How to Measure the Value of Virtual Health Care

Digital Article

Technology

by Meg Barron, Vimal Mishra, Stacy Lloyd, and Jared Augenstein

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How to Measure the Value of Virtual Health Care

by Meg Barron, Vimal Mishra, Stacy Lloyd, and Jared Augenstein Published on HBR.org / June 24, 2021 / Reprint H06FNF

Steven Puetzer/Getty Images

The Covid-19 pandemic has spurred a dramatic increase in virtual health care in the United States. The rise has been driven by the need for social distancing and enabled by a wide range of policy flexibilities implemented by federal and state legislators, regulators, and payers. However, many of these allowances are temporary. As the pandemic ebbs, policymakers and payers are deciding whether and how much to pay for virtual care services in the future, leaving clinicians uncertain about whether they will be able to afford to continue their virtual care programs. But parties are often making these decisions based on outdated or limited

measures of success that do not holistically reflect the realities of how value is being generated.

To address this need, the American Medical Association (AMA) and Manatt Health, a legal and consulting firm, have developed a framework for assessing the value of digitally enabled care. It accounts for the various ways in which virtual care programs may increase the overall “return on health” by generating benefits for patients, clinicians, payers, and society going forward. The framework can be used by care providers to develop and evaluate new digitally-enabled-care models, by payers to inform coverage and payment decisions, and by policymakers to establish regulations that guide the future of virtual care.

Before the Covid-19 pandemic, virtual care adoption was slow going and represented less than 1% of overall health care volume. In most cases, virtual care existed outside of the traditional health care delivery system and was often uncoordinated with in-person care. A patient would develop a fever over the weekend and would see a virtual urgent care provider who, in most cases, was not his or her primary care provider. Some innovative health systems or tech-enabled health care delivery companies such as One Medical and Cityblock Health had implemented integrated virtual care tools, but for the most part, the virtual care ecosystem existed in parallel to and disconnected from the in-person health care ecosystem.

Accelerated by the pandemic, we are entering an era, where in-person and virtually enabled care will be seamlessly integrated and the mode of care delivery will be based on clinical appropriateness (i.e., when telehealth should and should not be used) and factors such as convenience and cost. When given the option of telehealth during the pandemic, patients largely saw their existing physicians for their needs versus a new provider. Digitally-enabled-care models will be developed across the full range of disease acuity and across all clinical conditions. The integration of new digital health solutions such as video visits, remote monitoring, asynchronous telehealth, continuous and passive sensors, and AI into

digitally-enabled-care models offers the potential to provide access to high-quality care and positive patient and physician experiences at a lower cost.

While there has been much progress, the existing body of evidence for telehealth is narrowly focused on short-term measures of the financial value of virtual health. There is much opportunity to now gather details on broader benefits such as improvements in access to care, clinical outcomes, the impact on the patient and clinician experience, the potential for operational efficiencies, and the impact on health equity. These benefits will also vary based on a wide range of factors that affect value and outcomes such as payment models, virtual care modalities (e.g., audio/ visual visits, asynchronous), or the clinical use case. That’s why we developed a comprehensive framework to help stakeholders measure the various ways in which virtual care programs can generate value based on their specific imperatives.

Measuring the Value of Virtual Care

To do so, we examined the existing literature on telehealth’s impact and interviewed national experts on virtual care delivery, financing, technology, and research. We also consulted with current and former leaders of Ochsner Health System, Virginia Commonwealth University Health, Cityblock Health, the Healthcare Financial Management Association, Harvard Medical School, the Medical Group Management Association, private practices, and others.

The framework describes several environmental variables that impact distinct value streams, which collectively seek to capture the overall value derived from a specific digitally-enabled model. The environmental variables include practice type, payment arrangement, patient population, clinical use case, and virtual care modality. The framework is flexible because it acknowledges that different provider organizations will have different clinical or business rationales for pursuing different models based on their environmental and strategic context. For example, a small rural

primary care practice with a largely Medicare population paid on a fee-for- service basis will experience the value of digitally-enabled care very differently from a large vertically-integrated regional health system.

Next, the framework includes six value streams: clinical outcomes, quality, and safety; access to care; patient and family experience; clinician experience; financial and operational impact; and health equity. The impact of a digitally-enabled-care model should be measured on all these value streams — a Balanced Scorecard approach, if you will, to measuring and realizing the full potential of virtual care.

Some leading health systems are starting to measure value more holistically. One is VCU Health a Virginia health care system, which increased virtual visits from less than 1% of outpatient psychiatry visits to more than 90% last year in response to the pandemic. It has begun to evaluate the impact of its new virtual model on the various value streams in the framework and has identified some novel findings. For instance, the visit no-show rate (an element of financial and operational impact) dropped from 11% pre-pandemic to 6% during the pandemic, and VCU Health is now considering how it can use virtual care to reduce the number of wasted time slots to improve its operational performance and improve access (another value stream). VCU Health is also measuring the impact of virtual care on health equity given concerns that older people may not be as digitally savvy as younger people; it found that there were no differences in access to care by age group when delivery shifted from nearly all in-person visits to nearly all virtual visits. This report provides additional case studies from organizations such as Ochsner Health and Massachusetts General Health and resources, such as upcoming sessions and virtual discussions for the industry to share their own experiences.

Virtual care is here to stay, but many stakeholders across the industry are in the process of determining how best to invest in their programs and measure their success. This value framework can help.

The authors wish to thank Jacqueline Marks and Michelle Savuto from Manatt Health and numerous AMA colleagues for their valuable contributions to this article.

Meg Barron is vice president of digital health strategy at the American Medical Association.

Vimal Mishra, MD, is director of digital health at the American Medical Association (AMA) and a medical director and associate professor of medicine at Virginia Commonwealth University (VCU).

Stacy Lloyd is director of digital health & operations at the American Medical Association.

Jared Augenstein is a director with Manatt Health, an interdisciplinary policy and business advisory group of Manatt.

2021-07-28 QPSC A2 Article More Hospitals Impose Vaccine Mandates for Employees NYT

7/17 7/22/2021 More Hospitals Impose Vaccine Mandates for Employees - The New York Times

https://www.nytimes.com/2021/07/21/health/covid-vaccine-hospitals.html

More Hospitals Are Requiring Workers to Get Covid Vaccines With some health care workers still refusing to be immunized, medical centers around the country are requiring shots as cases climb once again.

By Reed Abelson

July 21, 2021

More and more hospitals and major health systems are requiring employees to get the Covid-19 vaccine, citing rising caseloads fueled by the Delta variant and stubbornly low vaccination rates in their communities and even within their work force.

Many hospitals say their efforts to immunize their employees have stalled, in much the same way the nation’s overall vaccination rates are stuck under 60 percent, behind many European countries and Canada. While more than 96 percent of doctors say they are fully vaccinated, according to the American Medical Association, health care workers, particularly in rural areas, have proven more resistant even though thousands of workers have died from the virus and countless more became sick.

One recent estimate indicated that one in four hospital workers were not vaccinated by the end of May, with some facilities reporting that fewer than half of their employees had gotten the shots.

Some hospitals, ranging from academic medical centers like NewYork-Presbyterian and Yale New Haven to large chains like Trinity Health, are going ahead with a mandate because they recognize that the only way to stop the virus is to vaccinate as many people as possible, as quickly as possible. A large Arizona-based chain, Banner Health, announced Tuesday that it would impose a mandate, and New York City said it would require all health care workers at city-run hospitals or clinics to be vaccinated or undergo weekly testing.

Watching cases rise prompted Trinity Health, a Catholic system with hospitals in 22 states, to become one of the first major groups to decide earlier this month that it would mandate inoculations. “We were convinced that the vaccine can save lives,” said Dr. Daniel Roth, Trinity’s chief clinical officer. “These are preventable deaths.”

At UF Health Jacksonville, in Florida, the number of Covid patients being treated has surged to levels not seen since January, and only half of its health care workers are vaccinated, said Chad Neilsen, the director of infection prevention. Seventy-five employees are out sick with the virus, the vast majority of whom are unvaccinated, while more are waiting for test results. “We are absolutely struggling for staffing right now,” he said.

“It’s like déjà vu,” said Mr. Neilsen, who described growing frustration with colleagues refusing to get the shots. “We have a reason to believe this could be over if people got vaccinated.”

Despite dozens of virtual town halls, question-and-answer sessions and educational videos, many employees are wary. “We still stagnated,” Mr. Neilsen said.

https://www.nytimes.com/2021/07/21/health/covid-vaccine-hospitals.html?auth=link-dismiss-google1tap8/17 1/4 7/22/2021 More Hospitals Impose Vaccine Mandates for Employees - The New York Times

Dr. Leon Haley Jr., chief executive of UF Health Jacksonville, getting the shot in December. Bob Self/The Florida Times-Union, via Associated Press

Some employees want more data, while others say the process has been too rushed. Many of the same conspiracy theories and misinformation — that the vaccines will make women infertile or contain microchips — hold sway among staff members. “Our health care workers are a reflection of the general population,” he said.

Hospital leaders and others plan to meet with state officials in the coming weeks about the possibility of imposing a mandate, he said.

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Unvaccinated workers also continue to care for even the sickest patients, raising concerns that they will spread the infection, especially now that the highly contagious Delta variant comprises more than 80 percent of the nation’s cases.

“Nowhere is this more important than in hospitals, where health care personnel — who have been heroic during this pandemic — are caring for patients with a wide variety of health challenges under the assumption that the health care professionals treating them are not at risk of acquiring or transmitting Covid-19,” Dr. David J. Skorton, the chief executive of the Association of American Medical Colleges, which represents teaching hospitals, said in a statement last Friday calling for a mandate.

On Wednesday, two more groups, including the American Hospital Association, joined the growing clamor for vaccine mandates. “We have lost too many of our caregivers to Covid-19,” said Dr. Bruce Siegel, the chief executive of America’s Essential Hospitals, which represents hospitals in underserved communities. “Vaccination can reduce the risk we lose more.”

With formal approval of the vaccines by the Food and Drug Administration potentially months away, hospitals find themselves at the center of the national debate over whether to impose mandates. While the vaccines are being offered under emergency use authorization, supporters argue there is ample evidence that the ones available in the United States are both safe and effective.

In states like Missouri, which has reported a sharp increase in cases, there is newfound urgency. “We felt we could not wait,” said Dr. Shephali Wulff, the director of infectious diseases for SSM Health, a Catholic hospital system whose headquarters are in St. Louis. SSM, where about two-thirds of employees are now vaccinated, is requiring everyone to get their first dose by Sept. 1.

SSM’s decision was also motivated by concern that Covid infections could spike this fall when there could also be a surge in other respiratory infections. “We need a healthy work force going into the flu season,” Dr. Wulff said. “We do not have the time to wait for approval.”

Doses of the Pfizer-BioNTech vaccine at the University of Iowa Hospital in December. Kathryn Gamble for The New York Times

But some systems are already worried about staffing shortages caused by departures during the pandemic, with many employees quitting because of the stress and burnout experienced by caring for Covid patients. Hospitals are hesitant to risk losing more workers if they force the issue.

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“They are afraid it could be a tipping point,” said Ann Marie Pettis, the president of the Association for Professionals in Infection Control and Epidemiology, one of the professional organizations that is urging hospitals to require the vaccine.

At Mosaic Life Care, a small Missouri hospital group, executives are reluctant to adopt a mandate if other hospitals do not. “We have the potential to lose some caregivers to other systems,” said Joey Austin, a spokeswoman for Mosaic, which has vaccinated about 62 percent of its staff.

Many hospitals already require their employees to get a flu shot, a mandate that has been in place for over a decade. While that was also met by resistance from employees skeptical of the vaccines’ safety, it is now largely accepted. Individuals can seek a medical or religious exemption, typically representing a small sliver of the work force, which hospitals say would also apply to the Covid vaccines.

Mandates “establish a social norm and say it’s an institutional priority,” said Saad B. Omer, the director of the Yale Institute for Global Health, who emphasized that hospitals need to strongly encourage workers to voluntarily get the vaccines to be successful.

Unions like the National Nurses United and 1199 S.E.I.U. say they want members to be vaccinated but oppose making it a condition of employment. At the first hospital to impose a mandate, Houston Methodist, a group of employees sued to challenge the requirement but the lawsuit was recently dismissed. About 150 employees ultimately resigned or were fired for refusing to meet the deadline for vaccination out of a total work force of some 26,000 people.

Workers protested vaccine mandates outside the Houston Methodist Baytown Hospital in Baytown, Texas, in June. Yi-Chin Lee/Houston Chronicle, via Associated Press

Hospitals say they are working hard to dispel much of the pervasive misinformation around the vaccines, even among physicians and nurses.

“I have to remind them that reputable scientists do not publish their findings on YouTube,” Dr. Wulff said. In addition to presenting hard data about the vaccine, she and her colleagues at SSM are also sharing their personal experiences, like getting vaccinated while trying to get pregnant. “What I’m finding is people are moved by stories and anecdotes,” she said.

“Generally it’s a lot of listening and homing in on what is driving their fear,” Dr. Wulff said.

Some high-profile systems like Intermountain Healthcare and the Cleveland Clinic are waiting. The clinic, which has a sprawling network of 18 hospitals in the United States, said existing policies, like masking and closely tracking infections, protect patients and workers.

“We know if we ensure these safety precautions are in place we know we can continue to keep our patients and caregivers safe,” said K. Kelly Hancock, the Cleveland Clinic’s chief caregiver officer. https://www.nytimes.com/2021/07/21/health/covid-vaccine-hospitals.html?auth=link-dismiss-google1tap10/17 3/4 7/22/2021 More Hospitals Impose Vaccine Mandates for Employees - The New York Times About three-quarters of employees are now vaccinated, and efforts are continuing “full force,” she said.

At Intermountain Healthcare, based in Utah, “a good majority” of employees are vaccinated, said Dr. Kristin Dascomb, medical director for infection prevention and control and employee health.

If more safety data is compelling and the F.D.A. approves the vaccines, Intermountain may require immunization along with other hospitals in the state. “We are starting the conversation now in Utah,” she said.

The lack of full F.D.A. approval has also influenced other hospitals. Mass General Brigham, which has vaccinated more than 85 percent of its work force, said it would adopt the requirement as soon as the vaccines were approved.

A nurse at the University of Iowa became emotional after receiving her first dose of the vaccine in December. Kathryn Gamble for The New York Times

Some hospitals argue a mandate is not necessary. “In my opinion, there isn’t one right answer,” said Suresh Gunasekaran, the chief executive of the University of Iowa Hospitals & Clinics. About 90 percent of its workers are now vaccinated, he said, adding that he was confident that virtually everyone would be immunized by the end of the year.

The system has been “successful in chipping away” at vaccine hesitancy, Mr. Gunasekaran said, in part because Iowa was involved in the clinical trials for the Pfizer-BioNTech vaccine.

Northwell Health, the large New York hospital group, does not require workers to be immunized against the flu but about 90 percent of its work force is vaccinated against it, said Maxine Carrington, Northwell’s chief human resources officer. It is taking a similar approach to Covid.

“We want people to be believers,” Ms. Carrington said, so they are better able to persuade the community at large to get vaccinated. She described the system as “pounding the pavement on education, education, education.” About 76 percent of its work force is currently vaccinated against Covid. Northwell will revisit the idea of a mandate after F.D.A. approves the vaccines, she said.

Yale New Haven Health is now requiring employees to get vaccinated, as have the other hospitals in Connecticut.

“From the very beginning, we messaged that it isn’t mandatory — yet. We emphasized the yet,” said Dr. Thomas Balcezak, the chief clinical officer for Yale.

“Health care has to lead,” he said.

Reed Abelson covers the business of health care, focusing on health insurance and how fnancial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. @ReedAbelson

A version of this article appears in print on , Section A, Page 12 of the New York edition with the headline: More Hospitals Are Requiring Workers to Get Covid Vaccines

https://www.nytimes.com/2021/07/21/health/covid-vaccine-hospitals.html?auth=link-dismiss-google1tap11/17 4/4 Separator Page

2021-07-28 QPSC A3 Article New York to Require Vaccination or Weekly Testing for City Health Workers NYT

12/17 https://www.nytimes.com/2021/07/20/nyregion/mandatory-vaccine-public-hospitals.html

New York to Require Vaccination or Weekly Testing for City Health Workers The new city policy takes aim at improving vaccination rates at public hospitals. Around 60 percent of workers in the city’s public hospital system are vaccinated.

By Joseph Goldstein

July 20, 2021

For months, Mayor Bill de Blasio has been reluctant to make coronavirus vaccinations mandatory for anyone, hoping that encouragement, convenience and persuasion would be enough.

But with two million adult New Yorkers still unvaccinated — including a high percentage of employees in the public hospital system — and the Delta variant threatening the city with a third wave of cases, City Hall is trying out a new tactic: requiring workers in city-run hospitals and health clinics to get vaccinated or else get tested on a weekly basis, the mayor’s spokesman said Tuesday.

The new policy, which will be announced by Mr. de Blasio on Wednesday and goes into effect at the beginning of August, goes nowhere near as far as San Francisco’s announcement last month that it would eventually require all municipal employees to get vaccinated. Still, it is Mr. de Blasio’s first move to require any city employee to show proof 13/17 of vaccination or a recent negative coronavirus test as a condition of showing up to work, city officials said. It will apply to more than 10 percent of the well over 300,000 people who work for city government.

It remains unclear whether City Hall intends to expand this approach to other city employees — police officers, teachers, clerical workers — or will limit this to those who work in hospitals and clinics.

“It’s all about the safety of a health care setting,” Bill Neidhardt, the mayor’s press secretary, said of the policy.

Hospital workers were the first group to get access to Covid-19 vaccines, when the city’s vaccination campaign kicked off in December amid New York’s second wave. Seven months later, the vaccination rate among workers in New York City’s public hospital system is slightly below the citywide average for adults, to the dismay of public health experts and government officials.

City Hall’s policy — which is more of a mandatory testing policy than a mandatory vaccination policy — seems crafted to avoid litigation or a fight with labor unions. Some of the largest labor unions representing city health care workers have publicly stated their opposition to mandatory vaccination requirements.

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The city’s new policy will apply to the entire 42,244-person work force of the public hospital system, Health and Hospitals. The system has 11 hospitals, which include Bellevue and Elmhurst, as well as nursing homes and clinics. The policy will also cover some employees of the city’s Health Department.

There are still two million adult New Yorkers who have yet to receive a dose of any coronavirus vaccine.

As the initial crush of adults eager to get vaccinated began to subside in late April, the city tried knocking on people’s doors and offering shots in settings ranging from subway stations to museums, among other tactics. And yet that has not done much to jump-start the flagging vaccination campaign. Each day, fewer than 10,000 New York City residents 14/17 on average are opting to get their first shot.

Getting more adults vaccinated is a pressing concern as the Delta variant has already sent case counts spiking to nearly 600 a day in the last week, more than double the daily average in late June.

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And while nearly 54 percent of city residents of all ages are fully vaccinated — some five percentage points more than the national average — there are some neighborhoods with far less protection. The vaccination rates across the Bronx and Brooklyn are below the national average. Black neighborhoods and Orthodox Jewish neighborhoods in particular tend to have lower vaccination rates, with as few as 35 percent of residents fully vaccinated in some ZIP codes.

Hospital workers tend to be vaccinated at slightly higher rates than the general population. Across New York City, 70 percent of hospital workers are fully vaccinated, according to state data, compared with an adult citywide vaccination rate of nearly 65 percent.

But within the city’s public hospital system, Health and Hospitals, the vaccination rate is markedly lower. Almost 60 percent of the system’s work force is vaccinated, a Health and Hospitals spokesman, Christopher Miller, said.

15/17 One reason for the low rate, city officials have said, is intertwined with the demographics of the public hospital system’s work force. About 44 percent of city hospital workers are Black.

Black New Yorkers, who make up about a quarter of the city’s population, have gotten vaccinated at lower rates than other groups. In interviews, many Black New Yorkers have voiced doubts about the safety of the vaccines and expressed concern that a full understanding of the side effects had yet to emerge. Others also cited the long history of doctors treating Black patients differently from white patients and past medical experimentation on Black people.

The city’s largest private hospital system, NewYork-Presbyterian, announced last month that it would require employees to be vaccinated against Covid-19, becoming an outlier among the city’s large hospital systems.

But it has yet to enforce that policy, allowing employees until Aug. 1 to apply for exemptions and until Sept. 1 to get the first shot. More than 70 percent of employees are vaccinated, according to Alexandra Langan, a spokeswoman for NewYork-Presbyterian.

Other major hospital systems in New York City have yet to make coronavirus vaccinations mandatory.

NYU Langone Health, a large New York City hospital group, said that 81 percent of its staff was currently vaccinated against Covid-19. Vaccinations would become mandatory for employees without valid exemptions after the vaccines receive full approval from the Food and Drug Administration, an NYU Langone spokeswoman, Lisa Greiner, said. Currently, the vaccines are being administered in the U.S. under an emergency use authorization.

District Council 37, the union that represents city workers, has been part of conversations with Mr. de Blasio’s administration about vaccinating health workers, although the union did not learn about the mayor’s new policy until Tuesday, according to two people familiar with the matter.

“The union strongly encourages vaccinations among membership and we’ve done a lot to help our members get vaccinated,” a union spokeswoman, Freddi Goldstein, said. Still, she said, “the union does not believe it’s the place of the employer to mandate it.” 16/17 Ms. Goldstein added that the union was supportive of more testing. “Of course with all things, we’ll need to see how it’s being implemented,” she added.

One epidemiologist said the new city policy was better than nothing, but he wondered why testing was only occurring once a week, and why the policy was not expanded beyond health care settings to include other city employees.

“One test a week is better than no test, but more frequent testing is always better when you have a lot of community transmission and we may have that situation among unvaccinated people in the fall,” said Denis Nash, a professor of epidemiology at CUNY School of Public Health.

Emma G. Fitzsimmons contributed reporting.

17/17