Kaminski Speaks on Behalf of Telehealth During COVID-19 (VIDEO)

MHE: Can you define the terms population health and telehealth?

Kaminski: Population Health is a discipline that has grown over the past decade. It really represents an effort to take the discipline of public health and better align it with healthcare and healthcare systems. Over the past 10 years the Jefferson College of Public Health was the first establishled in the country. We've looked to bridge that gap and to better collaborate to help healthcare systems better collaborate with public health and with communities.

The driving force behind that is realizing that you don't manage a population of patients just from within the four walls of a hospital or your examining room. You really need to work in collaboration with community agencies, public health experts, and the government to address all of the forces that impact the health of our patient populations.

And I should say that population can be defined many different ways. It may be a regional population, within your catchment area for your health system. It could be the population of the country or the world. It could be a population for just one of them. Your employers, their employees and family members, or even in a stricter medical sense, it can be a population of all of your patients with diabetes or all of your patients with congestive heart failure.

Moving on to telemedicine, it is a tool. It represents different applications of technology. So, if I had a patient with congestive heart failure and they had a Bluetooth scale that sent their daily weight to me into my electronic medical record, that is one example of the tool of telemedicine.

But I think what we're talking about today are telemedicine visits, which is usually video and audio just like we are doing today on this interview, with patients [and] between patients and providers, or their nurses or community health advocate or someone from the medical system.

MHE: I've tended to think of population as sort of a paradigm shift in terms of the way you practice healthcare. I think the paradigm of delivery of care has been the doctor working within a patient at a time. And that population health is looking at the unit of care as being many people. Maybe just a panel of patients, but maybe, as you say, it could be people in a neighborhood or the whole city, depending on where you sit in the healthcare system. Is that the way you think about it?

Kaminski: Yes. paradigm shift is a good way to describe it. And it's at different levels.

So, for example, physicians who are used to being in the office and they take care of the patient who is sitting in front of them in an office visit, might have a staff member reach out to that patient, if they haven't come in for a visit, maybe talk about their need to come in for a visit or need to have testing done to monitor their chronic disease.

But, an even deeper aspect of that paradigm shift is to realize that patients who we might call before noncompliant, which is a pejorative term. Now it's better to call them nonadherent. Well, there are different reasons for nonadherence. For example, they may not have child care or they may not have transportation, or they may not be able to afford their copay - or they may not have health insurance at all.

So the paradigm shift [of population health] pushes us to consider the social determinants of health, as well, either because it's the right thing to do if you're caring for your population or to recognize that a lot of the high costs of medical care affect patients who don't get the care, the medications that they need, because of the social determinants of health working against them.

MHE: Let's discuss how telehealth and population health might fit together. If, in some sense, we're trying to reach out into communities with population health and address issues like adherence, it seems like it could be a marriage made in heaven.

Kaminski: It is. It's a tool, and we talked about how the technology can be applied to better monitor patients with chronic conditions. But most important, it affords greater access for patients to medical care and primary care, including greater convenience and less cost when you think about having to miss work to come in for a visit or having to get child care or to pay for transportation. So it is a tool that ultimately helps us better care for our patients.

MHE: Why has it taken a crisis like COVID-19 for telemedicine to be used more both by doctors and patients? 

Kaminski: There are [many articles] out over the past five to 10 years saying that this is a very useful tool and should be adopted. I think there is a natural resistance to change so providers may be comfortable with the way they conduct visits and not comfortable with new technology. So I think that's some of the resistance.

But I believe the biggest impediment to more widespread and quicker adoption has been the payment model. If you have a healthcare system that is predominantly based on getting paid for face-to-face visits and generating relative value units which guide your pay, then that will be the dominant model of care.

That's where the pandemic has really moved an incremental change to a transformative change. At Jefferson, our emergency room doctors began highlighting telehealth visits about three years ago. They created an app and called the program Jeff Connect. They offer it to any patient who wants to download the app and request a visit. They have, up until now, charged a relatively small amount for those visits. It's out of pocket because insurance companies wouldn't pay for it. If you're a Jefferson employee, you have only a copay and Jefferson does pay for those visits. They were providing about 50 telemedicine visits per day until the pandemic hit. And suddenly they found themselves with requests for over 3,000 visits a day, a 60-fold increase.

The emergency doctors turned to the primary care providers at Jefferson and we all stepped up to the challenge. We are all doing shifts of Jeff Connect telemedicine visits to meet that demand of over 3,000 a day. It's forced us all to learn the technology.

In terms of payment, my understanding is that rule changes by CMS mid-March really opened the floodgates here. There were various rules, I think, that [telemedicine] patients had to go to a designated area outside their home. I think there were HIPAA rules that prevented the use of FaceTime, and I presume you're using Zoom for some of these visits. So am I correct and believing that it was the relaxing of those regulations that open things up here?

Kaminski: Absolutely. And CMS usually is first in terms of paying for new care models, and then private insurers follow.

They had been on an incremental path of change since 2019. [CMS] put new regulations in place that developed a new code to allow a limited amount of payment for a very specific type of telemedicine  

With the pandemic, on March 6, they create new rules that really advanced the payment for telemedicine visits with new codes and with clearer payment opportunities.

MHE: If we do flatten the curve, if this does recede, presumably some of the anxiety will go away. And therefore, the sorts of visits where you're just talking people through, their worries will go away. When there's one scenario where this is, if not a flash in the pan, maybe not as much of a fundamental shift into the use of telemedicine as perhaps we imagine, right?

Kaminski: So we're providing these Jeff Connect telemedicine visits for any patient who wants to within our Family Medicine Department. For our patients’ safety, we've converted most of our scheduled face-to-face visits to telehealth visits. So we're conducting primary care, not just around COVID-19 issues, but around regular medical care.

I think of it as opening Pandora's box. We see all the benefits of this technology patients are experiencing - greater access and convenience for care and we’re finding that it's effective for their care just as providers are.

When the pandemics over, I don't think anyone can predict what is going to happen. But it's hard to imagine that we can put Pandora back into the box and say, let's go back to this less efficient, more costly, fee-for-service–based, RVU system that we had before.

If nothing else, I think it will accelerate the incremental changes and we need to continue using this tool going forward in our healthcare systems. 

MHE: So there's another lane of activity in telehealth, which is the direct-to-consumer companies. The big names are Teladoc, Amwell, a few others. If telehealth gets incorporated into the practice of mainstream Medicine, how do you think that will affect the direct-to-consumer provision of telehealth? In broad strokes, it would seem like it might mean there's less of a need for that sort of service. 

Kaminski: Your question really brings up another important feature of telemedicine visits, and that is the issue of continuity of care. So Teladoc and those kinds of services really are similar to the minute clinic or the drugstore clinics. I think there are a couple of issues with that. One is their continuity of care, particularly, if you're not addressing acute issue like a sore throat, but you're addressing a problem such as diabetes control. So is there continuity of care? I know that the Jeff Connect visits were really designed for acute illnesses. Continuity may not be as important in that situation. But if you're talking about comprehensive care, you have to be mindful of the whole issue of the coordination of care.

MHE: Do you see those direct-to-consumer companies as perhaps eroding continuity of care - that those contacts should take place now with primary care physician or even, say, the cardiologist, if you have access to those providers via telehealth?

Kaminski: I think that there is the risk of a reduction in continuity of care through those services. Another aspect to consider is the data and the sharing of the data, the information, right. So when a patient has a visit with a nonaffiliated service or provider, whether it's at a corner clinic in a drugstore or through a virtual telemedicine visit, does that information get back to that patient's primary medical record? It will matter if it affects the medications they take for their illnesses. So where there's concern about the continuity with providers, you also have to think about continuity of data.