How Telehealth Helped Keep ACOs Afloat During the Pandemic

Telehealth has become a critical part of the care delivery mechanism at organizations across the country, including accountable care organizations (ACOs), which share savings accrued from coordinating care for patients.

Like most healthcare entities, accountable care organizations benefited from the regulatory flexibilities enacted during the COVID-19 pandemic.

These waivers included allowing applicable ACOs to begin providing and receiving payment for covered telehealth services without geographic restrictions, including in cases where the originating site is the beneficiary's home.

Further, waivers instituting payment parity between telehealth and in-office visits were implemented.  

As a result, telehealth usage among ACOs grew. Medicare ACO telehealth utilization peaked in April 2020, when it represented 23 percent of total visits, after which it declined steadily to about 8 percent of total visits by November of the same year, according to a May 2021 report by the Institute for Accountable Care.

Further, telehealth visit rates were twice as high for high-need and high-cost beneficiaries, including those with Alzheimer's disease, chronic obstructive pulmonary disease, and heart failure.

Telehealth thus became a crucial part of ACOs' pandemic survival strategy, enabling them to provide continued access to care and, in turn, meet their financial goals in a period of great uncertainty. 

USE OF TELEHEALTH IN ACOS

MultiCare Connected Care, an independent ACO, has been offering telehealth services since it was founded in 2014, said Anna Taylor, the ACO's director of operations, population health.

The ACO, whose 4,200 participating providers cover 350,000 lives, saw the use of telehealth spike to 257,617 virtual visits during the peak of the pandemic.

"The use of telehealth during the pandemic shot up at least four times as much as we normally see," said Taylor during a phone interview. "What we found within our populations is that it was a place to meet people where they are. We are continuing to offer more telehealth options and make them more visible than we had before."

The ACO uses both asynchronous modalities, such as a messaging system, and synchronous options, like video visits, telephone calls, and real-time texting, to deliver care.  

Similar to MultiCare, when Northwestern Medicine created Northwestern Medicine ACO, LLC, telehealth was already a part of care delivery among its participating providers.

"However, telehealth represented a minute fraction of services rendered prior to March 2020," said Jessica Walradt, director of performance-based reimbursement, value-based care at Northwestern Medicine, during a phone interview. "COVID dramatically augmented the use of telehealth services."

In the last week of March 2020, over 60 percent of Northwestern Medicine's ambulatory encounters occurred via telehealth. As the pandemic wore on, many specialties such as family medicine, cardiology, and oncology that are part of the ACO have seen their telehealth usage rate hover between 5 percent and 10 percent, except psychiatry, which still has a usage rate of over 60 percent, according to Walradt.

ACO members are using a wide range of synchronous telehealth technologies, including carts that have pan, tilt, and zoom cameras, and peripherals like stethoscopes, otoscopes, and dermatoscopes on the inpatient side, said Richard Bernstein, MD, medical director for telehealth and professor of neurology at Northwestern Medicine, in a phone interview. On the outpatient side, video visits and phone calls are the primary methods used.

Privia Quality Network, a group of physician-led accountable care organizations within Privia Health, has seen broad utilization of telehealth across primary, specialty, urgent, and behavioral health services since it implemented virtual visits in 2018.

"To date, we have conducted close to 2 million telehealth visits covering more than 14,500 ICD-10dx primary diagnoses," said Graham Galka, senior vice president of strategy and innovation at Privia Health, in an email.

Though ACO providers can decide how best to integrate telehealth into their individual practice workflows and care models, Privia Health does provide training and technology. For example, synchronous video visits across the ACO are made possible through a proprietary platform that Privia started building in 2017.

"Additionally, we have providers that often use audio-only telephonic consults as a backup to live video," Galka said. "Having this audio-only option as a backup is particularly important given that technology is not perfect and that there is still a sizable portion of the population without access to reliable broadband technology."

Privia Health is also working with vendors to pilot the use of asynchronous telehealth.   

IMPACT ON FINANCIAL GOALS

When the COVID-19 pandemic hit, in-person care fell drastically, with one estimate showing visits to ambulatory care providers declined by nearly 60 percent in April 2020. Though in-person care has since rebounded, telehealth played a vital role in helping providers stay afloat during the pandemic.

Telehealth proved especially critical for ACOs, which must meet certain financial goals to generate shared savings.

During the pandemic, temporary regulations widened access to telehealth utilization by removing insurance- and location-based barriers to virtual care and increasing reimbursement for telemedicine.

"To have the same value placed on those [in-person and virtual] primary care visits and outpatient visits enabled us to be better at reducing utilization for acute care services," said MultiCare's Taylor. "[We managed] our total cost of care through lower acuity services and [got] the value out of that for both the system and for the patient."

MultiCare Connected Care generated $15 million in shared savings by meeting quality and cost goals in 2020.

Galka echoed Taylor, adding that telehealth allowed Privia's ACOs to improve access, patient experience, and provider experience. 

"[We used telehealth to] provide 24/7 access to coordinated care, address wellness and quality, and better manage chronic disease," he said. "Telehealth enabled us to provide continuity of care through COVID-19 and is a tool to help us provide more value-oriented care."

Privia Quality Network achieved shared savings of $86.5 million through the Medicare Shared Savings Program in 2020.

Though Northwestern ACO did not generate any shared savings in 2020, Walradt said that telehealth played a vital role in the ACO's operations during the pandemic.

"It is difficult to isolate telehealth's impact on overall care utilization and overall expenditures," she said. "We believe that telehealth is one of many tools that can help ensure that patients have timely access to care; a key contributing factor to reducing preventable emergency department visits and hospital admissions."

Bernstein added that telehealth can help reduce costs that arise at the onset of major illnesses. For example, a stroke patient is more likely to remain at their local community hospital and avoid an expensive transfer if telehealth is available as the modality can enable a stroke specialist to oversee care remotely.

TELEHEALTH LESSONS LEARNED

Implementing telehealth and scaling services is not without its challenges. So ACOs looking to implement telehealth should first have a clear plan and understand who they are implementing the services for.

"From a clinical perspective, I think it's important to know why you're doing it, and it should not be done as a way of making an individual clinician's life more efficient because it doesn't necessarily do that," he said. "What it does do is make life much easier for the patients and make their medical care much less obtrusive in their lives."

This means assessing clinical situations and identifying patients who would benefit most from telehealth should be key strategies for ACOs implementing telehealth, Walradt added.

Further, when deciding on a virtual care solution, MultiCare's Taylor suggests selecting one that can scale up and down to meet your organization's financial needs appropriately.

And more importantly, as telehealth use becomes more common among ACOs, organizations also need to consider those who cannot access these services but would benefit from them.  

"As we think about putting systems and solutions into place, such as telehealth, we need to be able to think about who are we leaving out?" Taylor said. "Such an important question: who could we be leaving out of this access to this service? Really enable your organization to see things differently with different lenses to ensure that you are enabling just and equal [care]."

There are also financial concerns regarding the continued use of telehealth that ACO leaders need to consider. Though waivers have been introduced that bring about telehealth payment parity, these flexibilities may not be made permanent.

"The long-term reimbursement outlook for telehealth is still undecided," Galka said. "[I] recommend organizations proactively engage in collaborative discussions with payers and policymakers about the importance of ensuring parity payment."