EPISODE 210

Cementing the Gains Telehealth Made During COVID – Ann Mond Johnson, CEO of the American Telemedicine Association

08-31-2021

Whenever we ask Raise the Line guests about the biggest changes in healthcare during COVID, the use of telehealth is always at the top of the list. Aside from the need to keep patients and providers safe, a combination of regulatory relief, reimbursement changes and new technologies are giving telehealth a bigger role in U.S. healthcare than ever before. But this golden moment might not last. “Americans need to know that any day, the ability to use telemedicine might be taken from them if Congress doesn't act,” says Ann Mond Johnson, CEO of the American Telemedicine Association. A lot is at stake. As Mond Johnson explains to host Dr. Rishi Desai, increased use of telemedicine is filling critical gaps in access, particularly for mental health services, and can help address the health disparities the pandemic laid bare. Stay tuned to find out about common telemedicine myths, to get peek at the future of the technology and to hear about plans for the first ever Telehealth Awareness Week, coming up September 19 to 25.

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Dr. Rishi Desai: Hi, I'm Dr. Rishi Desai. Whenever we ask guests on Raise the Line about the biggest changes in healthcare during COVID, the use of telehealth and telemedicine is always at the top of the list. Aside from the need to keep patients and providers safe, a combination of regulatory relief, reimbursement changes, and new technologies are giving telemedicine a bigger and bigger role in healthcare in the U.S. really than ever before. Here to help us assess the impact of telehealth during the pandemic, discuss what the future holds and tell us about Telehealth Awareness Week -- coming up September 19 to 25 -- is Ann Mond Johnson, CEO of the American Telemedicine Association. Thank you so much for being with us today. 

Ann Mond Johnson: It's a pleasure. Thank you for having me. 

Dr. Rishi Desai: So I'd like to just first start with your background. You earned a master's in Healthcare Administration, worked for WebMD among many other healthcare companies before coming to the American Telemedicine Association. What drew you to the healthcare sector in the first place?

Ann Mond Johnson: Well, I've been at this for a while, and I think that one of the real attractions was that this is an industry at large that just has so many opportunities for improvement. So I got my master's in Healthcare Administration but I also got my MBA in Finance. Among other things, joined an early-stage company that was focused on data and software for hospitals to do planning and marketing. This was about the time that hospitals realized that just because you are a nonprofit did not mean that you were supposed to lose money. 

So, taking some of the best of what happens in the business world and bringing it to health care was a big motivator. And then I started a company with some friends in 2000, and that was focused on helping consumers make better decisions about their healthcare using data and decision support tools. That company and then two other subsequently, are how I've spent most of my time. 

What's really driven me is that I think that healthcare can be very confusing and not particularly satisfying, if you're a patient or consumer. There's a lot of just general confusion because it's not put in terms that make sense for us as users. So that's really been my goal.

Dr. Rishi Desai: That's really helpful. And that confusion, I think, continues and is obviously gotten a lot worse during COVID as well. With telemedicine on the rise, I'm just so curious to hear what are the priorities of the ATA right now? Especially in light of what you just said in terms of clearing up confusion and how to get good healthcare... 

Ann Mond Johnson: Yeah. Well, it's a great question. When I joined the ATA at the beginning of 2018, I really wanted to focus on why we are here. Pre-pandemic, the 'why we were here' was to ensure that people get care, where and when they need it while knowing that it was safe, effective, and appropriate; enabling the system to do more good for more people; and realizing at the same time that before the pandemic we had, as evidenced by things like the Dartmouth Atlas, this uneven distribution of healthcare services. Your geography really defined your healthcare destiny, and to me that, that's wrong. As a country that spends as much as we do on health care, that's just wrong. So I saw telehealth as really an opportunity of meeting people where they are, and really expanding our capacity to treat more people. Because we don't have enough physicians and you can only use technology to bridge the issue of access. So that was really a driver, and then the pandemic hit. 

What had been sort of, "Oh, trust me, telemedicine is really good", became a household word. People were talking about telemedicine all the time. And so our priorities, which again were formulated pre-pandemic, were to ensure that people had access, and they had a choice, and they had high satisfaction. We were really agnostic when it came to telehealth modalities like device and venue and so forth. We wanted to really ensure that we use technology to make sure that we reach underserved and at-risk populations, which was a problem, again, way before the pandemic. 

Now, from a policy perspective, our focus in the middle of all of this is to ensure that number one, telehealth is not viewed as a pandemic only tool. It's very easy for all of us, when we're back into what we consider our normal lives, to revert back to old behaviors. We don't want that to be the case. We want telemedicine changes and reforms to be made permanent. Second, is to ensure that telehealth is really used to address this notion of systemic racism that we're now having national conversations about.

Dr. Rishi Desai: You mentioned just now the idea of using telemedicine to make sure that care is safe, effective, and appropriate. I'm curious, do you hear common misunderstandings or myths around telemedicine that might be worth clearing up for folks that don't believe that it's safe, effective, and appropriate? 

Ann Mond Johnson: Well, it's interesting because, again, prior to the pandemic, the myth that I heard was somehow telemedicine was second class medicine. That it wasn't as good as face-to-face. We were talking a little bit about this whole notion that we have an edifice complex. We have a bias towards physicality and healthcare, and yet it's not necessary all the time. You as a physician don't have to lay hands on someone to really come to some conclusion about what might be the right course of action for them as a patient. So, that's been a pervasive myth and it's a little bit of romanticizing of what health care is. 

And yet, we see things like remote monitoring. As a physician, you can't possibly monitor 12 people at once simultaneously, whatever the number is and yet with technology now, you can monitor literally dozens if not hundreds of people and use a dashboard in that regard.

So, I think that we have plenty of evidence that it's safe and it's effective. Part of the work that we have to do is inform the regulators and the legislators at the federal and the state level, but also to promote it amongst Americans so they know that at any day, the ability to use telemedicine might be taken from them because Congress doesn't act. 

Dr. Rishi Desai: You and I both have used the words telemedicine and telehealth. Do you mind just laying out exactly what the two terms mean, and maybe what some nuances are between them? 

Ann Mond Johnson: Well, I would, except I really shy away from that and I'll tell you why. Because, first of all, we define telehealth as the ability to effectively connect individuals and their health care providers when in-person care is not necessary or it's not possible. Likewise, providers can work with other providers when in-person is just not possible. So, that to me is the general rubric. 

There are a lot of folks who spend time slicing and dicing what telehealth is versus telemedicine, and digital health, and virtual care, and virtual medicine. At the end of the day, as a consumer or as a lawmaker, I don't really care. I want to make sure that the standards of care are maintained and as an advocacy focus, I want to make sure that clinicians have access to this modality of care...that telehealth is viewed as health. So getting too caught up in the definitions, I've found, has not been a very fruitful exercise.

Dr. Rishi Desai: That makes a lot of sense. Given what you just said about lawmakers in particular and the potential risk of some of these regulations being turned back, what is your thinking on why that might happen? If we're seeing all these wonderful positives come out of the expansion of folks being able to practice across state lines and whatnot, what are the main arguments for why it might get rolled back and what are your thoughts on mitigants to those arguments? 

Ann Mond Johnson: So, the first thing to appreciate is from the federal level, there are laws and regulations that were put in place 14 years before the iPhone was invented. The idea was that for a telehealth visit to be reimbursed by the federal government, the patient has to be in a specific venue and your physician has to do a specific thing, and it's just arcane. It's absolutely ridiculous. We have every indication that the Biden Administration -- and previously, the Trump Administration -- supports the permanent availability of telehealth. At a federal level, we're really focused on Section 1834[m] of the Social Security Act. This is a very important piece of law that actually needs to be put to bed once and for all. 

The other is that we've learned that not only did telehealth serve to help people stay safe and at home, but in many instances, it really enabled people to get care when they otherwise would not have been able to get care. So, look at mental health services in the U.S. I think it's 50% of counties in the U.S. don't have a mental health provider even though one out of five Americans pre-pandemic had a mental health issue. So, the idea of trying to meet all of that need -- and that growing need -- physically, one-on-one, is just not doable. 

What we saw was a huge surge in telemedicine being used for mental health services. With that, we saw a lot of satisfaction with the quality of the services and the quality of the visits. The no-show rates dropped precipitously. So I think, while our bias is towards in-person and our bias is on physicality and we have a predominantly fee-for-service system, the right thing to do is to get people to be able to use care so that they can seek it where and when they need it. The objections are, typically, around cost or that it's more susceptible to fraud and abuse or it's not as high quality. We refute each of those categorically.

Dr. Rishi Desai: You mentioned the ability of telehealth and telemedicine to address the economic disparities that we see in the U.S., sometimes based on race and ethnicity as well. Are there some examples that you've seen that have come out of the last 18 months that you'd want to share with the audience?

Ann Mond Johnson: We really believe that you cannot solve for access without using telehealth, right? You just can't reach as many people as you want to. As you look at some of the levers that might be pulled associated with telehealth, there is legislation pending now with a $65 billion 'down payment', we call it, on broadband. That's obviously important. The whole notion of connectivity is important. You're seeing a lot of innovation where buses have hotspots that they bring to parking lots and people would be able to innovate in that regard. 

But then the next level is devices and not being able to have sufficient access to devices. So, again, a lot of innovation there in terms of people driving into parking lots of their physician's office or the hospital and getting tablets so that they could actually communicate and receive services. 

The third is, this whole notion of literacy -- cultural, digital, and technical -- and these are all really important issues. You can have a great clinician, but if they are not grounded in some of the barriers or are not able to adequately communicate with their patient because they can't get them to turn on the device, that's a problem. Again, if you take a consumer-centered approach, it's not the consumer's job to be literate. It's our job as inventors, as entrepreneurs to make sure it's easy for them to do things.

Finally is the whole notion of bias and trust. This is really important in communities of color and in the LGBTQ community...the idea that we want to make sure that when you have an encounter with a clinician, that you really feel like you can trust them, that you can be honest with them, and you can be open. What's interesting about this is, as you know, there's been been a lot of study and talk about what's happening with AI and how it has inherent bias associated with it because of how it was pulled together. We have to expose that. We have to talk about that. We have to correct for that. What we want to make sure that we do in telehealth and technology in general, is to ensure that we don't perpetuate the things that don't work. We want to fix the things that don't work.

Dr. Rishi Desai: Telehealth Awareness Week is coming up, September 19 to 25. Do you mind just sharing a little bit more about what's involved and why you decided to hold one for the first time?

Ann Mond Johnson: We know the ATA's job is to have a legislative and regulatory perspective, but it's also about convening a broad community. There are over 400 organizations that are members of the ATA, including delivery systems, payers, solution providers, associations and other organizations that are partners. We jointly promote a lot of activities that are consistent with each other's policy, priorities, and goals. 

We decided to create Telehealth Awareness Week as a platform for inviting champions and supporters from every sector of healthcare to join together to underscore the growing value of telehealth and its critical role in providing access to safe quality care to everyone who needs it. The platform is engaging patients, providers, payers, and policymakers at every level. 

I'd encourage your listeners to go to www.americantelemed.org and link to our Telehealth Awareness Week because we have the ability to collect stories, and there's nothing like a story to really hit home the importance of what's happening. We have a lot of special events and educational materials. We have a lot of founding partners that have been working with us, as well as endorsing organizations like the National Organization of Rare Disorders, the ALS Association, Susan Komen...I mean just really phenomenal organizations representing the patient voice. Then we also have a number of Congressional folks who are on our host committee and these are federal policymakers and they're just really fantastic in terms of their interest and commitment to Telehealth Awareness Week.

Dr. Rishi Desai: That sounds fantastic. I've had, just on a personal note, a lot of positive experiences providing telehealth and it's been also the same as a patient. So, I totally resonate with what you're saying. What is your prediction for the use of telehealth in the next couple of years. Do you expect any big changes on the horizon? 

Ann Mond Johnson: So as you know, it went sky-high. It was like the hockey stick that every entrepreneur dreams of for the revenue of their company, right? It had been at less than 1% and then I was over 50% of all encounters that were done by telehealth, at least in the Medicare community. We think it's going to be somewhere between twenty to thirty percent of all encounters that will be done using telehealth because it's more than just for urgent care. It could be used for managing chronic conditions, for engaging, as we talked about before, in mental health services. So we think, twenty to thirty percent depending on the patient, the specialty, the location. It's not for everyone. It's not a panacea, but it's certainly an effective tool and it's a modality that should be made available to patients and physicians alike.

Dr. Rishi Desai: So, we're a teaching company. We love to fill knowledge gaps, wherever we spot one. Are there any myths or gaps in knowledge about telehealth and virtual care that you'd like to tell us about?

Ann Mond Johnson: Well, there are a lot. One is that somehow telehealth is more subject to fraud and abuse. Unfortunately, health care fraud is not new in the United States and you have bad actors everywhere, but telehealth is not telemarketing. It's really important that we call out that distinction and we don't conflate the two. In the telemarketing scams that are really set up to defraud patients and taxpayers...these are just bad people trying to take advantage of folks. The cornerstone is to facilitate illegal kickbacks and bribes from medically unnecessary services and medical equipment, and of course, we're really opposed to that. The Office of Inspector General has said they have not seen increased fraud and abuse with the pandemic and with the surge in telehealth services. We think that's important to note.

The second is that at the end of December a massive piece of legislation was passed, and one little element had a requirement for a patient to have an established exchange in person before they could access telehealth services. That in-person requirement is, again, wrong. It's just not necessary and totally defeats telehealth if you will, particularly in areas like telehealth for mental health. Evidence has demonstrated that telehealth when used for mental health services is as effective, if not better, than in-person visits. So there's a clear consensus that you can establish a relationship with the patient via a telehealth visit.

Another myth that we think is wrong is the whole notion that you use more services with telehealth. I think what we're learning is that technology really can be used to streamline the intake process, so there's a lot there. We're hearing the myth that telehealth is more expensive all the time. What our data and what our community shows is that's not the case. You can in fact use telehealth to close gaps in care. So lots of myths still. We have lots of opportunities for improvement. 

Dr. Rishi Desai: That's really helpful that you went through that one by one. The cost one is a little perplexing because it seems pretty obvious that it wouldn't be as expensive and that it would be probably a lot cheaper, but maybe I'm not....

Ann Mond Johnson:...well, let's say you're operating in a fee-for-service environment. I'll use the example that my friend and colleague Joe Kvedar uses. He's chair of the ATA board and a dermatologist. So, for intake, his staff will look at photos which are sent through whatever mechanism of the patient and decide whether or not the patient should come in person or can be handled over the phone for a telehealth visit. In some instances, you will have a patient that Joe will consult with and say, "Actually, I need you to come into the office."

If you bill for both situations -- the triage and the visit -- then that's a problem and so that's why it's considered additive. But again, as you said, it probably makes sense that it's not more expensive in the long run. And then there's always the idea that if you didn't go to seek care at all and delayed treatment because you didn't feel like you could afford it, then that's really bad medicine. We think Telehealth can help that. 

Dr. Rishi Desai: Yeah, that makes a lot more sense. I do hope and wonder whether telehealth and telemedicine will help us close the gap with other high-income countries, because as you know we're doing pretty poorly in terms of health outcomes per dollar spent, so maybe that would help to close that gap a little bit. 

You've had, just on a personal note, an incredibly interesting career in healthcare. Do you have any advice for students that are maybe in the early stages of their health care career or maybe they're just thinking about the health care field in general? Any advice in terms of meeting the challenges of this moment with COVID and figuring out how to get into a place where you've found yourself, at the forefront of something very exciting? 

Ann Mond Johnson: Well, I would say that most important is to put the patient first and to be very patient-focused, very patient-driven. Recognizing that patients are not a monolith. You have different communities of patients, different types of patients. I think that would be an important adage. The idea of realizing that our user experience in healthcare is pretty horrific. It's not designed with the patient in mind. It's not designed with the disabled person in mind. It's not designed with a number of different communities in mind. So take it from the patient, whatever perspective that is, and really build that because chances are there's a huge opportunity to improve life for a lot of people.

Dr. Rishi Desai: That sounds like a fantastic way to end the conversation. Thank you so much for being with us today, Ann. 

Ann Mond Johnson: It was a pleasure. Thank you for having me. 

Dr. Rishi Desai: I'm Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.