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Some Plans Ignore Nay-Sayers When It Comes to Telemedicine

MANAGED CARE March 2013. © MediMedia USA
Feature

Some Plans Ignore Nay-Sayers When It Comes to Telemedicine

A controversial study challenges backers to prove that these technologies are cost-effective

Frank Diamond
Managing Editor

Wootton tells Managed Care that “the idea of telemedicine has a polarizing effect on people: They are either fervently for it, or vehemently against it. There are few who inhabit the middle ground.”

“The use of remote monitoring devices alone is not a cure-all for chronic disease,” Jonathan Linkous, CEO of the American Telemedicine Association, admits.

His study — “Twenty Years of Telemedicine in Chronic Disease Management — An Evidence Synthesis,” http://tinyurl.com/tele-study — concludes that “the evidence base for the value of telemedicine in managing chronic diseases is on the whole weak and contradictory.”

Quite a statement, says Al Lewis, the founder of the Disease Management Purchasing Consortium. “It’s rare that a journal devoted to a topic publishes something negative about it. For instance, the Journal of Health Promotion has never once published an article showing a negative return on investment from wellness. So when one does, the article is almost certainly right.”

Furthermore, “telemedicine vendors lie,” says Lewis. “One brochure clearly promises reductions in health care spending up to 25 percent, but when pressed they say 25 percent of primary care visits, which are only about 6 percent of total spending. And it isn’t even clear that they do that.”

Despite Wootton and Lewis’s concerns, some major health insurers want to increase their telemedicine efforts. “You have me in a challenging position,” says Wesley Valdes, MD, the medical director of telehealth and virtual medicine at Intermountain Healthcare. “Intermountain is embarking on an ambitious telemedicine implementation, but at the beginning stages, so it would be poor form to let the world know of our plans at this juncture — particularly as we are inventing on a number of fronts.”

Valdes and Intermountain are true believers. “Intermountain is looking at this as a systemwide initiative that allows the organization to realize benefit for both clinical and non-clinical purposes.”

Telemedicine is as effective as how it’s used — or even if it’s used. “A typical desktop computer is worthless to people who refuse to type, or if there is a policy that states if they use the desktop computer they won’t be compensated while they get paid in full for handwriting a document,” says Valdes. “The same equipment has high worth for a person who integrates the equipment into his workflow and uses it a lot, or if his compensation is based on the ultimate outcome of the product rather than based on the method used to produce the same product. Same equipment — different situations — different perception of worth.”

Some agreement

As might be expected, Jonathan Linkous, chief executive officer of the American Telemedicine Association (ATA), would also like to qualify Wootton’s bottom line. “We agree with the basic conclusions of the author as it reiterates what has been said in many earlier studies: The use of remote monitoring devices alone is not a cure-all for chronic disease. As has been widely documented, the real benefit in the use of remote monitoring for chronic patients is when such remote monitoring is incorporated into a larger care management approach to patient care.”

More on what Valdes and Linkous think about Wootton’s study later. What about that study itself?

Well, first notice the phrase “evidence synthesis.” Wootton wanted to do a meta-analysis. “Such analyses have indeed been conducted for specific outcomes in certain chronic diseases,” the study states. “Here the problem is that the published trials have employed a wide range of outcome measures, so that a pooled estimate of any one outcome reduces the size of the dataset very considerably.”

For instance, there were at least 11 randomized control trials of telemedicine for COPD, but the published estimate of the risk ratio for mortality was based on only three studies. Since a conventional meta-analysis could not be used, even though the overall number of telemedicine studies increased by a factor of five since 2003, Wootton had to come up with something new. (See “Methodology of an Evidence Synthesis,” below.)

Methodology of an Evidence Synthesis

Although there have been “vast implementations” of telemedicine in recent years, almost nothing is known about its cost-effectiveness, says the study “Twenty Years of Telemedicine in Chronic Disease Management — An Evidence Synthesis.”

The author, Richard Wootton, PhD, of the Norwegian Centre for Integrated Care and Telemedicine is a British citizen and gets his health care from the National Health Service.

Cost-effectiveness is a crucial consideration for the NHS to adopt any new technology, but there have been very few studies of telemedicine’s cost-effectiveness.

Here’s what Wootton did instead:

The analysis was confined to RCTs (randomized clinical trials) in which one or more telemedicine interventions had been compared with a control group. It was restricted to patients with one of these common chronic diseases: asthma, COPD, diabetes, heart failure, hypertension. The telemedicine intervention could include telephone support, telemonitoring, videoconferences, and other methods. The value of the trial result was defined in terms of the outcomes specified by the investigators in each study individually. A synthesis was carried out by meta-regression.

Wide definition

The ATA says that “telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, e-mail, smart phones, wireless tools, and other forms of telecommunications technology.”

Wootton’s study notes that telemedicine has a “wide definition,” and is mostly used to support integrated care, another “fashionable term with rather elastic definition.” Another expert who has studied telemedicine but who asked not to be identified, points out that one of the problems with measuring telemedicine is that the technology evolves so quickly.

Wootton looks at the use of telemedicine in managing five chronic conditions: asthma, COPD, diabetes, heart failure, and hypertension. “A total of 141 randomized controlled trials (RCTs) was identified, in which 148 telemedicine interventions of various kinds had been tested in a total of 37,695 patients,” the study states. “The value of each intervention was categorized in terms of the outcomes specified by the investigators in that trial, i.e., no attempt was made to extract a common outcome from all studies, as would be required for a conventional meta-analysis.”

In 108 studies, telemedicine seemed to have a positive effect, while only two showed that it had a negative effect, suggesting publication bias, says the study. Also, no matter what the disease, telemedicine seemed to be equally effective. In addition, the studies were usually short-term, with a median duration of six months.

“It seems unlikely that in a chronic disease, any intervention can have much effect unless applied for a long period,” the study states. “Finally, there have been very few studies of cost-effectiveness.”

Wootton tells us that “One central problem, in my opinion, is that there are strong commercial interests in all this, especially in the United States. So your medical readers will no doubt be bombarded with offers from companies who want to sell them home monitoring services. I suppose the acid test would be to ask a putative vendor if he can produce some data from a randomized controlled trial. Otherwise, it’s all a bit like snake oil.”

Proven to be beneficial

Not so fast, says Linkous. Wootton’s study is fine, as far as it goes. It “is an excellent review of a number of small, device-centric remote monitoring trials for chronic diseases. It is not looking at all of telemedicine and is not a negative review of telemedicine. Such chronic disease monitoring services are an emerging and still very small subset of overall telemedicine activity. Other telemedicine activities dwarf this use and have long been proven to be beneficial.”

The ATA estimates that 10 million Americans received remote services last year, only a fraction of them related to chronic care monitoring.

Linkous cites a study about how telemedicine fares in the Veterans Health Administration (http://www.va.gov/health/default.asp) that comes up a lot in this discussion. The study is called “Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions,” published in the Dec. 14, 2008 edition of the Telemedicine and e-Health in which telemedicine was used successfully in 80,000 homes.

The study does not include a control group, however. The lead author, Adam Darkins, declined to comment.

“More and more studies are being published that do validate the utility and effectiveness, defined in a number of ways, of telehome care.” — Elizabeth Krupinski, PhD, University of Arizona

What it delivers

Keep an open mind, says Elizabeth Krupinski, PhD, a researcher in the departments of radiology and psychology at the University of Arizona. “But have a specific goal and application in mind. I tell people it helps to start small, maybe with one application known to work for an existing documented need. It is necessary to decide what exactly you want to measure in terms of effectiveness. Is it the bottom line? Is it patient outcomes? Is it travel time saved? Once you have your metric, then decide how and when to measure and set target goals.”

“I just remain to be convinced,” Wootton says. “I’d like to see some real scientific evidence. As a UK health care consumer, what I want from my own government is consistency. There is a well-rehearsed scheme for assessing the value of new pharmaceuticals and deciding whether they can be paid for in the public health service. As you know, this involves estimating cost-effectiveness — if the drug produces benefit in terms of quality-adjusted life years at a lower cost than a particular threshold (about 30,000 pounds at the moment), then the National Health Service will pay for it.”

Anthem begins vast telemedicine effort

One of the problems with studying telemedicine is that it’s hard to hit a moving target. The technology just won’t sit still long enough for a comprehensive cost-effectiveness analysis to be conducted, says John Jesser, MBA, the vice president for provider engagement at Anthem Blue Cross Blue Shield. Meanwhile, the difference between how it was done then (see our story from 1998 — http://tinyurl.com/tele-article) and how it’s done now is like the difference between watching a fuzzy clip of Walter Cronkite talking about the Apollo program and watching a 3D video of an actual spacewalk. One cannot blame health plan officials for getting carried away about the potential.

Rate of adoption will be the real test for a huge telemedicine effort currently being rolled out by Anthem, says John Jesser, MBA, the insurer’s vice president for provider engagement. “People will vote with their feet and ... adoption will be the real driver.”

“How excited am I? Bursting at the seams,” says Jesser, talking about the insurer’s LiveHealth Online program that’s currently being launched. “I’ve been working in health care with doctors, hospitals, and health plans to try to make health care safer and more affordable for 25 years. Rarely do things come along that are truly game-changing.”

He pulls back from that assessment, saying that there will be a modest start. The program, to be rolled out in the next two years, will initially be offered to small- and large-group fully insured customers and self-funded national employers. It offers beneficiaries live video consultations via the Web with primary care physicians from 7 a.m. to 11 p.m. daily, including holidays. The speed of the rollout will depend in part on how well and how quickly regulations in various states are addressed.

The scope of treatment will be modest as well. Consultations will focus on colds, aches, sore throats, allergies, infections. Wellness and nutrition advice will also be offered.

“Traditional telemedicine was equipment with camera in one location and equipment and camera in another location where a patient was expected to go sit and the doctor would sit at the other end,” says Jesser. “Now we’re really focused on telehealth. It’s instant. We’ve created a program where consumers can access a doctor on demand in a structured, HIPAA-compliant manner and actually engage in a visit without having cumbersome equipment involved. They can use just a Web browser and a Web cam.”

LiveHealth Online will be offered first to Anthem beneficiaries in Ohio and California, but Jesser says the long-range goal is to make it available to all of the insurer’s nearly 29 million members.

The program mirrors one undertaken by Blue Cross & Blue Shield of Minnesota for its own employees. “Blue Cross worked with the same technology that we’re working on and rolled this kind of care out to their employees. After each visit, the survey asks, What would you have done? Employees responded that a certain percentage would have gone to the emergency room. Some would have gone to an urgent care center. Some would have gone to their doctor. Others would have done nothing. When you run those numbers, particularly urgent care and emergency room … you’re avoiding about $45 in costs for each online visit.”

Not that he’s making any guarantees at this stage. “We aren’t claiming that in our financials in any way,” says Jesser. “We are confident that it won’t drive costs up. The question is what will it do to lower costs, and we’ll measure that very carefully.”

It will be 18 to 24 months before a cost analysis can be done, he says. “We want to have some period of data that’s significant, that’s statistically meaningful.”

Primary care

Jesser is also excited about what LiveHealth Online will mean for primary care physicians and for the much-reported-on shortage of those doctors. There has been a lot of fretting over the shortage, given that health care reform brings many of the uninsured onto the rolls and drives demand up even more.

“Think about that and think about where these doctors are going to come from,” says Jesser. “There are many doctors today that are young parents on their second or third child who can no longer keep office hours. So they are retired or semiretired, but are high-quality doctors. To allow, through technology, a working parent-physician to log in at 9 p.m. after putting the kids to bed and to work with patients until 11 p.m. — that is a great thing.”

Other than cost-effectiveness, how will success be measured?

“Adoption,” says Jesser. “Do consumers find it easy to use? Do they like it? People will vote with their feet and, as with any consumer product, adoption will be the real driver.”

So many studies, so little knowledge

It’s not that telemedicine hasn’t been studied, it’s just that the studies don’t move much beyond 2003, when “good quality studies were scarce and … the generalizability of most findings was rather limited,” says the study “Twenty Years of Telemedicine in Chronic Disease Management — An Evidence Synthesis” in the June 2012 issue of the Journal of Telemedicine and Telecare. Nonetheless, health plans and the government have implemented telemedicine at a quickening rate. “Despite this enthusiasm, almost nothing is known about the cost-effectiveness of telemedicine in chronic disease management,” the study states.

Medline publications about telemedicine and 5 chronic conditions

Publications per year

Source: “Twenty Years of Telemedicine in Chronic Disease Management — An Evidence Synthesis,” Journal of Telemedicine and Telecare, June 2012