Chronic conditions are justifiably an area of broad concern because of their adverse impacts on patients and effects on health care costs. Recently, the COVID-19 pandemic has drawn attention to the role of telemedicine as a powerful tool for revolutionizing chronic condition management. Going forward, the policy question is whether clinicians should have complete flexibility as to when and how often to substitute telemedicine services for current in-person services, or whether Medicare and other payers should restrict the types of patients or frequency of use. Based on studies, the right answer is neither.
Proficient prescriptions are needed for chronic care management’s blockbuster drug
The support of patients’ effective self-management has long been seen as critical to improving outcomes for chronic conditions. Patients who claim to be very confident that they can manage and control most of their health problems generally do much better than those who are less confident. Furthermore, optimum care for a chronic condition is attained when patients and health care providers are both engaged in managing the health concerns that matter—when patients and providers are on the same page, as it were. Mutual engagement has been likened to a “blockbuster drug.”
However, to extend the analogy, an effective, “blockbuster drug” has to be prescribed at the dose and interval best suited for what matters to each patient. Unfortunately, a clinician is typically inclined and reimbursed to interpret dosing in bio-clinical, disease-specific terms rather than to evaluate standardized patient responses about what matters. Each ensuing clinician-generated care plan is then scheduled for delivery over each clinician’s preferred follow-up interval. Predictably, in this environment, a recent survey conducted by the Physicians Foundation established that less than a third of adults in the United States attest they are very confident they can manage their health problems.
Insights from two complementary randomized trials of telemedicine for chronic condition management
Two randomized, controlled trials each enrolled 500 patients with chronic conditions, used the same telephonic technology, had primary care clinicians deliver both intervention and usual care, and measured the same outcomes.
One trial doubled the clinicians preferred face-to-face revisit interval and substituted three brief telephone-based contacts instead. The substitution was continuous over two years during which time the telephoning clinicians were also required to use a standard checklist to ask about their patients’ concerns. Significant benefits were apparent for the patients who received this telephone care: 1) for patients, “increased frequency of clinician contact, less waiting and travel time, lower cost, and the possibility for reduced mortality and improved function,” 2) for providers, “a mechanism to give frequent follow-up in an efficient manner,” 3) for payers, “the unusual combination of cost savings and improved outcomes.” The estimated savings was six dollars for every dollar paid for telephone care.
The other study encouraged clinicians to have frequent phone contact without reducing face-to-face clinic visits, and no standard checklist was used to assess patients’ needs. During the two-year study period, total clinic visits were increased, and patient time spent with other health care providers was greater than that spent with their assigned primary care clinician. Patient outcomes were not better.
Looking ahead: proficient clinical behaviors that support patient self-management
The complementary studies cited here provide a timely insight into effective telemedicine implementation. The results strongly support the hypothesis that a very large return on investments is possible when two simple principles are followed for patients with any chronic condition that needs longitudinal management: 1) in order to co-create a plan of care with less variability based on clinician preferences, routinely obtain a few measures that matter to assess a patient’s needs and risk for subsequent costly services, and 2) routinely substitute easy-to-use telemedicine for a significant portion of what would have been prescheduled, face-to-face visits.
This analysis strongly suggests that if new incentives after COVID 19 merely promote more use of telemedicine for chronic condition management patient outcomes will be no better, care may become even more fragmented, and both direct costs for payers and providers and opportunity costs for patients will be increased. In contrast, cautious acceptance of a few high-value principles such as those described here while continuing to address open questions should enable patients, providers, payers, and policymakers to get the most out of telemedicine management of chronic conditions. Towards that policy question of whether telemedicine implementation should be left to clinicians or payers, shouldn’t it be organized around what matters to patients?
John H. Wasson is a geriatrician.
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