61 © Springer Nature Switzerland AG 2021 A. B. Bhatt (ed.), Healthcare Information Technology for Cardiovascular Medicine, Health Informatics, https://doi.org/10.1007/978-3-030-81030-6_5 Chapter 5 Financial Value for Cardiovascular Telemedicine Andrew Watson and Ritu Thamman Telemedicine has been present in healthcare for over 20 years, and initially it solved fundamental challenges and focused on the technical aspects that enabled it. Starting with the digital era revolution in the United States, the time between 2007 and 2015 saw a technological transformation. This digital transformation enabled hospitals, doctors, patients, and all the types of telemedicine and created a new horizon for virtual clinical delivery. This new view of telemedicine began to surface our understanding of its financial value. Healthcare, at its most fundamental level, is dedicated to providing healthcare for patients, and it is based on business models. Therefore, telemedicine is providing care for sick patients and also providing well care, but it has to follow a sound financial model. The rise of the technical capabilities of telemedicine has enabled financial experts to begin to understand the long-term and more holistic model that incorporates telemedicine into the business of healthcare. Telemedicine continues to evolve, primarily through remote patient monitoring, and the outcomes are growing in terms of volume and a level of sophistication. Therefore we have reached a crucial point in telemedicine where virtual activity must be based on financial models with a sound economic underpinning. All the major cardiovascular diagnoses can be impacted by telemedicine: CHF, AFib, CAD/STEMI, and HTN. The COVID era of March through May of 2020 forced healthcare almost entirely to be delivered through telemedicine. There were services such as surgery or face-to-face emergency care, which followed the traditional in-person methodologies. Still, in essence, the rest of the delivery system went virtual in an emergent fashion. This gave us a unique perspective on A. Watson Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA e-mail: watsar@upmc.edu R. Thamman (*) Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
62 telemedicine’s financial value and accelerated the adoption of telemedicine throughout the United States. As the first wave of COVID slowed in June 2020, the healthcare systems looked to understand the new norm, which is a combination of telemedicine and face-to-face encounters, all of which are based on the financial model behind telemedicine [1]. With cardiovascular medicine for both sick and patients, telemedicine represents a significant opportunity to provide value and, in particular financial benefit. Financial value falls under the broader rubric of value as a whole, and value is defined as the cost of healthcare combined with the quality healthcare. The cost of healthcare is based on the unit price and the rate of utilization. Therefore, telemedicine’s financial value for cardiovascular care can be impacted by changing the unit cost, the rate of utilization, and quality of care metrics, which increase in importance. The quality of care is a critical feedback loop for the financing of healthcare, for both the hospital and payer side. Hospital and payer quality metrics govern the high-level funding of all healthcare. Therefore, when we discuss cardiovascular telemedicine care’s financial value, the quality of care is an important consideration. Now that telemedicine is becoming more commonplace and more central throughout healthcare, defining its monetary value is critical not only for how payers, providers and hospitals use it today but also in long-term tactical integration. The year 2020 represents a landmark year for the deployment of telemedicine. Still, behind the scenes, it also represents the defining moment for how we position time telemedicine for financial value moving forward. Cardiovascular medicine has been at the forefront of innovation to advance patient care during the digital era revolution in the United States. The cardiovascular digital transformation enabled the creation of a new horizon for virtual cardiac care delivery. As infrastructure changed, telemedicine required the development of a financial model to parallel the novel care paradigms. The implementation of telemedicine has the potential to cut healthcare costs by an estimated $7 billion a year in the United States alone [2]. Financial leaders in institutions and practices now must devise a long-termmodel that incorporates telemedicine into the business of healthcare. During the COVID-19 era of March through May 2020 healthcare was forced to be almost entirely virtual. There were services such as surgery or in-person emergency care, which followed the traditional in-person methodologies however, the rest of the delivery system went virtual in an emergent fashion. This gave us a unique perspective on telemedicine’s financial value and accelerated the adoption of telemedicine throughout the United States. Reducing or containing the cost of healthcare is one of the strongest motivators to fund and adopt virtual care technologies. Telehealth reduces the cost of healthcare and increases efficiency with better management of chronic diseases, shared health professional staffing, reduced travel times, and fewer or shorter hospital stays. Telemedicine’s financial value for cardiovascular care can be impacted by changing the unit cost, the rate of utilization, and quality of care metrics. Hospital and payer quality metrics govern how we define monetary value and are critical in establishing how payers, providers and hospitals create a blended and in person care model. A. Watson and R. Thamman
63 5.1 Defining Financial Value in Telemedicine Telemedicine has three key facets, which influence integration into clinical cardiovascular care and financial value. Clinical outcomes, access to care and patient experience are all essential to financial success. The recent history of telecardiology has evolved over the past two decades. From 2000 to 2010, synchronous video visits to live rural clinics, access to care over broadband, remote EKG readings, tele- echocardiography and video consultations were predominant. The payment methodologies were often standard contracting fees for subspecialty cardiac care. The system wide downstream value of expanding outreach using these remote clinics was significant and allowed programs to continue, though not necessarily expand, especially as reimbursement rates were limited by rural local designation. The Evolution of Telecardiology Telephone visite Synchronous video to rural clinics Remote EKG readings Image transfers and eConsults Access to care over broadband Remote monitoring and EMR integration Each of these three areas (asynchronous, live video-based and RPM care) of telemedicine has financial implications for the field of cardiovascular medicine, and each in a very different way (Table 5.1). As these three areas evolve, their integration into the healthcare systems and physician offices will impact the root level finances of healthcare. They may add more capability for encounter and management billing, they might provide significant value for risk arrangements such as pay for performance, or they could play a significant role for cost avoidance which is a positive in a bundle type setting or a negative for reducing hospital utilization. Therefore, watching the evolution of telemedicine and understanding the basis for its financial value is critical for cardiovascular virtual care evolution. In the wake of COVID-19, the use of telemedicine grew exponentially causing the value of telemedicine to increase. Catalyzed by necessity and supported by emergent regulatory implementations, many cardiology practices globally transitioned to primarily virtual care for some portion of 2020. This has allowed healthcare systems to see the potential financial benefit of telemedicine deployment on a large scale. The two most influential factors in creating a positive financial impact using cardiovascular telemedicine are space utilization and clinician top-of-license 5 Financial Value for Cardiovascular Telemedicine
64 care. Optimizing these factors has long driven cost savings in outpatient medicine, and the use of virtual care clearly supports decreased space utilization and increased staff engagement [4]. 5.2 Financial Impact of Telemedicine Based on Location of Care Telecardiology care delivery influences the financial impact of the provision of virtual care. There is data supporting the financial impact of both hospital-based and outpatient care models of in-person care and now telemedicine, with each demonstrating unique financial advantages and challenges. The cost of implementation and maintenance of telemedicine systems must be incorporated into the value equation. The use of in hospital telemedicine allows for increased community based care, maximizing the physical use of those locations, while expanding expert clinician reach. The development of efficient telemedicine clinics reduce clinical revenue and increase operational expense, thus adequate design and implementation is critical. The consumer-electronics market has enabled patients to purchase their own phones, wireless plans, computers and broadband plans that minimize the financial outlay for hospitals and outpatient offices for home telemedicine. Much of Table 5.1 Types of telemedicine tools Store and Forward Asynchronous Care: During the early 2000s, methodologies such as teleradiology and store-and- forward technologies became the norm. A similar approach in cardiovascular imaging and electrophysiology monitoring is now utilized for capturing data in remote geographic locations. It reduces workforce redundancy which is appealing to hospitals with low margins who cannot afford to have underutilized physicians at remote sites. Live Video- based Care: From 2010 to 2015 this new type of telemedicine evolved based on the maturation of consumer-electronics, cellular technology and smartphones. Although it was initially used in the urgent care setting, this technology has become incorporated into electronic health records (EHRs) and the basis for large telemedicine platform delivery companies such as Teladoc. MD Live and American Well. There are key features developed around the live video visits such as waiting rooms, documentation, and registration that enable large cohorts of patients to be seen by multiple providers akin to a normal busy clinic. During the COVID-19 pandemic, the hospital and doctor financial revenue became almost entirely dependent on this technology. Remote Patient Monitoring [RPM]: This is an asynchronous form of telemedicine where data is gathered from a patient at home or a remote location, the data is filtered by a central intake setting such as a call center and is fed into source systems such as EHRs. In comparison to face-to-face visits for data gathering such as BP measurement in a clinic, these systems allow practices to monitor many patients simultaneously, for example allowing rapid iterations of BP medication adjustments leading to shorter time to guideline directed medical therapy and target goals [3]. A. Watson and R. Thamman
65 the expense for patients at home is “free”, which is a major benefit for scaling all types of home-based telemedicine for cardiovascular care. Thus the connectivity and integration of telemedicine from the provider side has a real expense, which is partially offset by consumers handing the cost of their endpoints. In low socioeconomic settings, communities and employers may need to partner with hospitals and patients by investing in the technology infrastructure to promote access to virtual care. There is research supporting the financial value of telemedicine, which can be used to improve upon inpatient and outpatient care delivery by promoting blended in-person and virtual care which creates the optimal safety profile while reducing healthcare costs. 5.2.1 Hospital-Based Care 1. Telemedicine based cardiovascular ICU care is already used in approximately 15% of the beds across the United States [5]. Telemedicine ICU care leads to a decreased length of stay, reduced mortality rate and increased quality of patient care while financially benefiting the hospital. 2. Remote inpatient consults have long been used in rural and underserved areas [6] and expanded in 2020 in many countries to allow continued comprehensive high quality cardiovascular patient care during the pandemic, while also preserving revenue generation and fiscal health. 3. Pre-hospital care from the home or ambulance prior to the patient’s arrival in a hospital is a growing use of telemedicine which has demonstrated cost savings [7, 8]. 4. Telemedicine promotes physician wellness and engagement, thereby decreasing burnout associated patient safety errors and decreased patient satisfaction. Costs associated with staff turnover, lost revenue from decreased productivity, and financial risk with burnout-related lower quality of care highlight the financial need for cardiovascular telemedicine [9]. 5. Physicians and practices also benefit from decreased travel time to rural and outlying clinic locations, improving strategic implementation of brick-and- mortar clinics with increased physician time efficiency. 5.2.2 Outpatient Care 1. Pacemaker and defibrillator surveillance based on remote monitoring is well established to be safe, efficient and cost effective while also reducing hospital visits in the long term [10, 11]. Implantable devices also provide meaningful longitudinal patient data while increasing practice revenue [12]. 5 Financial Value for Cardiovascular Telemedicine
66 2. Physicians in outpatient settings can interpret remote patient monitoring data and other store and forward type data gathered from implantable devices, and can bill chronic care E&M codes and remote patient monitoring codes [13]. Mobile applications for telemedicine evaluation of atrial fibrillation was also recently developed for outpatient follow up [14]. 3. Limited echocardiography by nurses in an outpatient heart failure clinic supported by interpretation by an out-of-hospital cardiologist, has been found to be feasible and reliable when using tele-echocardiography in a heart-failure clinic [15]. 4. Post-discharge remote patient monitoring (RPM) enables early discharge and avoids readmissions and associated penalties [16]. Virtual cardiac rehabilitation has demonstrated improvement in exercise capacity, improves cholesterol levels & diet quality in a 16 week randomized controlled trial [17]. 5. Telemedicine improves outpatient access by helping patients overcome barriers including travel limitations, time off from work, and childcare, thereby benefiting lower socioeconomic groups, primary child caregivers and the elderly [18]. 5.2.3 TeleCardiology in the Home Another new location that impacts how cardiologists practice telemedicine is the home (See Home Hospital Case). There is a growing awareness about work from home options which impacts physician quality-of-life, burnout and satisfaction. If physicians have less burnout and have more flexible hours because they can work at home, this provides an opportunity for them to see more patients or be more efficient which will translate directly into increased E&M billing. This is additional revenue to the physician’s office or the hospital. Most important is maintaining a healthy and efficient workforce with low turnover. Staff recruitment, unplanned time off work due to burnout and inefficiency are financial stressors to outpatient offices and hospitals alike. There is enough justification to be made for investing in physician wellness and engagement. Increased physician burnout is associated with higher physician turnover, and decreased productivity which can lead to lost revenue. In addition, hospitals see more patient safety errors and decreased patient satisfaction. Costs associated with turnover, lost revenue associated with decreased productivity, as well as financial risk with burnout and lower quality of care highlight the financial need for cardiovascular telemedicine [9]. One important consideration about location-based telemedicine is the expense of providing the telemedicine service as the entire financial equation is not entirely based on revenue. Telemedicine involves “tele” technology which has a capital expenses and also an operational expense. The telemedicine systems and the endpoints such as echo machines that gather the data all have communication needs, are depreciated overtime and need routine maintenance. The cost of implementing A. Watson and R. Thamman
67 telemedicine solutions and maintaining them must be added to the value equation; typically they are paid for by a hospital or outpatient office. An incomplete telemedicine technology implementation may result in low provider efficiency, duplicate patient records, or more technical challenges that lead to less productivity and greater maintenance expense. This would reduce clinical revenue and increase operational expense, both unfavorable for the net value for cardiologists. Therefore, the clinical design and implementation of the technology is critical. One favorable factor about technology location is that the consumer-electronics market has enabled patients to purchase their own phones, wireless plans, computers and broadband plans that minimize the financial outlay for hospitals and outpatient offices for home telemedicine. In essence much of the expense for patients at home is “free” which is a major benefit for scaling all types of home-based telemedicine for cardiovascular care. In summary, the connectivity and integration of telemedicine from the provider side has a real expense which is partially offset by consumers handing the cost of their endpoints. This creates a valuable future for scaling telemedicine for quality and other key clinical outcomes within a viable business model. 5.3 Stakeholder Based View of Cardiovascular Telemedicine Care There is a second way to view telemedicine financial value for cardiovascular care, and that is from the perspective of the healthcare stakeholders. The key stakeholders include providers, payers, and patients. Although there are commonalities seen by location it is worthwhile seeing the care of cardiovascular telemedicine using the perspective of these primary stakeholders to tease out nuances and specific quality and economic advantages. Practice Logistics to Support Financial Value (United States) Practices must develop standardized front-end registration processes for telehealth patients in addition to in-person appointments. Demographic and insurance coverage verification using eligibility software can help maximize reimbursement. Addition of new networks to your practice which align with virtual care models may also be financially beneficial. CMS publishes a list of currently approved telehealth codes and The American Medical Association (AMA) compiles the CPT handbook, in which the “starred appendix” includes those codes that are telehealth eligible. National and local telehealth policies should be reviewed routinely as they will likely change over the next several years. These policies may affect licensing and credentialing requirements.As a best practice, to understand state-specific policies, providers can check the Center for Connected Health Policy State Telehealth Laws and Reimbursement Policies Report [19]. 5 Financial Value for Cardiovascular Telemedicine
68 5.3.1 Stakeholders: Cardiologists Healthcare providers, and cardiologists in particular, benefit financially from using telemedicine when caring for their patients as was seen in the location perspectives described above. This group of providers also includes advanced practice providers, nurses and allied health professionals. Traditional face-to-face visits can be replaced to a significant degree with telemedicine, and in the setting of Covid telemedicine may be the only modality to reach out to and provide clinical care for patients. The main challenge with routine at home telemedicine for cardiologists is the inability to listen to heart tones, but not every examination requires such data such as a routine blood pressure or medication symptom evaluation. There are peripherals and digital stethoscopes that can transmit virtual heart tones but they can be expensive and or require pairing with a phone. The capabilities and less-expensive such peripherals are emerging and may become commoditized in the near future. If telemedicine care is able to increase compliance with patient visits, one would expect to see better quality of care and more E&M revenue captured. Yet, there can also be technical challenges with patients setting up video call software on their phones or working with remote monitoring which may slow down providers and create delays in clinics. These two facts point to a need to educate patients and providers with training and marketing materials to ensure a value-based deployment of telemedicine. Many cardiologists perform procedures such as implanting pacemakers, implanting defibrillators, and stents during angiograms. Procedural physicians have to do a routine post-procedural evaluation of incisions and basic functionality with symptom checking. As has been seen with surgeons, this type of post-procedure or care can routinely be handled with telemedicine video visits to the home. This has significant benefits to the patients because they do not have to travel. It also impacts physician clinical efficiency as they post-procedure patients do not have to be roomed, get vital signs, and consume staff time. This typically results in more streamlined outpatient clinical operations and saves face to face time for new patients and thus new revenue. Telemedicine also is in the emerging stage of being used to capture new patients, especially those from a wide geographical range. Meeting a new patient virtually prevents driving and expands a cardiologist’s outreach geography. An in-person new visit may be difficult for a variety of social or geographical reasons for patients to come for multiple face-to-face clinic visits before or after procedures. Therefore, telemedicine enables cardiologists to expand their practice without the inefficiency of driving. There are also telemedicine pre-procedural services that evaluate patients beforehand to ensure the procedures are successful, the patients are appropriate for a procedure, and that the procedure is not canceled. With procedures, there should not be cancellations or unnecessary delays because of the negative safety implications and financial impact. As cardiologists are rated by patients using vehicles such as Press-Gainey scores or CHAPS scores, they are held accountable for post-procedural or post-hospital A. Watson and R. Thamman
69 care. Using technology such as remote patient monitoring and video visits to increase routine access without driving can prevent readmissions or early transfers back from nursing homes. In other words, telemedicine is a risk mitigation strategy and a patient satisfaction strategy that impacts reimbursement and provider ratings. Patients are favorably responding to telemedicine and the avoidance of unnecessary driving. As discussed above, burnout with physicians is becoming commonplace, and therefore if a hospital or a practice group is trying to recruit a cardiologist to join them, offering telemedicine is essential [20]. Giving doctors flexible schedules that facilitate individual styles of practice can reduce burnout and may be more feasible with telemedicine [21]. Telemedicine offers the flexibility of work from home or other strategies to prevent burnout. Telemedicine based employee assistance programs or employer health clinics will result in a healthier and more productive workforce, directly tied to bottom-line financial performance. Physicians, especially those in private practice and those in large academic medical centers may have to drive to multiple clinics to cover sufficient geography for referrals and recruiting procedures. Driving wastes valuable time and also incurs travel expenses. Therefore, using telemedicine to engage or replace remote clinics strategically is a useful and efficient way to cover or expand a cardiologist’s geography. Therefore, telemedicine can offer a wide array of benefits for providers from reducing travel time, a better quality of life, expanded patient catchment arê, and more efficient clinics. The diverse nature of telemedicine from the providers’ perspective has made it challenging to quantify the exact bottom line of the financial impact. Over time, analytics and finance teams focusing on telemedicine will start better to quantify the financial performance for the cardiology community. Inherently and intuitively, telemedicine adds economic value in its current form, and it will only increase in value over time. 5.3.2 Stakeholders: Payers Payers are one of the most important stakeholders when discussing telemedicine’s financial advantages when taking care of patients or members who have cardiovascular diseases (See Medical Diagnoses using Remote Patient Monitoring). Payers represent a critical waypoint between employers and front-line healthcare. Payers also offer care delivery methodologies by their care teams such as pharmacists or care managers who interact directly with members to promote health and wellness. Payers can impact the financial landscape of telemedicine through payment policies, benefit design, sales channels, government bid process, and, more specifically, to third-party payers how they manage their Medicare advantage. Payers directly control the financing of telemedicine through policies that dictate reimbursement for telemedicine services. They also contract individually with the 5 Financial Value for Cardiovascular Telemedicine
70 delivery side of healthcare and negotiate rates that include telemedicine services. Payers also help manage risk, especially with chronic diseases within their member cohort, using care managers. These teams can impact the total cost of care, unplanned utilization of care, and ancillary authorization. All of this directly affects the financial advantages and value of telemedicine care for cardiovascular patients. How they work with physician groups, hospitals, or the network at large through telemedicine services can have a significant impact on their medical spending across all business lines. The Covid epidemic in particular highlighted the use of telemedicine when CMS expanded the codes for the use of telemedicine. Their forward leaning view was important to show the use of telemedicine for traditional E&M visits and in risk arrangements. Payers also are looking to utilize niche telemedicine solutions for particular diseases such as COPD, diabetes, and heart failure that tend to be focused on remote monitoring solutions. For example, using asynchronous text messages improved glycemic control in patients with diabetes mellitus and coronary heart disease [22]. These telemedicine solutions help to help manage costs for those high spend patients and also coordinate aspects of their care such as medication reconciliation or social determinants of health. Companies such as Livongo offer a suite of remote clinical services that could augment outpatient or inpatient cardiovascular care, and overall could favorably impact the spend on these patients. Many chronic diseases have ineffective management contributing to increased health care. Remote patient monitoring RPM can an effective tool for assisting in the self-management of chronic CVD risk factors like diabetes as shown by the Mississippi Diabetes Telehealth Clinical Care model [23]. Another key area for payers is access to care for their members, and clearly telemedicine is one of the critical new tools to provide virtual access. The other Medical Diagnoses using Remote Patient Monitoring Medical diagnoses involving remote monitoring are ideal for payer supported virtual care 1. Asynchronous text messages improve glycemic control in patients with diabetes mellitus and coronary heart disease [22]. 2. Remote clinical services augment outpatient and inpatient cardiovascular care, while favorably impacting cost [14]. 3. Telemedicine models assist self-management of chronic CVD risk factors including glycemic control, weight and blood pressure reduction and increase in physical activity [23]. 4. Mobile health use reduces risk of rehospitalization and clinical adverse events in patients with atrial fibrillation compared with usual care [24]. 5. Home blood-pressure telemonitoring among adults in the US with uncontrolled hypertension, a 1 year intervention led to over 4 years of target BP measurements [25]. A. Watson and R. Thamman
71 traditional options of face to face clinics and inpatient care are typically expensive and can be difficult to control the unplanned and total spend. Synchronous audiovideo telemedicine consults can take care of patients remotely and avert more expensive care settings and decrease costs [26]. Even if the patient stays at home, visiting nurses can drive to the patient’s house which is still episodic and leverages E&M billing which is a cost accelerator. So the ability for telemedicine to provide access to patients at home or in other remote locations including care facilities is very important for care coordination, chronic disease management, and cost avoidance. There have been challenges for the payer community in deploying telemedicine and their constant focus on financial value, and one area is the evolution of RPM. For congestive heart failure patients there is real promise for RPM, yet to date there are not the financial returns that would drive long term payer financing mechanisms put in place behind it. On the other hand, a recent study of Mobile Health technology use found reduced risks of rehospitalization and clinical adverse events in patients with Atrial fibrillation with it compared with usual care [24]. A good portion of this initial literature is likely due to early operational models and evolution of the RPM technology, but nonetheless there remains the promise that the RPM early warning system should help to provide value to the payers and help the patients avoid the care and financial challenges of unplanned care. Third-party pears in the United States are also very cognizant of their star ratings and their health effectiveness and data information set (HEIDS). Star ratings are impacted by HEDIS scores and there is real hope that telemedicine can help close HEDIS gaps to increase scores and thus revenue. As payer quality becomes more dependent on subjective feedback, the member’s convenient access to care using telemedicine should favorably impact those quality metrics and eventually revenue. For example, home blood-pressure telemonitoring among adults with uncontrolled hypertension, a substantial percent of all hypertensives in the USA, showed that after 1 year after intervention, BP remained significantly better, and didn’t return to “usual” levels for over 4 years [25]. The largest payer in the US is the federal government, CMS, which has been supporting telehealth and expanding its support through increased codes and opportunities surrounding COVID. On March 172,020 CMS announced temporary telemedicine codes building upon the regulatory flexibilities granted under the President’s emergency declaration allowing beneficiaries in all areas of the country to receive telehealth services, including at their home through a new waiver in Section 1135(b) of the Social Security Act. This explicitly allows the Health Secretary to authorize use of telephones that have audio and video capabilities for the furnishing of Medicare telehealth services during the COVID public health emergency. Even before the COVID pandemic, CMS was expanding the number of codes for reimbursement for RPM and the ability to conduct remote telemedicine visits using traditional E&M coding in the US. CMS and the administrator are openly supporting telemedicine. The Wall Street Journal quoted Seema Verma, head of CMS, 5 Financial Value for Cardiovascular Telemedicine
72 saying “the Genie’s out of the bottle” alluding to the COVID pandemic causing telemedicine to escape from its dormant confined state into an accelerated larger form [27]. With the COVID pandemic, the telemedicine landscape shifted from a nice to have feature to mission critical with financial value as the most important driver of its continued growth. Urgent care issues addressed with on-demand telemedicine and behavioral health were adopted early in the US payer community for reimbursement. However since 2020, the payer community, through multiple and overlapping strategies, are seeing the financial value of longitudinal cardiovascular telemedicine for prevention, chronic disease management and early identification of acute cardiovascular needs and putting in place high-level financial controls to drive its expansion and value. 5.3.3 Stakeholders: Patients There are multiple ways that patients themselves benefit financially from telemedicine when they have cardiovascular diseases. One of the most common ways is not having to travel to the clinic. Patients with cardiovascular disease typically require longitudinal follow-up, short interval follow up after procedures or routine medication adjustments. When patients have to travel, there is the cost of gas, tolls, parking, and meals, not to mention time off work through lost wages or having to pay for childcare. Older patients also could have a difficult time driving, and therefore have to pay someone to drive them or find a relative or friend who also has to take time off work to provide transportation. The cost-benefit of telemedicine has been recognized as it avoids the expense and hassle of patient travel. Also, as patients now have high deductible accounts through employers and payers and are more at risk for their health; having access to care can be less expensive at times if they engage the healthcare system virtually. Many payers offer lower copays for virtual first services, which directly reduces the expense of seeking healthcare. Patients can also get lower-cost advice about care options using telemedicine before incurring high-cost and high-deductible in-person services. The most important part of patients using telemedicine is receiving high-quality care for health and well care. Still, there are undoubtedly direct avoided costs that can be of significant cumulative value for patients who require longitudinal cardiac care such as patients with complex heart failure to those with uncomplicated hypertension who require medication adjustments. It is easier to use RPM and a home blood pressure cuff then to travel several hours every month or two to keep their blood pressure checked and medication adjusted. A. Watson and R. Thamman
73 5.4 Summary Telemedicine is now a foundational element of cardiovascular care delivery and benefits all healthcare stakeholders. Telemedicine impacts the entire spectrum of care delivery including consumer engagement, hospital based ancillary care, and home, outpatient, ICU and consultative care. Payers now look to telemedicine for access, care management and value. Over time, if quality and cost analyses are set up correctly, the field of cardiology will efficiently use telemedicine to optimize clinical and financial value for cardiologists, hospitals, payers, and most importantly, patients. We have reached a crucial point in telemedicine where virtual activity must be based on financial models with a sound economic underpinning. References 1. Watson AR, Wah R, Thamman R. The value of remote monitoring for the COVID-19 pandemic. Telemed J E Health. 2020;26(9):1110–2. https://doi.org/10.1089/tmj.2020.0134. 2. Duggal R, Brindle I, Bagenal J. Digital healthcare: regulating the revolution. BMJ. 2018;360:k6. 3. Fisher NDL, Fera LE, Dunning JR, Desai S, Matta L, Liquori V, Pagliaro J, Pabo E, Merriam M, MacRae CA, Scirica BM. Development of an entirely remote, non-physician led hypertension management program. Clin Cardiol. 2019;42(2):285–91. PMID: 30582181. 4. CDC. Using telehealth to expand access to essential health services during the COVID-19 pandemic. 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html 5. Vranas KC, Slatore CG, Kerlin MP. Telemedicine coverage of intensive care units: a narrative review. Ann Am Thorac Soc. 2018;15(11):1256–64. https://doi.org/10.1513/ AnnalsATS.201804-225CME. 6. Klein S, Hostetter M. Using telemedicine to increase access, improve care in rural communities. 2017. https://www.commonwealthfund.org/publications/newsletter-article/2017/mar/ using-telemedicine-increase-access-improve-care-rural 7. Miller AC, Ward MM, Ullrich F, Merchant KAS, Swanson MB, Mohr NM. Emergency department telemedicine consults are associated with faster time-to-electrocardiogram and time-to-fibrinolysis for myocardial infarction patients. Telemed J E Health. 2020; https://doi. org/10.1089/tmj.2019.0273. 8. Menees DS, Peterson ED, Wang Y, Curtis JP, Messenger JC, Rumsfeld JS, Gurm HS. Door- to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013;369:901–9. https://doi.org/10.1056/NEJMoa1208200. 9. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826–32. https://doi.org/10.1001/jamainternmed.2017.4340. 10. Watanabe E, Yamazaki F, Goto T, Asai T, Yamamoto T, Hirooka K, Sato T, Kasai A, Ueda M, Yamakawa T, Ueda Y, Yamamoto K, Tokunaga T, Sugai Y, Tanaka K, Hiramatsu S, Arakawa T, Schrader J, Varma N, Ando K. Remote management of pacemaker patients with biennial in-clinic evaluation: continuous home monitoring in the Japanese at-home study: a randomized clinical trial. Circ Arrhythm Electrophysiol. 2020;13(5):e007734. https://doi.org/10.1161/ CIRCEP.119.007734. 11. García-Fernández FJ, Asensi JO, Romero R, Lozano IF, Larrazabal JM, Ferrer JM, Ortiz R, Pombo M, Tornés FJ, Kolbolandi MM, on behalf of the RM-ALONE Trial Investigators. Safety and efficiency of a common and simplified protocol for pacemaker and defibrillator surveillance based on remote monitoring only: a long-term randomized trial (RM-ALONE). Eur Heart J. 2019;40(23):1837–46. https://doi.org/10.1093/eurheartj/ehz067. 5 Financial Value for Cardiovascular Telemedicine
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