It goes without saying that in the 3+ decades that I've been a doctor, I've seen a lot of changes in the medical profession. Many of these changes have been difficult, of course -- plummeting time with patients, ludicrous paperwork, and illogical financial incentives, among them.

From time to time, however, I see big changes in medicine that are deeply positive. The most powerful and progressive changes are happening through:

• Thoughtful integration of simple "good medicine"
• Alignment with current political and financial realities
• Creative use of existing technologies.

The "return of the house call" is one of these fantastic trends. For a long time, it has looked like the house call went the way of the doctor's bag -- a nice idea but not something that fits our current reality. Recently, however, there has been a resurgence in house calls and home care for everything from palliative care to wound care to concierge medicine.

The return to medical providers visiting patients at home is supported by common incentives and the current political climate. For instance, the Affordable Care Act penalizes readmissions within 30 days of discharge; integrated home care is seen as one way to decrease readmissions and improve outcomes. Also, a focus on a "fee for performance" rather than a "fee for service" model, and an overall push to cut costs, has encouraged the "house call" approach. Finally, as the New York Times reports, "Home care is generally cheaper than hospital care, and for more than a decade, government programs such as Medicare and Medicaid have worked to create incentives for hospitals to switch to less-expensive treatment."

Because home care is removed from the traditional hospital setting, medical collaboration is crucial to successful home care.

For instance, a 2007 study, by Dr. Richard Brumley and colleagues, found that palliative care patients who received in-home interdisciplinary care were less likely to visit the emergency room or be admitted to the hospital than those receiving standard home care. This resulted in lower costs. For house calls and home care to really work, they need to incorporate providers across specialities and across the continuum of care. Providers must collaborate because it is not efficient for every provider to visit the patient at home, but a home visit can be a crucial part of an integrated approach. And telemedicine is the key for this kind of medical collaboration to be effective, cost-efficient, and time-sensitive.

We've found that house calls and home care are especially powerful when the following components are in place:

• Healthcare providers at all points in the spectrum are included.
• Multiple specialties collaborate on a single patient.
• Tools like store-and-forward telemedicine are used to enable rapid and time-sensitive consults. 
• There is a focus on medical collaboration in service of good patient outcomes (rather than a simple "counting" of visits or services.) 

For our Quick Guide on medical collaboration, click here:

Image courtesy of myfuturedotcom on Flickr, used under Creative Commons rights.

Barely a day has gone by recently, that the Affordable Care Act (ACA), Accountable Care Organizations (ACO), or the Centers for Medicare & Medicaid Services (CMS) have not been in the news.

In the broadest strokes, the Accountable Care movement attempts to shift the health payment system from a pay-for-service (fee based) system, to a pay-for-performance (outcomes based) system. Of course, for hospitals that want to accept Medicare and Medicaid, these reforms are mandated. But the overall approach affects almost all practices, regardless of status or whether you are an ACO.

Part of the reason that these policies aren't going anywhere is that early data shows they're working. In 2012, ACOs established in the Medicare's Shared Savings Program generated nearly $400 million in savings, the Centers for Medicare & Medicaid Services said in a statement released last week. 

Despite the laws, it's not always clear how to use telemedicine to improve outcomes in a pay-for-performance system. Interestingly, telemedicine and telehealth has been identified as a key tool in compliance with Accountable Care. It is even written into CMS' final rule for the Medicare Shared Savings Program: accountable care organizations must "define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies." 

So here are 7 ways telemedicine can help you comply with Accountable Care: 

1. Telemedicine makes care coordination possible and effective. Just changing incentives is not enough to improve outcomes. As the New England Journal of Medicine reports, "Merely aligning financial incentives will not improve quality and reduce costs for episodes of care... True coordination of care is required to ensure the best possible outcomes." Telemedicine makes this kind of care coordination possible and effective, particularly in a hybrid store-and-forward context that adapts to provider parameters.
2. Telemedicine makes transportation less necessary. Whether home monitoring or distance consults, telemedicine can save costs of unnecessary visits and lengthy transportation. When payment is linked to outcomes, even saving a patient or provider a single trip can make a big difference over an organization.
3. Telemedicine leverages provider time. In an age of provider shortages, telemedicine can make each provider's minutes count as much as possible. Through consults, collaboration, and even remote patient visits, provider time is leveraged. 
4. Telemedicine can decrease readmissions. Because telemedicine can help the right at-home care to happen, clarify which provider is responsible, and make sure patients follow through, telemedicine has been shown to have a strong effect on decreasing readmissions.
5. Telemedicine can drop length of stay. Data shows that care coordination, especially the kind of collaboration supported by telemedicine, is one of the strongest ways to drop length of stay. And length of stay is a key outcome in Accountable Care.
6. Telemedicine improves access to care. Telemedicine can improve access for the underserved in rural, urban, or Veteran populations. Especially as provider shortages worsen in different parts of the country, and for different specialities, this kind of access to care is proving crucial in keeping costs down and meeting patient needs.
7. Telemedicine supports good patient care, regardless of political climate and payment changes. Truth be told, many of our colleagues have been using telemedicine to improve the ways they care for patients -- regardless of whether it's rewarded by the current political context. We think that's good practice, in every election cycle.

Click here for our free guide on the pros, cons, and ROI of telemedicine options:

Image courtesy of chelseastirlen on flickr.com, used under Creative Commons rights.

Telemedicine is thriving these days -- there is even an ad on prime-time featuring it -- and a key reason are the ways telemedicine lowers the cost of healthcare. One indicator of this is the political support: "Telehealth is a major contributing factor to increased health care quality, convenience, and lower costs," said Reps. Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio). And there is certainly anecdotal evidence from around the country, like this tele-dermatology program in Nantucket saving nearly $29,000 a year.

In fact, we've found that the people and organizations that use iClickCare experience such significant and immediate cost savings that we've even incorporated an ROI calculator on our website. Dr Michael Moore, director of a wound care program, reported that "During a 3 month period, 70 patients were treated solely using iClickCare with an overall healing rate of 93% and an estimated savings of $24,000 in transportation costs alone."

Of course, despite its clear potential and proof points, telemedicine doesn't always cut costs. It's important to look at projects like this one for lessons from the front lines about what really works, and what doesn't.

So if you're considering a telemedicine program in your hospital, practice, or region... 

5 things to keep in mind to ensure telemedicine lowers the cost of healthcare:

1. As we shared in this post, you are not setting yourself up for success if you make huge investments in hardware. We recommend investing in software (which can be updated, and is generally the lowest portion of costs) rather than hardware which gets obsolete quickly. Use the equipment you already have, the spaces already available to you, and just start. 
2. Give special attention to readmissions and length of stay. Readmissions within a month of discharge cost $16 billion per year. And as we all know, readmissions and length of stay are big parts of the ACA shared outcomes focus. So we're interested in data showing that medical collaboration may be one of the strongest ways to decrease length of stay... and in this Connected Cardiac Care program, which has achieved a 51% decrease in readmissions with telehealth monitoring.
3. Prioritize rural areas or very urban areas. Geographically removed areas (whether rural or inner-city) find the most cost-cutting benefits from telemedicine. "By decreasing the importance of location for healthcare provision, telemedicine can help increase competition and further lower healthcare spending for primary care and specialist consultations... using technology to allow health care workers to quickly serve those where there is the greatest demand will create a more efficient health care system overall," says Ben Miller of the WFS.
4. Use your people effectively. Because of the provider shortage, the leveling of access helps cut costs and use our provider workforce most efficiently. As Dr. Brian Rosenfeld, Chief Medical Officer at Philips Healthcare, said, "Telehealth offers the opportunity to provide the access, quality and cost that will be necessary to increase prevention and leverage our current workforce."
5. Work in coordination with the Affordable Care Act. Telemedicine may prove to be the linchpin in controlling costs and outcomes as the Affordable Care Act comes into being more broadly, according to Mario Gutierrez, executive director for the Center for Connected Health Policy.

Overall, we've seen over and over again the cost savings that can be experienced through telemedicine. But we do suggest keeping it simple, start small, and start today.

For an overview of choices in telemedicine, download the Quick Guide to Telemedicine

Image courtesy of seeminglee on flickr.com, used under Creative Commons rights. 

Telemedicine practitioners can feel isolated. They are often among a handful of people in their immediate practice or hospital who are using telemedicine to perfect care, improve outcomes, and make their lives easier. 

The truth, however, is that healthcare providers using telemedicine are part of a large, growing, and thriving community. When we started working in this field almost two decades ago, telemedicine was rare. Now, however, the most committed, innovative healthcare providers all use telemedicine in one form or another. 

Telemedicine is actually thriving. Here are 5 reasons why: 

• Politics are catching up. As this article details, parity laws are going into effect in several states. Also, the Telehealth Modernizaion Act -- to establish a clear definition of telehealth -- is on its way to going through. "Telehealth is a major contributing factor to increased health care quality, convenience, and lower costs," said Reps. Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio)
• Telemedicine is reaching critical mass. Research and Markets is predicting 18.5 % growth in global telemedicine in the next 4 years. 
• New providers are more familiar with technology. For some of the same reasons as we highlighted in our discussion of concierge medicine, and as this article discusses, new providers are adopting practices like telemedicine at higher rates.
• Providers are using smartphones in their practice. According to Verizon, "38% of physicians with smartphones use medical apps on a daily basis, and that number is expected to increase to 50% this year. Two-thirds of healthcare providers said that implementing or improving their use of mobile technologies is a high or mid-level priority during the next 12 months."

We're thrilled to know that providers are connecting better, people are collaborating, and patient care is improving as telemedicine becomes more widespread.

If you're looking into the options, get our Quick Guide to Telemedicine here:

Image courtesy of thomaslevinson on flickr.com, used under Creative Commons rights. 

The phrase "concierge medicine" conjures up visions of white glove treatment, house calls to yachts, and luxury medical experiences. Some even suggest that these luxury, tailored, out-of-pocket approaches may be unethical because they divert resources from the rest of the medical system.

New models, however, are demonstrating that concierge medicine is not just for the elite. As we detailed in our last post, concierge medicine is, at its core, a direct payment model. Rather than providers caring for patients and collecting payment primarily through government or insurance programs, providers provide care and arrange payment directly. These models are sprouting up in a variety of contexts and with a wide spectrum of payment structures -- but all are beginning to prove that concierge medicine -- or at least some kind of direct care and payment model -- may be used more broadly.

One model, often termed "direct primary care", is being used for everyone from tech entrepreneurs to long-haul truckers. Sherpaa and Qliance are two companies that are providing primary care plans for as little as $50 per month, often in combination with insurance coverage for further treatment. “The concierge model carries a lot of baggage in being health care for the wealthy,” said Dr. Erika Bliss, a family physician and Qliance’s chief executive. “We want to grow this and bring the price point down to average Americans.” The outcomes have been very promising in decreased costs, increased patient satisfaction, and improved health outcomes.

In an age of physician shortages (especially for poorer patients), healthcare provider burnout, and inflated costs, researchers and government officials are seeing opportunity in direct care. An even more populist model, which is also being looked at as a possible opportunity, are clinics in major US cities that meet the needs of the uninsured, especially Spanish-speakers. These clinics offer offer round-the-clock-hours, cultural and linguistic fluency for recent immigrants, and upfront pricing that assumes a lack of insurance -- all things that make these solutions perfect for many. It is reported that "Health officials see in the clinics an opportunity to fill persistent and profound gaps in the county’s strained safety net, including a chronic shortage of primary care physicians."

Of course, there are concerns that the standard of care with low-income clinics and even direct primary care models could suffer. Some patients may not have coverage for specialists or hospital services. Some doctors may not have admitting privileges at local hospitals. And many worry that patients with more severe health needs or more limited funds may not actually end up with the care they need. That said, models like Qliance's and Sherpaa's do seem to be meeting some significant needs, and we'll likely see plenty of innovation in this direct care model in the years to come.

Telemedicine is crucial in a direct care model. Get our guide to your options: