Patient Care, Policy & More: A Look at This Year’s Virtual Care Trends

In many ways, 2023 was a year of reckoning for virtual care. From sky-high funding and clinical promises verging on hyperbole to bankruptcy filings and an ongoing patient preference for in-person care, virtual care stakeholders had to concede to some hard truths. Still, the appetite for virtual care is alive and well, making it the stakeholders’ responsibility to assess and optimize the adoption and use of virtual care in the year ahead.  

In the third quarter (Q3) of 2023, telehealth use dropped to 5.8 percent from 31.2 percent in the second quarter of 2020, the peak of the COVID-19 pandemic, data from Epic Research shows.

“During COVID, we saw this explosion in virtual care, virtual visits, video visits,” said Steven Shook, MD, lead for virtual health at Cleveland Clinic, in an interview with mHealthIntelligence. “And we had imagined that we were going to hold onto a lot of that — the patients were going to really love it, and they did. But we've seen a lot more of a fall-off in demand for that after COVID ended than we expected.”

As a result, provider adoption has become more discerning, impacting venture capital interest in the space. Investment in the digital health arena has declined, dropping to $8.6 billion in Q3 2023 from $29.2 billion in 2021, according to Rock Health.

The mood of healthcare stakeholders going into 2024 may be more somber than in the recent past, but the work of integrating virtual care into the US healthcare system is ongoing. Here are some key trends healthcare leaders, policy experts, and consultants expect to see in the new year.

PATIENT CARE TRENDS

As in-person care returned following a significant decline early in the pandemic, patient preferences for visit type became more nuanced. Patients appear to be leaning toward a blend of virtual and in-person care customized to their needs.

“So, I think moving into next year, we're going to find ways to really bring together the best of in-person and virtual care to deliver the best possible outcome for our patients,” Shook said. “And I think that's the challenge. Not every patient journey, not every care journey is going to be really heavy in digital care. Many of them will be, but really striking the balance between in-person and digital is going to be key.”

For instance, mental healthcare services are a better fit for virtual care delivery and can have more digital touchpoints than, say, orthopedic care. According to Shook, online therapy has proved so convenient and clinically successful that it's hard to imagine these services returning to in-person.

Patient interest in virtual care modalities, including asynchronous telehealth and remote patient monitoring, is growing. So, healthcare providers must set up efficient digital workflows that ensure frequent connections between patients and clinicians and a streamlined data strategy to effectively leverage these modalities, he said.

Not only that, but providers in the virtual care space will have to contend with the rapid evolution of artificial intelligence (AI) — the buzziest technology of the year.

“I think patients are seeing how AI can enhance their own lives through ChatGPT,” Shook said. “I think they're going to expect their providers to be able to have access and use those tools as co-pilots to really drive better outcomes and improve their care.”

Cleveland Clinic is exploring the use of AI in complex care. Patients with complex conditions often have multiple providers and come to Cleveland Clinic with numerous medical records. AI could help sort through medical notes and enable clinicians to zero in on the information they need, Shook said.

The organization is also looking into using AI to support ambient documentation, which involves using a platform to automate some clinical documentation based on patient-provider conversations and queue up orders and prescriptions.

Emily Fry, vice president of innovation at Geisinger’s Steel Institute for Health Innovation, echoed Shook, noting the growing interest in asynchronous telehealth, remote patient monitoring (RPM), AI chatbots, and even virtual reality.

“We've seen an uptick in people trying to develop virtual reality and augmented reality technologies,” she said in an interview with mHealthIntelligence. “I don't know that we're there yet, and I don't know if 2024 is going to be the year for them just because of the clunkiness of the technology, and we still need to make it more usable and practical within the settings. [But] I am going to watch it for sure.”

Another area of high interest is virtual nursing. Burnout among nurses is worsening, with a May 2023 survey showing that 56 percent of 7,400 nurses polled are experiencing burnout. Not only that, but nurse turnover is also still above pre-pandemic levels, with 39 percent saying they were likely to leave their current position.

Thus, there has been significant adoption of virtual nursing and sitting models across provider organizations, with virtual nurses helping support nurses on-site with administrative activities like discharge summaries and virtual sitters keeping patients company and alerting care teams to patient needs, Fry said.

Further, the utilization of RPM technologies and approaches is expanding.

“Not all remote monitoring devices may have met the need of the patient or chronic disease management or managing [patients] appropriately in a hospital-at-home [setting], and we need to adjust accordingly, she said. “But overall, those technologies are here to stay, and they're going to stand the test of time, I think.”

Kaiser Permanente, which has one of the largest RPM programs in the US with over 90,000 members enrolled, views the care modality as a critical aspect of its virtual care strategy.

“Our integrated remote patient monitoring programs have proven to be a successful tool for our members to receive care in the convenient setting of their home,” said David Strickland, vice president of telehealth, Care Delivery Technology Services, at Kaiser Permanente, in an interview with mHealthIntelligence.

Kaiser’s RPM program enrolls patients with various chronic conditions, including diabetes, hypertension, congestive heart failure, pneumonia, and diverticulitis. 

This year, Strickland expects to see a shift from Bluetooth-enabled wearable devices to cellular-based tools.

“Cellular technology has the potential to create more stability and provide data to our care teams even quicker, without the requirement of a smartphone to act as an intermediary,” he said. “This technology also has the potential to remove human error and expand the audience of who could benefit from remote patient monitoring programs.”

The rising adoption of RPM has also spurred the implementation of hospital-at-home programs.

Margaret Paulson, DO, medical director of Mayo Clinic Advanced Care at Home in Northwest Wisconsin, highlighted this rise, stating that provider organizations are still struggling with capacity constraints, resulting in a growing need for at-home healthcare services.

Paulson believes that AI will play a vital role in the evolution of hospital-at-home programs.

“AI has the potential to improve efficiency and decrease administrative burden for team members, allowing them to focus on aspects of their day that may bring more joy,” she said. “We have seen this at Mayo Clinic with the algorithm we created to identify appropriate patients for our hospital-at-home program.”

However, there are several ongoing challenges healthcare providers must contend with as the virtual care landscape continues to evolve in 2024. Patient access and comfort with technology and internet connectivity are among the most pressing.

“Geisinger and many systems across the nation have rural populations where the accessibility to stable Wi-Fi, stable internet or cellular range is a challenge,” Fry said.

Both Geisinger and Cleveland Clinic are looking at ways to close connectivity gaps by partnering with nonprofits and other local community resources.

Further, Cleveland Clinic is tracking platform adoption rates among its patient population to determine technology access challenges.

“What percentage of the patients did I see in the past year that are on our digital platform? That tells me if they're active,” Shook said. “They're able to check labs, communicate with their doctors, schedule appointments. I mean, to be on that platform is to be able to take advantage of the digital portion of the ideal hybrid care model. So, that's something we're actively looking at.”

HEALTHCARE CONSUMERISM TRENDS

Going into 2024, patient expectations for easy access to virtual care will continue, according to Bill Fera, MD, former family practice physician and principal at Deloitte Consulting, in an interview with mHealthIntelligence.  

“This is a basic expectation that patients are going to have, and we were seeing this even before COVID,” he said. “They will avail themselves of digital services. And so, if it's not through traditional providers, it will be from non-traditional providers.”

If providers are unable to keep up with the demand for virtual care and patients increasingly find that care outside of the traditional healthcare system, it could result in fragmented patient care, Fera warned. Fragmentation can lead to inefficient, ineffective, and inequitable care.   

Thus, providers must be more intentional about creating hybrid care models that seamlessly integrate virtual and in-person care. To establish these models, clinicians must change both their mindset and workflow.

“It's interesting to me because it should be easier to work virtually as a team because we can all be together in the same virtual space taking care of a patient,” Fera said. “But it's almost like our clinicians are having a hard time making that leap to understand we can behave completely differently.”

He added that physicians still think linearly about patient care: first, the patient will be taken to a room, then a physician extender will meet with the patient and take down their medical history and vital signs, and then the physician will come and see the patient. But with hybrid care, these services can be performed simultaneously, including bringing specialists into the visit in real time, Fera said.

Healthcare provider organizations must make changes from the top down to implement these hybrid care models.

“I think that in a lot of instances, this is just another expectation that the clinicians will figure it out,” he said. “Whereas being intentional and having a true strategy and plan that is conceived of and then implemented at an organizational level to support clinicians and patients is the most important piece of advice I would give.”

POLICY AND REIMBURSEMENT TRENDS

The virtual care policy landscape has remained relatively steady at the federal level as policymakers extended most of the significant temporary pandemic-era waivers through the end of 2024.

“Where we wound up at the end of 2023 is status quo — really where we were at the beginning of the year,” said Mei Kwong, executive director of the Center for Connected Health Policy, in an interview with mHealthIntelligence. “And if you look at it on the state level — if you look at it overall, encompassing all the states — it's the same story because a lot of states had already made their decisions [regarding virtual care policy] back before 2023.”

While there were some critical developments, such as the Drug Enforcement Administration (DEA) and the Department of Health and Human Services (HHS) lifting proposed restrictions on the virtual prescription of controlled substances through the end of this year, lawmakers have essentially kicked the decision down the road, making 2024 a crucial year for the future of virtual care. 

Kwong noted that key policy focus areas include audio-only telehealth and digital navigation. These have been recognized as important tools in extending access to healthcare and will likely see congressional support as lawmakers make decisions around virtual care.

In fact, most policies supporting virtual care expansion have bipartisan support, giving telehealth proponents reason to remain optimistic.

“It gets support from both parties on it, so there's not anybody who's against it,” Kwong said. “I think there's always still the struggle and the balance that policymakers try to make in assuring that people have access, but the concern, even now, even though we've used it so much during the pandemic, is does it work as well [as in-person care] or is it safe?”

Amy Lerman, a member of the law firm Epstein Becker Green, echoed this sentiment, stating, “While regulators at both the federal and state levels have remained committed to supporting the use of virtual care services, a related assumption among regulators has been that these services will be provided safely and effectively while acknowledging that healthcare professionals need and want a clear regulatory framework within which to operate.”

While Congress appears to be working toward developing policies that provide such a framework at the federal level, laws governing telehealth are more piecemeal at the state level.

“A continuing trend among states is that no two have been exactly alike in the approach to defining and regulating the practice of virtual care; rather, individual states continue to take their own unique approaches to creating and refining the legal and regulatory framework through which providers of virtual care services are expected to operate,” Lerman said in an interview with mHealthIntelligence.

Some states are more focused on the question of audio-only telehealth modalities and whether provider-patient relationships can meet professional standards of care if they are established solely via these modalities, while others are more focused on ensuring prescriptions are issued only as part of valid provider-patient relationships.

Other areas of focus in 2024 include the use of virtual care by non-physician licensed professionals, Lerman said. States are working to clarify scopes of practice for midlevel and advanced practice providers, as well as requirements around physician supervision of these professionals.

States are also looking into creating remote prescribing policies that are specific to certain types of treatment, such as substance use disorder, and assessing licensure regulations. Though the pandemic eased the cross-state licensure process by encouraging the adoption and use of interstate compacts and special use licenses, there is still more work to be done to ensure widespread access to out-of-state telehealth, and it “will continue to be a challenge in 2024,” Lerman said.

Healthcare providers favor making permanent telehealth flexibilities and streamlining virtual care deployment. However, they remain concerned about the uncertainty surrounding virtual care reimbursement.

“We don't currently have, I think, a stable model that allows people to really grow and expand these [virtual care] programs that can [provide] so much benefit for access, ease of use, and total cost of care to a patient,” Geisinger’s Fry said.

Payers need to recognize virtual care as a billable intervention and provide enough coverage so that healthcare providers can sustain the programs, she added.

This evolving telehealth policy and reimbursement landscape is stalling virtual care efforts at healthcare provider organizations.

“It is hard to plan,” said Cleveland Clinic’s Shook. “We don't know exactly what's going to happen... I think though that what we're trying to stay focused on is what's best for our patients, what our patients want within that framework, and how can we meet our patients' needs and deliver the best possible outcomes.”

REGULATORY ENFORCEMENT TRENDS

As lawmakers work to resolve the question of pandemic-era telehealth flexibilities, concerns around fraud, waste, and abuse remain. However, these may be largely unfounded.

Though some telehealth-related false claims schemes have resulted in Department of Justice intervention, federal assessments show a relatively low risk associated with high billing for telehealth services provided to Medicare beneficiaries.

According to Kwong, it is unlikely that further assessments of telehealth services will reveal a different story. Telehealth flexibilities have been in place since 2020, and there have been few cases of fraud, waste, and abuse or overuse during this time, so it is unlikely to change if the flexibilities are made permanent, she stated.

Still, even a few cases of fraud, waste, and abuse are a cause for concern among federal agencies. Lerman believes that “telefraud” will remain an area of focus for the HHS’ Office of Inspector General (OIG).

“As of November 2023, current open items in the OIG Work Plan include ongoing work on audits related to use of telehealth for the provision of opioid use disorder treatment services and the provision of home health services, as well as examination of claims and other data related to the general use of telehealth services by Medicare Part B beneficiaries and telehealth-related expansion efforts by state Medicaid programs during the public health emergency,” she said.

Thus, virtual care providers must remain vigilant about ensuring compliance with policies and operational guidelines. Lerman suggested that providers develop comprehensive compliance infrastructures and processes.  

The year ahead promises to be one of change for virtual care stakeholders. With the ongoing integration of virtual care modalities into healthcare — including synchronous, asynchronous, and audio-only telehealth, RPM, digital health tools, virtual reality, and digital therapeutics — these changes will reshape the contours of the US healthcare system.