Informing PTAC’s Review of Telehealth and PFPMs: We Want to Hear from You Responses On September 18, 2020, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) requested input from the public on information that could help inform their review of the use of telehealth to optimize health care delivery under physician-focused payment models (PFPMs) and alternative payment models (APMs). PTAC received nine responses from the following stakeholders that are listed below in the order in which their responses were received: 1. Eitan Sobel, MD 2. Center for Healthcare Quality & Payment Reform 3. American Physical Therapy Association 4. American Academy of Family Physicians 5. National Committee for Quality Assurance 6. National Association of Pediatric Nurse Practitioners 7. OCHIN 8. Jean Antonucci, MD 9. Partnership to Empower Physician-Led Care For additional information about PTAC’s request, see PTAC’s solicitation of public input. 9/24/2020 Physician-Focused Payment Model Technical Advisory Committee (PTAC) c/o US DHHS Asst. Secretary of Planning and Evaluation Office of Health Policy 200 Independence Ave., SW. Washington DC 2O20I TITLE: THE ‘MONEY-PIT’ BUSINESS OF REMOTE CARE (TELEHEALTH). Are there experiences and lessons learned?: Not long ago, we were inspired by the ​ emergence of EMR technologies. The promise of better care, cost-saving, error reduction, and better communication prompted us to heavily invest in those technologies. EMR technologies indeed improved care delivery but the results were nowhere close to what we hoped to achieve. Many small entities like private physicians and small clinics did not survive the technology revolution and had to close. The cost of healthcare skyrocketed beyond imagination. We have successfully created monopolies in this game and therefore, very little improvement and development of the technologies was made over the past 15 years. We accepted the monopolies as inevitable, and we generously paid them with public money. We failed to push back. The opportunity: Remote Care is an opportunity to learn from our past experience. We need ​ technologies that are much more than just “Zoom” applications associated with EMRs. The technologies should enable providers to manage larger groups of patients and to respond to multiple communications and needs. The current EMRs imitate the old ‘medical record’ of physicians. It is merely ‘horizontal thinking’ while new technologies are needed to support ‘vertical thinking’. The remote care technologies may initially work in conjunction with EMRs and eventually should replace them in order to prevent duplications. We should be able to control the development of new technologies and not be controlled by them. How might telehealth help to optimize care within and across services? Remote care can ​ and should be used anywhere within and across services. Remote care could be particularly effective between a lower level of care and a higher level of care but could be used at the same level of care as well. Remote care prevents duplication of care. For example, a visiting nurse in the field raises some concerns about a patient. Remote care offers immediate contact between the nurse and a primary care provider or a standby provider. There is no need to wait a week for an appointment with the primary provider during which the condition of the patient could get worse. There is also a good chance that the issue could be resolved via remote care and then there is no need for an urgent appointment. Perhaps the most useful situation is the interaction between a provider and a specialist. For example, providers operating at a lower level facility such as hospitalists can get specialists at higher-level facilities involved directly in the care of their patients without transferring the patients. Remote care could be used within an organization or a facility to simplify care and to save time and money. Productivity: Remote care can increase our productivity. As described above, with appropriate ​ technology, a supportive and reliable team, we can increase our productivity and provide low-cost care for larger populations. Teamwork: Remote care technology is about interaction and direct continuous communication ​ among members of the care team and patients. Teamwork is about relying on each other and trusting the work and conclusions of other members of the team. Better care: Remote care does not replace direct patient contact but it adds another dimension ​ of care. Remote care will improve care, prevent unneeded escalation of care, or alternatively bypass unnecessary steps of escalation that are unneeded, costly, and sometimes damaging. Cost Reduction: Remote care could easily become yet another ‘money pit’ with multiple ​ parallel care systems that do not support each other and practically doubling our cost of healthcare. The PTAC should be particularly concerned about endorsing specific remote care programs that seemingly save money and improve care. Expanding those programs may produce the opposite effect. Furthermore, approving only certain specific programs may exclude other remote care applications that could potentially save substantial costs. Cost reduction should be figured as savings for the system as a whole, and therefore, the system should be evaluated as a whole. Our objectives should be not just halting spending but actually reducing costs. Carefully detailed design of remote care today would substantially cut our healthcare costs tomorrow. In my proposals from 2019 and 2020: Remote specialists and experts on-demand - ​ improving care and saving costs, I explained how early involvement of specialists could be ​ implemented. Local services and traditional providers’ appointments are too slow and costly. The availability of remote care is immediate and does not depend on the workload of local specialists. Remote care offers scalability of services and flexibility that cannot be achieved by local programs. In addition, remote care promotes early involvement of other expert services such as social services, palliative care, wound care, and many other expert services that will reduce costs, prevent escalation, and improve care. Competition: Our current system promotes monopolies. It is designed to avoid oversaturation ​ of the market. The result is monopolies of providers, clinics, and hospitals. Even our technology companies enjoy an uncontested market. Remote care will open the system to competition which will improve care and reduce cost. Continuation of care: Our healthcare system demolished parts of the old patient-doctor ​ relationship. The principle of continuation of care was partially lost. The patients are exposed to multiple teams of care that have to learn everything about the patient again and again relying on a transition of care documentation that is not always flawless. The process diminishes trust in the system, exhausts patients and providers, and adds significant costs. Remote care should be built on the continuation of care principles that will improve care, increase trust, and save costs. What might be the most informative performance-related metrics and strategic approaches for monitoring and evaluating the use of telehealth as part of care delivery? The PTAC should be leery about performance-related metrics and benchmarks, as those are likely to drive the cost up. In addition, metrics do not necessarily translate into better care as providers are pressured to provide services and treatments aiming to satisfy requirements and benchmarks rather than to benefit patients. Remote care should be evaluated by patient satisfaction and efficiency of care and therefore, I am suggesting creating regional referral centers (RRC). Patient choice: Choices and market-driven economy are a great strategy for monitoring and ​ evaluating the use of remote care. Patient choice is linked to competition and competition improves the quality of care. Remote care technologies will provide Amazon-like portals that will present patients with alternative choices and will allow them to provide feedback and recommendations. Regional referral centers (RRC): In my proposal, I offered to create virtual organizations called ​ regional referral centers that will oversee and manage the interaction among the members of the health care team including specialists and experts, and the patients. The referral centers are responsible for the coordination of care, efficiency, and potentially will be given the power to negotiate contracts with providers and organizations. The regional referral centers will be held accountable for outcome and cost. Poorly managed RRCs could easily be replaced. The building blocks: We have all the building blocks needed to create a great healthcare ​ system. We have the providers, the facilities, the technologies, and the networks necessary for creating a better future of affordable healthcare in America. We just need to put it together. I applaud the PTAC’s attempt to gather public comments and thoughts about remote care. This document is probably the tip of the iceberg and the devil is in the details. Remote care is a whole new dimension of medicine that requires careful planning to get it right, as we cannot afford to get it wrong. Reference: PTAC proposal: Eitan Sobel: Remote specialists and experts on-demand - improving care and saving costs. Respectfully, Eitan Sobel, MD Hospitalist. (802) 345-4378 320 Ft. Duquesne Boulevard Suite 20-J Pittsburgh, PA 15222 Voice: (412) 803-3650 Fax: (412) 803-3651 www.CHQPR.org September