Telehealth: A Vital Piece of the Care Access Puzzle

0:06 Hello everyone and welcome to today's webinar, Telehealth A Vital Piece of the Care Access Puzzle. And before we get started I'd like to go over a few items that you know how to participate in this event. You have the opportunity to submit questions to today's presenters. Just type those questions in the questions section of the Go to Webinar control panel. You can send your questions in at any time during the presentation. We are collecting those and we'll address them during the Q and A portion at the end of the presentation. If you would like to see closed captioning, please click on the CC icon on the GoToWebinar toolbar. And lastly, the slides are available under the Handouts section of the GoToWebinar control panel. Simply click on a title, and it'll open up in a browser window for you to download. And with that, today's webinar is being recorded, and you'll receive a follow-up email within 24 to 48 hours with a link to view the recording.

1:04 And I would like to introduce Kathryn Santoro.

1:08 Thank you. Good afternoon. I'm Kathryn Santoro, senior director of programming at the National Institute for Health Care Management Foundation. On behalf of NIHCM, thank you for joining us today for this important discussion on how telehealth can address disparities, elevate the quality of care, and reduce costs.

1:27 This webinar is part of NIHCM'sAffordability Roadmap webinar series, where we are sharing research and expert perspectives on solutions to our nation's healthcare affordability crisis.

1:40 Previous webinars have covered the impact of private equity and consolidation on costs and quality, as well as the impact of escalating healthcare costs on the Federal budget.

1:52 Telehealth has improved access to a wide range of health care services by overcoming geographical barriers and improving the timeliness of care.

2:02 Understanding the challenges to telehealth wide adoption is important for its sustainable integration into health care systems.

2:11 Today, we will hear from a prestigious panel of experts to learn more about the state of telehealth policies, as well as research and strategies to ensure equitable access to care.

2:23 Before we hear from them, I want to thank them ... NIHCM team who helped to convene today's event. You can also find biographical information for our speakers, along with the agenda and copies of slides on our website.

2:37 We also invite you to join the conversation on social media using the hashtag telehealth.

2:46 I am now pleased to introduce our first speaker, Mei Kwong, Executive Director at the Center for Connected Health Policy.

2:54Ms. Kwong leads the organization's work on public policy issues as they impact telehealth on the state and federal levels.

3:02 She is also the Project Director for the National Telehealth Policy Resource Center.

3:07Ms. Kwong is a nationally recognized expert on telehealth policy, and in her current role, she works with the organization's national and regional partners on telehealth issues and oversees their projects, as well as providing technical assistance to state and federal lawmakers, industry members, providers, consumers, and others. She's been published in peer-reviewed journals and as a sought-after speaker at national conferences.

3:36 I'm also proud to have previously worked with and supported May through our research grant program, and we're so grateful. She took the time to be with us today to share an update on federal and state telehealth policies and the potential future of those policies.

3:56 Thank you, Kathryn, and thank you for inviting me here today and thank all of you for attending and listening to this talk. As Kathryn mentioned, my name is Mei Kwong, I'm the Executive Director at the Center for Connected Health Policy, and I'll be going over just a very high-level overview of the telehealth policy landscape in the United States, both on the federal and the state level. And also, what we can anticipate as far as what may happen, as far as developments, going throughout the year 2024 and the future, and where policymakers may be right now in making those considerations for those future policy updates.

4:34 Before we get started, I am going to use the term telehealth in my talk simply because that is how a lot of the policy is written right now. It references Telehealth or Telemedicine frequently telehealth, but you may hear other speakers use different terms. We're all really talking about the use of technology to provide health services, so that is basically what we're talking about though. We may not be using the same terminology, but it is the use of technology to provide health services in some way. If we can go to the next slide, please.

5:10 A few disclaimers before we get started. Please note that any information that I provide today is strictly for informational and educational benefits. It is not. Legal advice. We always recommend ... that if you're interested enough in a formal legal opinion, you consult with legal counsel. And if I happen to mention a company or show a picture of a product, know that neither I nor see CHP has any type of relationship, affiliation, or arrangement with such a company. 5:39 Next slide, please.

5:47 Next slide, please.

5:55 A bit of background about If We Could Go Back, Sorry, there seems to be a slight delay on my end, a bit of background, about CHP. Ashley was established Ashley as a California Telehealth policy organization. In 2009, underneath the Public Health Institute. We became the federally designated National Telehealth Policy Resource Center in 20 12 through a grant from HRSA. What that essentially means is we receive federal funding to provide technical assistance on telehealth policy primarily to the other telehealth resource centers who are underneath the same funding stream.

6:28 However, CHP does provide that service as well too, basically, the general public. So, we've helped everybody from the White House to congressional members, to state policymakers, different federal agencies and state agencies, health systems, hospitals, health plans, different organizations, and when covered 1009 hit more frequently, we were dealing directly with consumers and patients as well, and their questions around telehealth. We also see CHP access Administrator for the National Consortium of Telehealth Resource Centers. And what that is is the other 14 Telehealth Resource Center.

7:07A few years ago I realized that there was some duplication of development of resources and efforts that we're doing and providing technical assistance or materials and we decided to pool a portion of our federal funding together into a common pot to work more collaboratively on projects. So, CHP access and administrator of that work, CHP, also has an ... means a group in California called the California Telehealth Policy Coalition and that is made up of over 170 statewide and national groups who are interested in telehealth policy in the state. Next slide, please.

7:48So, to understand telehealth policy in the United States, you need to realize that there's actually two levels for it. There's what's going on with telehealth policy on the federal level and what's going on on the state level and coming out of covered 19 with the entering the public health emergency. Last year, the levels, the federal level and the state levels were not actually on the same plane, so they all did things differently and they approached the end of the public health emergency differently. For example, in the states.

8:20And, again, when I say states, it's not, I'm not talking about all 50 states doing the same thing. Each state was doing different things, and how they addressed the end of the public health emergency or what they were going to have as their permanent telehealth policies. But overall, when May 11, 2023 hit, which was the end of the national public health emergency, by that point, a lot of states had to decide what their permanent telehealth policies were going to be coming out of 19. So, unlike on the federal level, they were not making a lot of decisions about, like, you know, what are we going to do now?

8:56 ounce federal public health emergency is over. A lot of states had already decided there were a couple of states that did mirror what the federal government did, and did extend some of their policies out to future dates. But, for the most part, most states had already made decisions. And that decision, those decisions, a lot of them included in doing expansions and Medicaid, as far as, you know, the type of services that you can provide via telehealth and what they would reimburse, where the patient can be located. And, more interestingly also around, allowing only to be a modality that they would reimburse for.

9:31 Other items that they addressed at the state level were around licensure issues, as far as making certain exceptions for licensure in very specific scenarios, such as if there was already a patient provider relationship established, or if there were services being provided within a certain amount of distance from the border states. So, they were doing these specific carve outs on the licensure issue as well too, but not necessarily, you know, allowing sort of more full reciprocity of licensure, or you would see states joining professional compacts, licensure contacts to make that as sort of like a way of dressing the licensure issue. That is still something that states are continuing to look at. So, right now, some of the items that we have flagged that are ongoing for states appear to be the licensure.

10:26 And also, around prescribing as well, too, which is, the prescribing issues definitely mirrored on the federal level, but on the state level prescribing of specific in specific scenarios, such as for contact lenses or for hearing aids, or for, you know, things related to reproductive health on the federal level. And this is probably what a lot of people may be more familiar with on the federal level. They did delay a lot of their temporary policies and extend them out until the end of 2024. So, the temper waivers that we saw during Coburn 19 on the federal level, particularly around Medicare, have been extended to the end of this year. What's also been extended is allowing telehealth to be used to prescribe controlled substances without having an in person exam by the Telehealth provider or falling into some narrow exception that currently exists in federal law.

11:20So, the question now becomes, like, What's going to happen, because we are, at this point, seven months out from the end of the year? What's going to happen to all of these temporary policies? And, right now, as far as I can tell, the federal policymakers have not quite reached a decision on what is going to happen. There is bipartisan support for these telehealth policies, but right now, what their final decision will be as far as the future remains a bit unclear.

11:52So, there's been a lot of hearings over the past couple of months in Congress, Also different agencies or different panels have also discuss the future of Telehealth, as well to what we've been able to tell is these are some of the sort of major concerns have been raised in a lot of those hearings, and those are concerns around fraud. Overutilization, the efficacy of telehealth access. Will access be cut off?

12:21 And parity should telehealth be paid the same as the in person services? And then you'll see, like, the specific policy issues, themselves. They usually fall underneath one or more of these categories. Like, for example, some of you may have seen recently in the news the end of the end of the broadband funding program, the subsidy that they were giving to some people to allow them to access broadband that funding to an, essentially, because they've used up all their funding. Again, a program that has a lot of bipartisan support, but they just haven't quite gotten to that step of, like, extending the funding or adding more funding to it, even though there's a lot of support for it. So that falls underneath you know, access and subways. It falls underneath the access here, but that's like one of the areas. or one of the concerns that policymakers have.

13:15 The policy that they need to decide on impacts as well, to a common sort of theme that we're seeing running through all these things, all these issues or concerns over costs and money.

13:28 Also, the importance of data, because they're asking for data, to show that there is fraud, or to show that this actually works, and also impacts on patients and disparities. Again, like, running across all of these, in some ways, or multiple issue areas. Will patients lose access? You know, if we make a decision on parity, does that also impact patients? In some ways, efficacy? That's obvious, you know, does this work for patients?

13:57 This is to improve the health, the patients. If we can go to the next slide. So, some of these things, I think, have sort of been answered with some of the work that's been done over the last couple of years and human recently as well, that do address some of the policy makers' cancer. And if you listen to some of these hearings in these meetings, you do see witnesses bring these issues. These items put these resources up as well to, for example, concerns over utilization, the meta care telehealth trends report from 20 24 showed actual utilization, at least in the Medicare program, has gone down, like since the height of the beginning of the pandemic. So, we've had, like, sort of the most liberal telehealth policies out there, but we've seen it actually be used less as we've gone along. And I think that was to be expected just simply because of, you know, the change in the environment concerns.

14:49 Over fraught, there's actually been a couple of studies by the Office of the Inspector General saying that, you know, there hasn't been like the widespread fraud and telehealth or telehealth claims that they thought there were. There's been telemarketing fraud out there that Telehealth has been associated with the Telehealth claims itself. They have not actually found a lot of fraud. And then as far as efficacy, I just pulled out like one area that's around the use of Telehealth or to address opioid use disorders.There have been studies on there showing that it actually has helped like lower sort of bad outcomes for it if telehealth as you sort of like more adherent to their medication, and also lowering of fatal drug overdoses. So there is evidence out there that alleviates some of the concerns raised by policymakers. We go to the next slide.

15:43 Parity is a little bit more different so there's actually been arguments for parody and against parity against parity said, no. Why should we be paid the same? The overhead costs are not the same as they are in person. The service itself is different from in person, so it should be paid less, et cetera. Does a parody have countered that by saying like, well, you know, sometimes the overhead costs, especially if you have both, and in person practice and a telehealth practice as well, you still retain those overhead costs.

16:13 Also, a lot of people have also pointed out that, you know, things are different for what a herb and Provider may experience compared to rural providers. So, maybe Ann Arbor providers are able to distribute depending on how their practices are set up able to absorb those costs. Does overhead costs, for example and not have parody and reimbursement worse than say may not be for a rural provider and also noting that perhaps having a lack of parity for the reimbursement for telehealth may actually discourage adoption for it. Support providers might say like, well, why bother offering services via Telehealth? If you're going to pay me less, I'm just going to stick to an in person practice.16:55 So there have been, like, you know, valid arguments and reasons raised both for and against, and that's been one thing that's my policy makers struggle over, like, you know, what direction they should turn on this question, nuts.

17:15 Data, now, this has been an interesting thing, one thing policymakers always demand as far as, like, helping make their decision. It's like the data there, and I've shown a couple of things, such as, like, on utilization. And, unlike the efficacy, there is some research. There is some data out there, but they still are, asking more.

17:31 And, now, the interesting thing about this, as far as, like, data collection of what they are asking for it. We're seeing more and more groups trying to, like, collect that data and provide it. And I think probably the most interesting thing that we're seeing developed here are actually Medicaid programs making a serious effort to collect telehealth data. This is a snapshot from the California Department of Healthcare Services that oversees the California Medicaid program. They've created a data dashboard now to show what telehealth utilization is, like, the demographics of, like, people who are using Telehealth, and that's all available publicly on their website. And we're seeing more and more states do this, So we are slowly getting to some of that data that they, that perhaps may push policymakers to make a final decision here, now. What are possibly the final decisions that they may make?

18:30 As I said, we have, like, at least on the federal level, seven months before, 8, 8 or 7 months before the end of this year, where everything essentially stops all these waivers, all these temporary allowances here. I'm not quite sure where they may go. I think it's probably becoming more and more likely that on the federal level, they may see another extension, just so they have more time to make a decision. But it will be interesting to see, like, you know, if these questions that they bring up around, you know, access disparities and the data, will they be satisfied with what's coming out, what's being generated now throughout the year.

19:08 And I think if we go to the next slide, I think this is my last slide here. This is just some information on ... our website and newsletter you can subscribe to. And then the next slide, I think, is just our contact information. And I just wanted to say thank you, and I'll hand it back over to Kathryn.

19:28 Thank you so much, Mei, for this great update on policies, as well as, you know, some of the concerns related to future policy and decisions may mention the importance of data to inform future policy. And our next speaker will delve into this a little bit more, and share the work, share, his work and the work of his new Center. We're so pleased to have Dr. Saif Khairat route the principal investigator of the new Center for Virtual Care, Value, and Equity. Dr. Saif Khairat

19:59 is the big, big, stir black Stone Blackwell Distinguished Term Scholar and Associate Professor at the University of North Carolina at Chapel Hill. SAARC Highroad holds joint appointments at the Carolina Health Informatics Program, Cecil Sharp Center for Health Services Research and the School of Nursing.

20:21 As a health informatics expert, he investigates developing, implementing and evaluating health IT solutions to improve health, equity, and access. He has authored over 90 influential scientific articles, and more than 35 peer reviewed high impact journals and conferences. We're so honored to have him with us today to learn more about his work, to use data and research, to accelerate virtual care equity.

20:51 Thank you so much. And good afternoon as introduced ..., professor at the University of North Carolina at Chapel Hill and today I'll be speaking about her new center for virtual care, value and equity.

21:03 And previously, I was the co principal Investigator of the Great Plains Telehealth Resource and Assistance Center, focusing on six States and the Great Plains region and it's a funded center from HRSA.

21:17 And we continue to do research that actually informed the development of this Senate looking at utilization of telehealth, pre-pandemic and during the pandemic and also some of the challenges that we've been facing. And we identified for the center that there are two main themes that we are interested in further exploring.

21:39 one is, How can we make virtual care that encompasses Telehealth and in other digital modalities?

21:48 How can we make it more equitable for patients and more financially sustainable and valuable for providers and programs and institutions. And those two themes drove the idea of the center.

22:02 Next slide, please.

22:05 So, the Center for Virtual Care Value and Equity. ..., was established in 20 23, funded by the NIH and the National Center for Advancing Translational Science.

22:19 It's a five year award for three point seven million dollars to accelerate and, and be a catalyst for research in the virtual care realm, again, focusing on those two areas of making it a telehealth, that virtual care more equitable for our patients. And also more sustainable, from a program sustainability, in the continuum of care standpoint, the Senator has national partnerships with the Center for Telehealth.

22:54 Within the American Heart Association, we also are working very closely with the EAP, the EMA, and the local Government in North Carolina, and our Health Care System at UNC.

23:04 As well as with Health Economist from RTI International, to ensure the cost effectiveness of virtual care and identifying weight, ways to, to, to measure and evaluate ways to make it financially sustainable.Next slide.

23:26So there are four main goals for the center.

23:29one, we realize and are building on what my colleague May earlier said is, there's a dearth of evidence when it comes to the real-world data in telehealth, specifically understanding what data is being collected at the point of care.

23:48 To what extent is that data complete?

23:50 What are the gaps in the data that we currently are experiencing, and how can we improve our measurement approaches to ensure we have comprehensive and longitudinal data that could be used for monitoring evaluation and research purposes?

24:07 So we're building a library of or a repository of real-world data related to virtual care visits, that includes telehealth, E consults, hospital at home, and other virtual kit modalities.

24:22 What we hope to build from that exercise is expertise around what our current data structure looks like, ways that we can improve it.

24:33 And how can we measure, is our data repository at different centers and different institutions across the country are collecting the right measurements in the right form.

24:46 Our second goal is identifying, uh, one of the issues that we've been facing that we had to suddenly switch from in person to telehealth.

24:57 And that was kinda problematic, that we did not have evidenced based practices on how to establish it, implement telehealth programs.

25:08 And so one of the goals is going to be to develop and validate instruments that are frameworks that can inform how institutions and programs and companies can stand up telehealth programs that, again, serve the equity piece and value to make it sustainable from a financial standpoint. So, that's going to be a second goal for the center.

25:30 And the third is identifying What are the facilitators and barriers, two using telehealth and focusing specifically on underserved populations.

25:41We'd like to know, we recognize that Telehealth has the potential to bridge disparities.

25:46 But I also realize that there have been some subgroups left behind during the pandemic as a result of lack of infrastructure, or not having access to digital tools. And so, identifying vulnerable populations, what are their needs? How can we make telehealth more equitable for them?

26:06 We're going to do interviews with patients from various underserved populations of disadvantaged populations across the country to understand their needs for adopting telehealth.26:20And on the other side, we're also going to be interviewing providers and programs, an executive leaders and policymakers around what can be done to make telehealth, more valuable and more sustainable for financial standpoint, looking at payment models and some of the policy work than me was mentioning earlier.

26:40 In addition, looking at the provider as an entity and understanding what the impact of telehealth on well-being spending too much time in front of a screen for a full day is, are there barriers to a fully full telehealth schedule versus an in person, or a hybrid approach? I can agree to tell them.

27:04 integrated health delivery models.

27:06 And then, lastly, the Center aims to provide opportunities for trainees and clinicians across the country to obtain certification, education, and resources around telehealth and virtual care, from, how do you design a study? What outcome measures should you be thinking about?

27:28 Or frameworks out there, that would be a good, a good fit for your project, all the way to the data and data analysis, so we'll be offering consultations, in addition to other resources to the public, and to interested professionals to be able to build that skill set and knowledge. That's, next slide, please.

27:53 So we realize that this is a map of the US that shows the social vulnerability index that was developed by the CDC a few years ago, and it's widely accepted in many studies and also, uh, reports. And this shows, you know, the lack of social vulnerability and the access to care and the darker colors on the map indicate areas where there is a high social vulnerability.

28:23 Concentration in the zip code. And, also, lack of access or limited access to healthcare.

28:30 However, the digital piece is still missing, focuses on, on access and social, and there's still a gap of understanding, which of these zip codes have internet service providers.

28:43 How many percent of households that have access to a computer, these key fundamental knowledge of data that we need to be able to inform how we can scale up telehealth? Next slide, please.

28:58So, the problem is, Yeah, the challenge to be in in identifying people who lack digital access without having the right tool, So we don't have the right tool, isn't that great data at our fingertips, We are not going to be able to identify those populations that are. What that leads to is unequal access to Health care services, increased costs for programs and organizations, and lots of inefficiencies.

29:28 Even these can be measured in ED, re-admit, Hospital admission in 30 day readmission rates, and also unmet needs for these underserved populations and rural communities that may not have bandwidth, Internet bandwidth, and access to digital, uh, scale digital tools.

29:50 So this is a key problem that we're facing, and in order to be able to scale up and understand how telehealth can improve access, we need to be able to adjust that digital piece with data.

30:03 Next slide.

30:06 So, how can we improve health equity and make telehealth more valuable and sustainable?

30:13Well, first, we need a mechanism to allow us to identify which, where are the populations at risk, and why are they at risk? Is it because of social factors, access factors or digital factors?

30:27 That's going to allow us to do some risk stratification.

30:30We could then use vulnerable vulnerability scores to understand outreach.

30:36 And, how can we tailor our interventions to meet the needs of these individuals in these communities, rather than not one size fits all? Look at two earlier interventions.

30:45 Are we able to identify high risk individuals and target interventions to improve their health outcomes if we know that there is a zip code or a community that does not have a specialist or an oncologist?

30:59 And therefore, the ability to do mammograms may not be possible. We do targeted interventions to improve it. So, again, understanding the needs of the gaps at the, at the patient, and the population level is key. Number two is to be able to reduce inequities. They do exist, and we know that.

31:17And, to be able to identify ways to reduce, to improve equity, we have to, again, understand that digital health access and ownership of computer digital literacy, and some of these core factors that we have yet to explore at a national level.

31:36 And then, lastly, to be able to monitor and evaluate utilization.31:41 Nope, is every patient suitable for telehealth?

31:45What disease or conditions qualify for telehealth versus in person?

31:52 How can we allocate our resources from an organizational standpoint to offer both in person and telehealth in an integrated health delivery model, which would optimize our efficiency levels? So, those are, these are the needs that we currently have and that we're facing as people in the telehealth space. Next slide.

32:15So, we've developed a measurement approach. Still framework, because this was done by my colleague, doctor David Swayne, and his team.

32:22They developed a sprout telehealth evaluation and Measurement Domain for domains looking at health outcomes, quality, and cost of care, the individual experience of using telehealth and program KPIs. From a financial and economic standpoint, And then the fifth domain is the equity stratify are looking at social determinants of health health outcomes And the ways that health care is being delivered.

32:47 So, we plan to validate this instrument, housing consensus from an expert panel that we hope to get from across the nation, to come together and critique.

32:57 What are the pros and cons in this model? How can we improve it? And once we have consensus, this will be a validated framework that we can then share with key members of the community to be able to implement use.

33:12Next slide.

33:16 We've also developed a vulnerability index score that takes into account digital health. On this map here, I show, this is North Carolina.

33:25 On the left side, you have the social components.

33:27 We're looking at factors such as American Indian concentrations and our zip code, african American people living under the poverty line, single parent households with children under the age of 18, living on food stamps, Households with people over the age of 60 of the food stamps, and Medicare, and Medicaid patients.

33:44 Not the left, we have access components, How far is the patient from the closest MS?

33:50 How far are they from the closest highway?

33:52 If they're far away, there's a chance that they are going to delay care.

33:57The number of ISP or internet service providers in that zip code, an access to a vehicle to allow transportation.Then you can see in the middle here, we have three-d. maps. The first one is the accumulated axis components. So, just show us, know, if you're interested in, know, the zip codes that are struggling with geographic access, they are in the dark brown color.

34:21 To the next slide is the social, combined, I'm sorry, I'll go back to the previous slide.

34:29 Yeah, the next map, sorry, is, Is the social component looking at the most vulnerable social, socially vulnerable communities?

34:38 And then, finally, we have an agri combined social on an access equity map that basically tells us where to tailor our interventions, which neighborhoods and communities are struggling the most.Next slide.

34:54 So, we created this digital health, equity score, three, buckets, social factors, access factors, and digital factors.

35:01 I've covered the first two, and the last one is, we're looking at a number of the percent of households with Internet subscription, number of households, with sellers, a data plan, or for smartphones.

35:11An ability to have ownership of a computer smartphone, or a tablet.

35:15In addition, the number of ISPs, this will help us understand the access level to digital tools and whether telehealth would be a good, suitable and viable solution, or not.

35:25 Next slide.This is a map of the hold, the Digital Health Equity Index score at the national level.The areas in dark red are the highest.35:37Welcome to the zip codes with the highest vulnerability levels.

35:42 Where there's high social vulnerability, high access barriers and high levels of digital inequity or lack of digital access.What this will tell us is it will help policymakers and leaders and organizations to hone in on their own states and zip codes and understand the area around sight without insight.

36:07 It's a loss and we need to have data driven indices like this digital health equity index score to be able to inform us of where and how we can tailor our intervention to meet the needs of our programs, healthcare systems, patients, and providers.

36:25 Next slide? So the key takeaways from here is we are interested in adopting I think the future is going to be integrating Telehealth delivery months. It's not going to be one or the other, in person or telehealth, but ways that we can integrate those two together, hashtag two, we need a novel way to identify populations at risk using data driven approaches. And this is what the Center is working on.

36:51 But we hope by the end of the summer, that we will have this tool ready for use, and ready to be 70, and lastly, the need for validated implementation and evaluation frameworks that can drive the implementation on sustainability of virtual care.

37:13 So, thank you very much. This is, these are, you know, there's a QR code. if you're interested in participating as a, as a participant or as a subject matter expert.

37:22 Please join us for emails for any questions, and I thank you all very much for your time.

37:29 Thank you. Thank you so much for helping us understand how you're using data and research to help understand the state of digital health equity, and now your work will be incredibly valuable to inform both future policy and private sector efforts.

37:47 Our final speaker will provide us with the solutions oriented perspective on the use of telehealth from behavioral health services. We're joined by many, a Reso, Chief Network Officer, and President of the Employer Division at Caroline Behavioral Health. Many is a leader in health care, specializing in innovation, public health, health strategy, behavioral health, and health care integration.

38:14Many has been less carillon behavioral health for eight years, overseeing innovation across the business life cycle, life cycle for specialty behavioral health, foster care, and children with special health care needs within current and future Medicaid markets.

38:32 And, in his current role, he's also responsible for continuing the development and development and execution of a robust network access strategy to drive improved network performance and access to high quality integrated care. We're so grateful to have him with us today to share carolines comprehensive approach to using Telehealth to help solve behavioral health issues.

38:59 Great, and thank you, good afternoon, everyone, or good morning, And so, first, before I even begin, great work that is happening at the center site, Happy to also help participate and bring forward some of our data and information as well as, you know, high quality telehealth that's meaningful, that's impactful, is, surely the line goal that we have aligned back with the center and with overall good public policy.

39:24So we can move on to the next slide, and again, thank you all for having me here today.

39:29 Very quickly, I just wanted to highlight a little bit about carillon behavioral health.

39:33 Maybe some of you have in the past I've heard of it as Beacon, how option's prior to that, uh, value, behavioral health options, and Beacon Health Strategies.

39:47 And so in March of last year point 23, you actually changed our name to Carelon Behavioral Health.

39:53 And so we are, you know, we provide behavioral health solutions directly with states and local governments, as well as the federal government. We also work with and for health plans and developing solutions to meet a diverse set of Medicaid, Medicaid, Medicare, and commercially insured.

40:13 Membership as well as also serve many large employers and support them, either with their EAP offerings and their employee assistance offerings, and or just the broader mental health and substance use disorder needs.

40:29 We currently have no over 40 years in the industry, about, you know, 45,000 EAP providers covering over 50 million lives and over 140,000 inmates, ICT providers.

40:45 As you see, we're actively through our channel partnerships, Both virtual and from a brick and mortar perspective, expanding our networks fairly significantly, both for EAP, as well as for our mental health, and STD programs. So, that's a little bit about us.

41:02 one of the other areas, as we think about, our broad behavioral health strategy, we really bucket in three areas, the first area, being access. And when we say access, we don't just mean the number of providers in the network, all of that.

41:14 That is important, but overall, how easy is it to get into care? Do we understand the care patterns in the data to make the experience seamless and easy for someone to get into care and stay in care?

41:27 And, of course, telehealth is a significant opportunity connected with that.

41:31 The second strategy pillars around, we're focusing on specialized service populations, individuals with significant needs, the children with autism spectrum disorder, individuals.

41:45 Hmm, living with serious mental illness, individuals with substance use disorder, really thinking about how best can we align our systems of care to yield the greatest outcomes and opportunities for those individuals?

41:57 And the last king of pillar that we have is really around prices. How do we support our communities in prices?

42:04Be it fires and floods, Hurricanes, are being, you know, with situations in our communities occurring like a shooting or otherwise, how do we stand up? Immediate care, oftentimes, telephonically comes around, supporting those communities.

42:19 While at the same time, how do we think about individuals in crisis, and how do we mobilize prices connected to that, we currently support 10 different states in their crisis systems, deployed and working through those price systems. To ensure effective use of 98 and effective triage and care as well. Which of course, again, has a telehealth component. An angle to it, as we think about, you know, text, chat, and no telephone conversations, as well as kind of virtual, you know, through devices to ensure that there's engagement, those opportunities.

42:57 But above all, there's high quality care that posts that quickly when they need it.

43:08 So this here, this might be really the part of how we think about our overall solutions, right here.

43:12You know, we have, like I said, a robust network, an existing network that sits there. But we also want to ensure that we have the data and the quality behind it, and then also align to how we think about pain and expanding solutions.

43:26 And so, when we say digital solutions, a big part of that is telehealth and virtual care.

43:32 But another big part of that as, though, is, you know, digital cognitive behavioral therapy, coaching programs, other items that maybe are self guided and it made me the need that's Episodic or in the moment that we could then help solve for it, create capacity in other areas. So, we're really being thoughtful around what is the engagement model?

43:52 What is the need for individuals meeting that need at the appropriate type of care, and then also level of care? So as a part of that thinking, you even go about things like residential treatment, right? What do you think about reservoirs for the treatment? Not just virtually, but maybe in the home.

44:09So, again, part of it may be delivered virtually, part of it being delivered in the home face-to-face as well. So, back to the point that was stated around how do these things become more hybrid, and the opportunities arise to deliver quality care, expand, access, what at the same time make these vertical modalities are affected and drive.

44:27 It makes sense, using better quality outcomes and then paying for those outcomes, right? Thinking about how we pay for these opportunities. Difference, right, and ensuring that we have curated pathways for members and patients that actually are connected.

44:44 And then drive value for themselves with, again, like I said, the right type of care and then the right level of care.

44:50 And I feedback through that with the right off ramps, right? We want to make sure, as we think about telehealth, we think about the quality of care being delivered.

44:58 If there's a need for an off ramp, because an individual, maybe, you know, is entering a situation of crisis. That we have the right safety components in place, to off, ramp them into the more appropriate level of care that may be required for them. So, really thinking it from a person, first approach, patient first person first approach, around tailoring the opportunity. Working with the provider communities, working with those telehealth providers, and brick and mortar, you know, face-to-face providers to understand what the opportunities are. And being eyes wide open about it, because so much has happened over the last four years, right? We have moved so quickly, and changed so much, and behavioral health, that now is the up to truly, as we continue to move, and it continues to be investment, and private equity interests in some of these service delivery models.

45:49 How do we continue to do that, not slow down what at the same time really assesses, understand the delivery systems, understand the impact? So, we could then also rate, and, like I said before, pay for that value.

46:08 Mmm hmm, And so, on this slide here, I'm just going to, quickly, just to really start around, how we think about our, our overall cohesive, feasible strategy, right? And there's three main pillars that are underneath that, kind of broader access. But tied into that digital thread of strategy. One of them is about improving access.

46:29 How fast can I get someone into care in rural, non rural areas, but also certain other types of specialties, right? Services that maybe or you might be an inter-service Desert for certain kinds of services.

46:41 So, how do we improve access in a meaningful way?

46:45 How do we improve clinical outcomes, Right?

46:48 Now, let's not just take, you know, care, provided face-to-face, and put it on a virtual platform.

46:56 That's great, we could do that, and that's a lot of what we did with Covert right Coming, coming in and out of the pandemic, we quickly moved from doing a face-to-face, no, tell a therapy right, or telephonic, or, Excuse me, doing it face-to-face, and they're doing a virtually or telephonically.

47:16 Quickly, to make sure that we continue to have people, continuing to have people in care, you know, have access.

47:23 But now, the opportunity is, how do we improve that clinical care, right? How do we think about, you know, all the assets we have, the data we have, the opportunity to capture new data points and structure it in different ways.

47:34 How do we actually improve and ensure we have the ability to have evidence -based practices into that continuum, around improving those clinical outcomes?

47:44Then, the last piece of it all is, really, to strengthen that member experience, that patient experience.

47:50 How does it translate to the individual receiving that care?

47:54 Right? How does it translate to resiliency?

47:56 How do we ensure they're on a pathway of recovery and resiliency and how do we tie those things together? So that kind of those are the benchmarks or the, the, the strategies underneath our overall digital solution.

48:09So, above that, going a little bit more detail, Right, making it easy.

48:14 How do we make it easy for providers, right?

48:17 And how do we also advance our engagement models with our members, providers, patients, and make sure that we're investing in the right types of tools.

48:25 And so, very specifically, coming into Cove, and we spent, you know, we did a significant effort and investment on our webinars and engagement and, and working with providers to deploy the policies and the ... to ensure that folks continue to be in care.

48:43 Right, To ensure that providers knew how to engage, what to do next, how to work, where to go, what the changes were.

48:50 And so, we have to continue in other words out of that situation right now that we're post the pandemic.

48:57 Oftentimes, you know, that some of that support has been lifted.

48:59 We have to continue to drive those opportunities and, really, just not right.

49:04 Not just tried to access, but really also tied to improving those clinical outcomes around expanding access, right?

49:12 Supporting and contracting with providers across states, thinking about some of those compacts that are currently in place and deploying and thinking differently.

49:20About, you know, the site, the state sites versus, you know, delivery methodology and ensuring that, you know, payment policies are aligning right back through that.

49:30 We also want to make sure that we're all supporting at scale, Right? And look at those opportunities to scale differently, to provide value differently.

49:37 And then pursuing, Oftentimes, I mean, some non traditional care modalities, right. Really testing things that may be new that may be different than maybe haven't been displayed or worked through, like, how do we work on those things at the same time?

49:52 as well, to ensure that care delivery is happening in that we're expanding.

49:58Again, access, improving clinical outcomes, and strictly that number experience, which really leads us into paying for the value of saying this a couple of times. And how do we think about paying for it? Right? So, not just paying on a fee for service basis, right?

50:12

But really working through, both from a face-to-face, but also those definitely from from tell our perspective, how do we align incentives, Right? How do we align with payers and providers to ensure that we have a sustainable model going forward for telehealth and for these opportunities?

50:31 How do we pay for, you know, access guarantees, getting folks into care really quick?

50:36 How do we pay for accessx to the first appointment, the second and third appointments?

50:41How do we move to value based payment arrangements that take a look at measurement based care?

50:45

Took a look at functional improvements. Take, you know, not just heaters and, know, National Quality Forum and other types of things into account, but also look at new novel ways of measuring telehealth quality.

50:59

And again, pay for those things, right. I spoke to them speed to access incredibly important.

51:05

But so is therapeutically alignment. Right? How do we ensure that that is also existing?

51:11

And, again, aligning the things in a way that are going to drive improved clinical outcomes, and, like I said, than paying for those things, right? And oftentimes, instead of just doing bonus payments on the backend, or, or looking at data on the back end?

51:25

Really having a deep relationship, but maybe even front loading certain kinds of rates, opportunities, and then playing catch up on the back end, if folks and providers are not meeting those measures. So, really flipping some of those things on its head.

51:39

So, that's really so on an overall basis, our focus as it relates to Telehealth, and how we're looking.

51:45

And not only looking, but currently implementing it isn't the lens of improving access, improving our clinical outcomes, and strengthening that member experience then doing so in a way that creates sustainability for providers and their overall business model associated with Telehealth and paying for that value.

52:04

So, thank you.

52:08

Thank you so much, Manny, for sharing Carelon’s efforts to support providers and members, and really how you're thinking about the patient experience as well as improving access and outcomes. We're going to use our remaining time to engage in a Q&A with our audience. You can keep sending questions on the panel.

52:29

I'll ask our panelists to come off mute and back on video, And I wanted to start just with a quick question to see if we had a lot of interest. And the maps that you showed, especially the national map. And I think you said that's part of your work that'll be available this summer, but could you talk a little bit about that? I think that'll be really helpful. We have a lot of like, state and local government agencies on the line to that, would be able to use that.

52:59

Absolutely. So, maybe first, I can explain the methodology. So for every zip code, we have to calculate, it's one which is across the state.

53:09

And so, it's on the site level, 1 through 10. Where does that zip code follow throughout the whole state, state, specific, and then for the same zip code, we have a percentile across the country.

53:20

How does that zip code fall within the rest of the country so that we're comparing, And so, users of the tool will be able to hone in on their state and be able to understand the needs, and also a country nationwide. Currently, what we're doing is, we're finalizing the dataset into calculations and we're then going to build a Web tool to allow people to be able to generate maps, download the data, and be able to use it to their needs. And we don't anticipate, this will be for any cost. So, it's part of the Center's mission to advance the Telehealth research and policy.

54:04

And we also hope to incorporate AI so that people could see large language models.54:09 one of the goals is to be able to, for people, just ask questions and say, What is the most deprived zip code in my state, or what, you know, which, what community is really struggling to get health access from a geographic access? So, there'll be a second phase after the website. So, timeline wise, hopefully we like the end of the summer, or that.

54:32

We have another question that might be more for Manny, coming off of your presentation if, you know, if any of the practices you're working with ask questions about broadband digital access to patients, how have you been able to accomplish this?

54:50

What are the next steps, that, in terms of connecting patients to support, we, actually, now, we have two methodologies that we deploy very quickly. So, no, they're not asking those questions. But, also, through some of our care management programs, we will actually deploy smartphones as a part of it, under a Care Management Agreement, with that number, so that they then do also have access to digital components, at least from a smartphone. You know, digital bandwidth perspective concludes with certain apps, and it comes loaded kind of ready to go to engage in that care management, and participate in the care management activity. But we. But to the best of my knowledge, Those channel partners are not asking questions around the eyes. You know, internet service providers or digital capacities.

55:42

We had another question about, Well, first a statement from an audience member. We're working to implement Telehealth and schools.

55:53

We're struggling to get parent buy-in and more rural communities and do you have any suggestions for outreach and engagement to get people on board with using Telehealth, especially in rural communities?

56:08

I guess for any speaker I guess my question back would be, well, do they know what their hesitation is? Is it with technology? Or perhaps they don't have the resources?

56:22

Maybe they don't have the connectivity, or they lack something like a smartphone or a laptop. And that might kind of help them decide on, you know, the best approach to explain to the parents. If it's something that maybe, if they are working with a certain population and maybe a cultural thing as well too.

56:41

So they may need to examine that, and like how best to, to approach, approach them, because there are different populations that, you know, you need to like, approach them in a different way when you're suggesting using technology to provide services. So try to figure out what their hesitation is, it could simply be, they don't want to use it, because they just don't have a laptop or a Smartphone, but it could be something else. Like perhaps something related to culture or Language barrier. So that may be another answer or a way to address that particular issue.

57:17

I would also look for leaders in the community that you can write that can come alongside and encourage the utilization, or at least the review of it, right? It could be community leaders, spiritual leaders, whatever it is. in a rural community.

57:30

I'm sure those folks that are, you know, that, or have certain levels of engagement and opportunity, and getting those folks kind of engaged working through them, oftentimes will also kind of tip the tide, but what may be necessary to get the engagement you're looking for.

57:50

We had a couple questions about disability. I know for sure you had mentioned disability as one of the factors you're looking at, but just a broad question about, you know, any research on the use of telehealth and also telehealth outcomes for people with disabilities and how we're thinking about the population?

58:18

OK, the research is limited and there's really a gap in evidence. We're trying and that's one of the things we're trying to do. We're recruiting people who belong to this subgroup to be able to understand their needs.

58:33

But we have seen, now, people point out the lack of closed captioning as an example for some of our Telehealth users being an issue.

58:46

And also one of the other things that we've seen that's really interesting has brought an interesting perspective to our work is people experiencing domestic violence and doing telehealth visits.

59:00

It doesn't make sense, in some cases, because if you ask them if they're safe at home, the answer's probably going to be Yes, either way. And so, you know, being able to accommodate, in addition to people with disabilities, also, people are experiencing.

59:16

That's really helpful. We're almost out of time, so I'm just going to ask one broad question for each of our panelists, to weigh in on, kind of beyond some of the payment and policy challenges.

59:30

We've talked about today like, you know, we know one necessarily predict coven, pandemic and switch to Telehealth or are there other challenges you potentially see ahead for telehealth in terms then either AI, Cybersecurity. There's a lot of direct consumer Telehealth happening with weight loss. Drugs like, what are you kind of thinking about that? You know our audience: should be thinking about going forward.

1:00:02

I can go first, I think to fall to my answer to, the first one is the thinking of use of AI and integrating into telehealth. A lot of concerns around governance and liability. And also, a patient engagement from the get go. There's a lot of, and we've seen strikes and someplace in the country's nurses. Not willing to adopt AI.

1:00:22

So, there's the AI adoption key question, And then the other thing that we're facing there is, to the best of my knowledge, a lack of national data for telehealth at the zip Code level. So, you can get three digit zip codes. We, we think, to be able to advance and to do more investigations, we need to have, just like we have with EHR, data, and other conditions, a national dataset. That's representative.

1:00:55

I guess one thing, at least on the policy, and to look out for, is, as the policies develop, it's becoming more and more complicated.

1:01:05

one of the more recent news articles out there, like the Wal-Mart closing down their clinics and one of the reasons they cited was the complication on the reimbursement policies, but it's not just the reimbursement.

1:01:16

Policies are the other policies connected with it such as, you know, privacy protection of data . That's going to have an effect on the Telehealth use because again, it goes back to like why? A provider thinking why complicate my life?

1:01:35

Lift, trying to do do Telehealth if it has all these rules and regulations on it that you know, they don't understand or Are hard to navigate So I think that's one thing to watch is that you know, the more the policies being developed there Also, the rest of it they're making it way, way more complicated, are so complicated that it's just not going to be appealing to like use it as a way to deliver services.

1:02:02

Many, just quickly, you know, telehealth can scale pretty quickly and easily, yeah, at the same time, the potential lack for standardization of this basic practice through telehealth. Understanding how we're actually improving clinical outcomes and then when you think about state by state potential policy changes, they overlap with federal changes.

1:02:27

Does it make, you know, opportunities in certain states?1:02:30 For more folks who do telehealth?

1:02:32

You know, living in now, Florida. But supporting California because their payment methodology, the reimbursements and everything is better. And what does that then do we really do for access. Specifically going back to the rule and equity to the points that the map without was shown.

1:02:47

So these things have to be cohesive, and so, you know, the challenge is going to be how do we align these things, both from a policy and payment perspective, that don't create disincentives in certain geographies compared to others? Right? And so that's where I think we have to be eyes wide open.

1:03:06

No. That could be an unintended consequence of a lot of good work.

1:03:11

Great. Well, thank you all for staying with us. If you have extra minutes, we really enjoyed your presentations, and hearing about your work and perspectives. And thank you to our audience for your questions. A brief survey, well, open on your screen after the event, and we'd love to get your feedback. And then we also invite you to visit our website from previous webinar recordings and other resources, and you also can find our infographic on rural health that talks about telehealth as a strategy to support access to care. So, thank you, again, so much for joining us today.