“A lot of these companies have a model where they have a lot of touchpoints [with patients]said Ateev Mehrotra, a health policy professor at Harvard University who studies telehealth insurance claims. “Payments for a visit don’t really make sense from that perspective.”
Teladoc, for example, plans to gradually adopt greater risk sharing, CEO Jason Gorevic said at the JPMorgan Health Care conference last week. Teladoc offers on-demand video tours and a range of digital programs for chronic and behavioral health and currently earns most of its money through contracts with health plans and employers who pay a monthly fee per member, as well only a fee per visit. for appointments.
“Certainly we will move forward not just to get a share of the savings, but ultimately to take risks on a population,” Gorevic said. This could involve receiving a lump sum payment for patient care, known as a capitation, or a range based on the amount of patients who use their services, he explained. The company is piloting some of these models with customers, he said.
These different types of “risk-sharing” agreements aim to avoid costly medical care by encouraging providers to focus on prevention, such as managing diabetes or high blood pressure, to avoid the need for medical care. more expensive and more complex. They could also help health plans and employers ensure that the services they pay for significantly improve patient health and reduce costs.
Agreements that hold providers accountable for patient health are increasingly common in the physical world, including for Medicare and Medicaid patient-focused healthcare systems and payers. But many payers are still reimbursing per visit or per procedure, and telehealth companies billing their services as virtual doctor appointments can waive additional payment for services that can’t easily be billed in the telehealth system. current claim, Mehrotra said.
“It’s a realization that, ‘Wow, a significant portion of care can be delivered through a variety of different modalities within the telemedicine industry, ranging from chatbots to video chat,'” said Andy Altorfer, CEO of Cirrus®. “We need to move away from this transactional model… We need models where [patients] have continuous and ongoing access.
But telehealth companies and their customers are still struggling to structure contracts and price their offerings.
“We’re taking a pretty slow and steady approach,” said Jeff Wessler, founder of Heartbeat Health, which offers cardiac consultations and technology to help patients and doctors monitor heart health remotely. About a quarter of Heartbeat’s business comes from contracts that spread the costs it saves insurers by avoiding costly heart procedures, and it hopes that will reach 50% by the end of the year.
Negotiating these cost-cutting contracts can be difficult because it requires a company to compare patients to a reference group to show how much they could have accrued in medical costs without these services. With this data, telehealth companies need to convince their customers that their interventions are what drove costs down, he said. “You really need to understand what outcomes you can influence before you jump in,” Wessler said. “If a payer has to make the decision to take a risk, there have to be very clear lines as to what is attributed to an intervention.”
An insurer that also offers weight loss and smoking cessation programs to a member who might have been at high risk for a heart attack may wonder which program actually avoided hospitalization, Wessler said. “Who do you give credit to? These are tough decisions to make. »
Depending on their margins and business performance, the priorities of health plans and employers can shift year over year from reducing medical costs to increasing patient satisfaction with the benefits of digital health, said Altorfer of CirrusMD. CirrusMD, which offers text, phone and video consultations with physicians, assumes all risk for about a third of its clients. About a third of clients are opting for a per-member-per-month fee with additional fees for appointments — a more traditional approach that carries less risk to the business. “Literally every customer is trying to solve something different,” added Altorfer.
The way these new types of contracts are playing out hints at the role of virtual care in the traditional healthcare system and could prompt them to partner with physical providers to ensure patients can access preventative care, instead of just offering one. out of date, said Jennifer Goldsack, chief executive of the Digital Medicine Society.
“It’s possible to reimagine what healthcare looks like when it’s around the patient,” she said.