Telehealth Targeting Strategies

June 23, 2020

Today, I’d like to present a survey of telehealth strategies focusing on the timing and prioritization of outreach to members for prospective telehealth visits.  These strategies will tie in with the approach taken for transitioning back to in-home assessments.  It is assumed that whether using insourced or outsourced analytics, members have already been stratified and selected for prospective assessments based on their risk adjustment gaps, quality gaps, and other care management criteria, so those decisions are not discussed here.

If we had expected to only do telehealth visits through the end of the year, never returning to in-home assessments in 2020, then the decision making would have been simple:  just offer telehealth to all targeted members.  With some areas already resuming in-home assessments, and assuming we will be performing in-home visits everywhere, at some point later this year, we now have choices about how and when we offer telehealth visits.

Here is a list of things to consider when making decisions about how to target and prioritize members for telehealth vs. in-home assessments.

Transitioning to a dual in-home and telehealth offer

One factor which can affect other decisions around prioritizing members for telehealth is the approach taken for returning to in-home visits.  Some of the below items may seem like either-or choices.  If resuming in-home visits is done in a way where members will be offered a choice of either in-home or telehealth, then these options may not be mutually exclusive.  For example, it may be beneficial to offer younger members a telehealth visit.  If resuming in-home isn’t the end of telehealth, then these younger members can be offered their choice of venue even after in-home assessments resume.  This lessens the pressure to outreach to these members earlier.

Flexible return to in-home

Similarly, if your assessment program is flexible in where and when to resume in-home visits, then there is less pressure to engage certain members early.  More flexibility, such as making in-home decisions by state and county, allows a finer grain policy and avoids all-or-nothing high stakes decisions about in-home and telehealth.

Members with current needs

Separate from their risk adjustment and quality priorities, several clients I work with are prioritizing outreach to those members who are most likely to have current needs.  This identification is often done in conjunction with the care management team based on age, health status, and previously identified SDOH factors.

Prioritize by age

Members agree to telehealth assessments differently.  One of the most notable differences we’ve seen is the variation in rates of scheduling visits by age group.  The table below shows how much more (or less, if negative) contacted MA members schedule a telehealth visit than they schedule an in-home visit, broken out by age.

Age Range	Telehealth Change in Consent Rate
0 to 49	8.4%
50 to 54	2.2%
55 to 59	-1.2%
60 to 64	-4.8%
65 to 69	-7.1%
70 to 74	-11.2%
75 to 79	-16.6%
80 to 84	-22.5%
85 to 89	-25.2%
90 to 94	-26.0%

Average of two studies comparing telehealth consent rates to in-home consent rates

In-home visit consent rates increase with age, peaking in the 85 to 89 year old range.  Telehealth consent rates start higher, but consistently decrease with age.  The net effect we see in the above table is that members under 55 accept telehealth visits at a higher rate than in-home, and those over 55 accept at a lower rate, with the gap widening the higher the age.

Based on the higher consent rates for telehealth, you can see why it is advantageous to reach out to younger members while telehealth is an option.  We may not exclude older members from outreach at the same time, but we want to ensure that all of the younger members eligible for a comprehensive health assessment are offered a telehealth option.

Member who have said they don’t want someone in their home

In the Matrix contact center, the member relations team logs a disposition with each call.  When members decline a visit, they also record a decline reason.  Members aren’t always forthcoming with their reasoning, but many do share, and about 3.5% cite not wanting anyone coming to their home as the decline reason.  These members can be prioritized for telehealth outreach.  Given the inexact nature of the decline reasons, we could also more broadly prioritize telehealth engagement for members who have repeatedly declined in-home assessments.  Just like younger members, engagement may be more successful if a telehealth visit is offered before in-home.

Members harder to assess in-home

The realities of the clinician network doing the in-home visits, and the logistics of turning scheduled visits into daily routes, means that some members are easier to visit in their home and some are harder.  This is true whether you perform your own assessments or outsource them.  The factors that affect difficulty include driving distances, traffic, the density of your provider network, the days and hours clinicians are available, and sometimes weather and safety.  Completing virtual assessments earlier in the year means you don’t have to worry about these logistics for in-home assessments later.

In-person diagnostics and screenings

A few plans are also weighing which members have been identified for diagnostics and screenings.  The more optimistic your outlook is for performing in-home visits where the member lives, the less risky you would judge deprioritizing these members for telehealth visits.  Maximizing program yield requires time to run through cycles of outreach and rest.  Shortening the window for outreach puts downward pressure on the number of visits that can be completed, but can be a net win if the per visit value is increased enough.  I have discussed with several clients the risk adjustment impact of vascular disease diagnoses from PAD tests and the number of members with multiple quality gaps, so they can assess this tradeoff between expected volume and value per visit.  If the value is considered high enough, these members can exclusively be offered in-home visits until late in the year.  Typically, in the fourth quarter everyone is focused on completing as many visits as possible before the end of the year, not focusing on the per visit value.

Device lending

Another wrinkle which a few clients have discussed with me is lending devices to members so they can complete telehealth assessments.  Device lending programs have existed prior to the current pandemic, and it seems that the best candidates for this type of program may be members the plan is trying to engage in self-care.  The additional cost of device lending can pay big dividends if the result of a visit is patient activation in addition to a completed comprehensive health assessment.

Self-administered testing kits

One last telehealth option I will mention is mailing self-administered testing kits to members in conjunction with their telehealth assessment.  This idea is intriguing because it would enable closing several quality gaps with a telehealth visit.  It seems to me that the key to success of a kit mailing program is the test completion rate.  I’m planning to closely monitor test completion rates when we start mailing kits, to see how viable this option really is.

 

The intent of this overview is to give you a variety of dimensions to consider for configuring your telehealth program.  Which way to go with these choices will vary for each group or plan, depending on the scope and goals of the assessment program.  I hope this summary helps you move forward in a thoughtful way that serves both your members and your organization.

More telehealth reading:

Here are a few more telehealth articles worth giving a read.  In my last post, I shared an article with comments from Dr. Steven Green about allowing audio-only telehealth to risk adjust.  CMS has discussed this issue with plans, and they seem to be forming an extremely conservative position that would be highly restrictive.  The Better Medicare Alliance sent a response letter to CMS, making the argument:

“We believe that the ten guardrails CMS proposed in their entirety are unworkable, place an undue burden on health plans and clinicians, and detract from the focus on providing high- quality, accessible care during this period of social isolation”

Health Payer Intelligence summarizes the entire letter: MA Risk Adjustment Should Include Audio-Only Telehealth Diagnoses.

Another topic which so many of us working with telehealth are monitoring is what will happen to telehealth regulations once the public health emergency ends.  We see CMS saying some temporary telehealth provisions will become permanent.

Senate health committee Chairman Lamar Alexander (R-TN) has picked his two most important policies he thinks should be made permanent. It is exciting to see growing support for telehealth, but I’m waiting for the details to come from CMS to see whether the agency embraces the kind of progress we’re hoping for.