathan Neufeld:others are paid separately, but a primary care group or an ACO or some organization
Dr. Jonathan Neufeld:may have primary responsibility for all the outpatient health.
Dr. Jonathan Neufeld:It might improve behavioral health and might not, but and then get
Dr. Jonathan Neufeld:a single payment per person.
Dr. Jonathan Neufeld:And then the provider it's up to them to provide the care that's necessary
Dr. Jonathan Neufeld:and that's way over simplified.
Dr. Jonathan Neufeld:But the idea is that it motivates the provider to both
Dr. Jonathan Neufeld:be proactive and efficient
Dr. Jonathan Neufeld:. So they want to, not just test everybody
Dr. Jonathan Neufeld:just waste care when it's not needed.
Dr. Jonathan Neufeld:But also at the same time, if they just did a test last month and
Dr. Jonathan Neufeld:they need it again this month, where they need that information.
Dr. Jonathan Neufeld:They get more efficient at finding the old test and saying, oh, okay,
Dr. Jonathan Neufeld:we've already got this information.
Dr. Jonathan Neufeld:We don't need to do it again.
Dr. Jonathan Neufeld:Or they get more effective at saying let's reorder these services or let's figure out
Dr. Jonathan Neufeld:how to provide these in a more efficient way as well as let's do it now instead
Dr. Jonathan Neufeld:of a year from now, when it's going to be a much more complicated process
Dr. Jonathan Neufeld:or the person going to be much sicker.
Dr. Jonathan Neufeld:The outcomes will be much worse . The provider is motivated because of that
Dr. Jonathan Neufeld:overall payment that doesn't change unless, their population changes.
Dr. Jonathan Neufeld:But basically I'm going to get the same amount of money for this person.
Dr. Jonathan Neufeld:It's way cheaper if I keep them well, than if I let them get sick and then intervene.
Dr. Jonathan Neufeld:That's the holy grail of capitation is that everybody's motivated
Dr. Jonathan Neufeld:to really provide high-quality preventive and interventionists
Dr. Jonathan Neufeld:care in the most cost efficient way.
Dr. Jonathan Neufeld:And most cost efficient usually works out to be best for the patient as well.
Cameron Hilt:you for that explanation, Jonathan.
Cameron Hilt:Yeah.
Cameron Hilt:it really will be interesting to see, As the year progresses and wherever the
Cameron Hilt:pandemic lands and some of the public health emergencies, as well as some of the
Cameron Hilt:waivers that have been extended during the course of the public health emergency, it
Cameron Hilt:will be interesting to see, some of these different innovative payment models that
Cameron Hilt:will come and hopefully, we'll see some of these waivers begin to become permanent
Cameron Hilt:past the public health emergency.
Cameron Hilt:I want to thank you so much for coming onto our show.
Cameron Hilt:And I want to give you a little bit of time.
Cameron Hilt:I know you have a upcoming conference.
Cameron Hilt:So go ahead and just give our listeners some details.
Dr. Jonathan Neufeld:Yeah it's a ways off yet in May end of May 23rd to 25th.
Dr. Jonathan Neufeld:And it's in Minneapolis.
Dr. Jonathan Neufeld:We are fingers crossed, but very excited to be back in person for the last two
Dr. Jonathan Neufeld:years, we haven't been able to have an annual conference and we have a very.
Dr. Jonathan Neufeld:As you mentioned before, and as I said, a very collaborative and collegial group up
Dr. Jonathan Neufeld:in the great Plains states, Northern great Plains states that love to get together
Dr. Jonathan Neufeld:and share ideas and solve problems.
Dr. Jonathan Neufeld:So May 23rd to 25th at the Radisson Blu mall of America.
Dr. Jonathan Neufeld:So I'm going to have a day and a half and have some fantastic keynote
Dr. Jonathan Neufeld:plenary speakers already lined up and people can find out more about
Dr. Jonathan Neufeld:it at gptrack.org/conference that's where people can find out more
Cameron Hilt:Thank you, Jonathan.
Cameron Hilt:And with our show notes, we'll make sure that we also share the GP track website.
Cameron Hilt:So any individuals who are interested can signup for your conference
Cameron Hilt:thanks so much for joining us and thank you all for listening today.
Dr. Jonathan Neufeld:great.
Dr. Jonathan Neufeld:Thank you, cam.
Caroline Yoder:I want to thank you for listening to a virtual view.
Caroline Yoder:You can find more information about today's episode in the show notes below.
Caroline Yoder:If you would like to support our podcast, please rate and review us on your favorite
Caroline Yoder:podcast platform do you have any questions or topics you'd like us to discuss?
Caroline Yoder:If so, contact us at info at UMTRC.Org or through the form found in the show notes.
Caroline Yoder:Also, we'd like to give a special thanks to our editor.
Caroline Yoder:Finally a special thanks to the health resources and service administration.
Caroline Yoder:Also known as HERSA.
Caroline Yoder:Our podcast series a virtual view is sponsored in part by HERSA's
Caroline Yoder:telehealth resource center program, which is under HERSA's office of
Caroline Yoder:the administrator and the office for the advancement of telehealth.
Caroline Yoder:The content and conclusions of this podcast are those of Cameron hilt of the
Caroline Yoder:UMTRC and should not be construed as the official policy of, or the position of
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