1 00:00:08,884 --> 00:00:11,764 Dr. Jonathan Neufeld: I think that what we're finding with regard to quality, 2 00:00:11,774 --> 00:00:15,630 is that yes, there are things you can't do in a telemedicine encounter. 3 00:00:16,050 --> 00:00:17,810 But, you can do more than you think. 4 00:00:17,900 --> 00:00:22,520 And if you use telemedicine to do the things that you can do, you 5 00:00:22,520 --> 00:00:27,770 end up getting an awful lot of care, taken care of for way lower 6 00:00:27,770 --> 00:00:30,437 cost and with way more convenience 7 00:00:31,229 --> 00:00:34,169 Triston Yoder: welcome to a virtual view where we talk about telehealth, 8 00:00:34,349 --> 00:00:36,449 healthcare and everything in between. 9 00:00:36,869 --> 00:00:38,399 Cameron Hilt: Today we have Dr. 10 00:00:38,429 --> 00:00:42,439 Jonathan Neufeld, who is a clinical psychologist and integrated primary. 11 00:00:43,049 --> 00:00:47,579 Or the pre and post doctoral training at the VA Southern Arizona health care 12 00:00:47,579 --> 00:00:51,953 system and university of California Davis, the latter institution where he 13 00:00:51,953 --> 00:00:54,263 worked with several tele-health pioneers. 14 00:00:54,293 --> 00:00:58,853 He's a senior research associate at the Institute for health informatics 15 00:00:58,883 --> 00:01:02,843 at the university of Minnesota and the program director for the great Plains 16 00:01:02,843 --> 00:01:06,559 tele-health resource and assistance center, which is part of the national 17 00:01:06,559 --> 00:01:09,109 consortium of telehealth resource centers. 18 00:01:11,610 --> 00:01:11,970 Dr. 19 00:01:11,970 --> 00:01:12,510 Neufeld. 20 00:01:12,510 --> 00:01:14,100 Thanks so much for joining us today. 21 00:01:14,100 --> 00:01:16,320 It's a pleasure to have you on a virtual view. 22 00:01:17,320 --> 00:01:17,680 Dr. Jonathan Neufeld: Great. 23 00:01:17,710 --> 00:01:18,610 Thank you, Cam. 24 00:01:18,640 --> 00:01:19,540 Call me Jonathan. 25 00:01:20,540 --> 00:01:21,560 Cameron Hilt: Thank you, Jonathan. 26 00:01:21,590 --> 00:01:26,040 We're really excited to be able to have you be a part of the show today. 27 00:01:26,055 --> 00:01:29,977 It's a rare occasion that we actually get to have someone who has been a 28 00:01:29,977 --> 00:01:32,887 part of the UMTRC before in the past. 29 00:01:32,942 --> 00:01:36,210 Jonathan, do you mind telling us a little bit about some of your 30 00:01:36,210 --> 00:01:38,460 past history with the UMTRC. 31 00:01:39,460 --> 00:01:40,120 Dr. Jonathan Neufeld: sure. 32 00:01:40,170 --> 00:01:44,574 Boy, it goes back a ways and I'll probably get the dates a little mixed up, but we, 33 00:01:44,574 --> 00:01:47,552 I know that we first wrote, I joined. 34 00:01:47,678 --> 00:01:51,856 I was in Indiana at the time, still live in Indiana, but connected with the folks 35 00:01:51,856 --> 00:01:55,956 at Indiana rural health association for some grant related work I've been 36 00:01:55,956 --> 00:01:59,849 doing tele-health I know that Don Kelso at the time and others on staff 37 00:01:59,849 --> 00:02:02,411 were interested in tele-health work. 38 00:02:02,441 --> 00:02:06,791 And so I wrote a grant and evidence-based telebehavioral health network 39 00:02:06,791 --> 00:02:09,221 grant with Matt and he was there. 40 00:02:09,641 --> 00:02:12,020 And we did that for three years. 41 00:02:12,020 --> 00:02:13,910 And toward the end, we saw the announcement for the. 42 00:02:14,435 --> 00:02:16,055 Telehealth resource center grant come out. 43 00:02:16,055 --> 00:02:21,275 And we saw that Ohio and Indiana and Michigan and Illinois weren't covered yet. 44 00:02:21,335 --> 00:02:24,839 The tele-health resource centers grew one section at a time. 45 00:02:24,839 --> 00:02:27,479 And those four states just hadn't been claimed. 46 00:02:27,502 --> 00:02:28,749 So Matt, I. 47 00:02:29,379 --> 00:02:32,200 That grant to for the UMTRC originally. 48 00:02:32,200 --> 00:02:36,194 And then I was the clinical director while Matt was on staff and he was the titular 49 00:02:36,224 --> 00:02:38,984 director of the UMTRC for the beginning. 50 00:02:38,984 --> 00:02:42,794 And then after Matt left, Becky took over and we worked together for a while 51 00:02:42,794 --> 00:02:45,454 until I left for Oaklawn Indiana. 52 00:02:45,504 --> 00:02:47,660 Cameron Hilt: It's great to be able to have someone that, really 53 00:02:47,660 --> 00:02:52,262 understands the history of the UMTRC on our podcast years later. 54 00:02:52,262 --> 00:02:52,562 And. 55 00:02:52,922 --> 00:02:57,335 tell us a little bit about so now you work at, one of our sister 56 00:02:57,335 --> 00:02:59,724 tele-health resource centers GP track. 57 00:02:59,730 --> 00:03:04,544 Tell us a little bit about your journey to becoming the program director at GP Track. 58 00:03:04,584 --> 00:03:07,284 Dr. Jonathan Neufeld: So after I left UMTRC and you may 59 00:03:07,284 --> 00:03:08,567 have heard this from others. 60 00:03:08,628 --> 00:03:10,518 It's a wonderful community of people. 61 00:03:10,578 --> 00:03:12,048 Wonderful set of grantees. 62 00:03:12,148 --> 00:03:15,681 I think we're somewhat unique if you can be somewhat unique, but I think 63 00:03:15,681 --> 00:03:19,833 we're unique among grantee programs, at least at HERSA, just because 64 00:03:19,833 --> 00:03:21,199 we're collaborative and congenial. 65 00:03:21,219 --> 00:03:25,629 So it was a really tight organization when I left UMTRC I still had some sort 66 00:03:25,629 --> 00:03:29,409 of pending obligations to attend some meetings and help do some trainings. 67 00:03:29,919 --> 00:03:32,610 And my new CEO said, yeah, great. 68 00:03:32,641 --> 00:03:33,511 Go ahead and do that. 69 00:03:33,511 --> 00:03:36,132 Stay connected because it was one of the things that. 70 00:03:36,712 --> 00:03:40,432 That I brought to Oaklawn was this connection to the world of 71 00:03:40,432 --> 00:03:42,277 telehealth as well as expertise in it. 72 00:03:42,277 --> 00:03:47,463 I continued to be in touch with the TRCs and the former principal 73 00:03:47,463 --> 00:03:48,633 investigator and director. 74 00:03:49,463 --> 00:03:53,606 At GP track Stuart speedy decided to retire. 75 00:03:53,696 --> 00:03:57,146 He had been at university of Minnesota for a long time, was 76 00:03:57,146 --> 00:04:02,475 very instrumental in the growth and development of the informatics program 77 00:04:02,475 --> 00:04:04,512 at Minnesota, which is 50 years old. 78 00:04:04,512 --> 00:04:05,913 And it's an amazing program. 79 00:04:05,914 --> 00:04:09,504 And Stuart was retiring from IHI Institute for health informatics. 80 00:04:09,534 --> 00:04:14,880 And he knew me from UMTRC days and just kinda tap me on the shoulder and actually 81 00:04:14,910 --> 00:04:19,170 with some help from others around the TRC community, who said, Hey Stewart. 82 00:04:19,200 --> 00:04:23,420 Yeah, you gotta see if you felt interested. 83 00:04:23,483 --> 00:04:27,533 So that one thing led to another until I came to the university 84 00:04:27,533 --> 00:04:31,399 of Minnesota virtually, I still live in Indiana, but took over. 85 00:04:32,104 --> 00:04:35,974 After Stewart retired as director of the great Plains tele-health resource and 86 00:04:35,974 --> 00:04:41,284 assistance center with and kept a fabulous staff there who are still with us now. 87 00:04:42,284 --> 00:04:46,529 Cameron Hilt: Yeah, I can reiterate, it's a very close-knit community 88 00:04:46,529 --> 00:04:50,562 amongst the tele-health resource centers, both nationally and regionally. 89 00:04:50,562 --> 00:04:55,060 And it's cool to see, those connections that you were able to make just by 90 00:04:55,060 --> 00:04:59,187 working on another TRC, even being able to make that connection and just 91 00:04:59,187 --> 00:05:00,717 moving over to a different region. 92 00:05:00,749 --> 00:05:04,742 I was curious your background is as a clinical psychologist. 93 00:05:04,742 --> 00:05:10,567 So how did you first get introduced to telehealth and what really drew you into 94 00:05:10,567 --> 00:05:15,314 actually wanting to pursue, full-time work focusing specifically on telehealth. 95 00:05:16,314 --> 00:05:17,844 Dr. Jonathan Neufeld: So when I. 96 00:05:18,829 --> 00:05:23,955 Did my post-doc at UC Davis medical center, which is in Sacramento, just 97 00:05:24,105 --> 00:05:25,785 a few miles up the road from Davis. 98 00:05:25,837 --> 00:05:28,747 I was in the department of family and community medicine. 99 00:05:28,837 --> 00:05:29,017 And. 100 00:05:30,007 --> 00:05:35,529 Just, it just so happened that the postdoc position that they that I applied 101 00:05:35,529 --> 00:05:41,727 to and that they provided there, was supervised by a man named ed Callahan. 102 00:05:41,727 --> 00:05:45,117 Also a psychologist who was in family medicine at UC Davis. 103 00:05:45,687 --> 00:05:50,307 And ed had had worked with a number of other researchers at the university 104 00:05:50,307 --> 00:05:51,699 and the department of psychiatry who. 105 00:05:52,414 --> 00:05:56,191 Some early, early is relative in tele-health right. 106 00:05:56,228 --> 00:05:58,028 This was late nineties. 107 00:05:59,028 --> 00:06:03,677 So Medicare had passed its rules and UC Davis had an active 108 00:06:03,677 --> 00:06:06,450 telemedicine program with folks like. 109 00:06:07,450 --> 00:06:12,460 Don Hilti, who is a widely published psychiatrist in the tele-health world, 110 00:06:12,730 --> 00:06:18,310 actually, while I was there, Peter, who's a former president of ATA joined 111 00:06:18,310 --> 00:06:20,330 UC Davis faculty, and he's still there. 112 00:06:20,339 --> 00:06:24,480 And it just so just in my work with Ed and said, Hey, there's these guys doing 113 00:06:24,480 --> 00:06:27,690 this interesting stuff over in psychiatry, are you interested in working with them? 114 00:06:28,140 --> 00:06:31,140 And so I got connected there and when I joined the faculty, 115 00:06:31,140 --> 00:06:32,400 then after my post-doc. 116 00:06:32,494 --> 00:06:37,060 I actually joined first, as an analyst in psychiatry, they had a behavioral 117 00:06:37,060 --> 00:06:41,089 health capitated plan that they ran out of the department of psychiatry 118 00:06:41,089 --> 00:06:44,292 and they brought me on as an analyst for that plan while I was finishing. 119 00:06:44,396 --> 00:06:48,004 Doctoral hours licensure hours in the family medicine clinic. 120 00:06:48,514 --> 00:06:50,614 And then after I finished and was licensed, then they brought 121 00:06:50,614 --> 00:06:54,124 me in, on faculty at UC Davis in the department of psychiatry. 122 00:06:54,604 --> 00:06:59,784 And I got to work with Peter and Don and Jim Marson from emergency medicine. 123 00:07:00,054 --> 00:07:01,434 You still around quite a bit. 124 00:07:01,524 --> 00:07:05,106 And A lot of just got a lot of exposure. 125 00:07:05,106 --> 00:07:08,346 They had the first tele-health learning center I think Kathy was 126 00:07:08,461 --> 00:07:10,358 involved at the time there. 127 00:07:10,658 --> 00:07:16,355 And just was, became immersed in that work that they were doing there. 128 00:07:16,715 --> 00:07:20,269 So then when I left UC Davis and came to Indiana, it was one of the things that 129 00:07:20,269 --> 00:07:21,619 I just wanted to stay in touch with. 130 00:07:21,629 --> 00:07:27,005 I wanted to keep finding out what was going on in tele-health in Indiana. 131 00:07:27,005 --> 00:07:31,685 So I made a lot of cold calls, met some people through the folks in California 132 00:07:32,135 --> 00:07:36,496 because Greg Beck, who had been working for children's in Indianapolis 133 00:07:36,617 --> 00:07:41,057 Had been trained at UC Davis and was doing a telehealth program down there. 134 00:07:41,057 --> 00:07:42,917 So I called him up and met him. 135 00:07:42,917 --> 00:07:43,727 We hit it off. 136 00:07:44,187 --> 00:07:47,414 And then a group just started meeting and talking about telehealth 137 00:07:47,414 --> 00:07:48,344 in Indiana for a number of. 138 00:07:48,461 --> 00:07:52,043 And that led to meeting Matt, writing the grant with Indiana rural health 139 00:07:52,043 --> 00:07:54,383 association and et cetera, et cetera. 140 00:07:54,793 --> 00:07:56,743 I was always interested in the technology. 141 00:07:57,343 --> 00:07:58,813 I was interested in tech stuff. 142 00:07:58,813 --> 00:08:00,883 One of my first projects at UC Davis was working. 143 00:08:01,588 --> 00:08:05,427 Palm pilot the precursor of the cell phone, or the, of the, 144 00:08:05,427 --> 00:08:09,107 yeah, the little handheld device, their personal digital assistant. 145 00:08:09,167 --> 00:08:13,916 And so I wanted to stay involved in technology and I just had some great 146 00:08:13,916 --> 00:08:17,486 opportunities there at UC Davis to do that and ended up hanging on to 147 00:08:17,486 --> 00:08:21,026 it had ended up having some great opportunities in Indiana to continue. 148 00:08:21,623 --> 00:08:22,253 Cameron Hilt: No, that's great. 149 00:08:22,253 --> 00:08:25,430 It sounds like early in your career, you had seeds. 150 00:08:26,035 --> 00:08:29,252 Different ways that you can get plugged into tele-health where you 151 00:08:29,252 --> 00:08:31,352 know, that interest grew over time. 152 00:08:31,352 --> 00:08:35,188 And as you got involved to really leading you where you are now and you 153 00:08:35,188 --> 00:08:40,770 gave a little bit of background of how you seen, tele-health kind of grow and 154 00:08:40,770 --> 00:08:42,872 change over the course of your career. 155 00:08:42,872 --> 00:08:45,580 So you know, what have been some of the biggest changes 156 00:08:45,580 --> 00:08:46,930 that you've seen in telehealth? 157 00:08:46,986 --> 00:08:48,319 Over the past few years, 158 00:08:48,863 --> 00:08:51,203 Dr. Jonathan Neufeld: The biggest changes that have driven it 159 00:08:51,623 --> 00:08:54,653 are in the mid nineties when Medicare started paying for it. 160 00:08:54,653 --> 00:08:58,133 And actually it really didn't hit its stride until about 2000. 161 00:08:58,313 --> 00:09:02,437 When Medicare finally decided to pay for both intakes and 162 00:09:02,437 --> 00:09:04,177 therapy in behavioral health. 163 00:09:04,447 --> 00:09:09,397 And since that time, behavioral health has been the majority of what Medicare 164 00:09:09,397 --> 00:09:11,277 pays for in telehealth until Covid. 165 00:09:11,802 --> 00:09:15,692 But still the largest single specialty, the longer largest 166 00:09:15,692 --> 00:09:18,678 single lump of encounters that Medicare pays for telehealth. 167 00:09:18,678 --> 00:09:23,122 But the biggest things besides that reimbursement in the technology 168 00:09:23,122 --> 00:09:28,345 world are first of all, the public internet when I started, we were paying 169 00:09:28,705 --> 00:09:32,058 multiple ISDN lines or multiple DSL. 170 00:09:32,107 --> 00:09:35,846 Lines to various sites or there's another acronym I'm 171 00:09:35,846 --> 00:09:37,465 forgetting now with gang lines. 172 00:09:37,465 --> 00:09:41,555 But anyway, UC Davis is paying a dollar a minute for connectivity. 173 00:09:41,795 --> 00:09:45,005 So you can imagine what it would take to make a telehealth program 174 00:09:45,005 --> 00:09:47,885 sustainable when every hour it's 60 bucks. 175 00:09:47,885 --> 00:09:50,435 Your first 60 bucks just goes for the connectivity. 176 00:09:50,441 --> 00:09:55,029 Not to mention the little set top boxes from Tanberg and poly-com that. 177 00:09:55,029 --> 00:09:59,929 Upwards of three, four, $5,000 to plug them into , your ISDN lines. 178 00:10:00,379 --> 00:10:05,157 The fact that you could get to the point where, your connectivity was basically, 179 00:10:05,236 --> 00:10:08,656 a hundred bucks a month or 200 bucks a month, whatever it was when we first 180 00:10:08,656 --> 00:10:13,284 started getting a more ubiquitous internet, that was a huge change in how 181 00:10:13,314 --> 00:10:15,157 those expenses impacted tele-health. 182 00:10:15,547 --> 00:10:17,497 The other thing is just. 183 00:10:18,412 --> 00:10:24,442 Just the rapid transformation or the rapid advances in video compression 184 00:10:24,502 --> 00:10:26,122 and transmission technology. 185 00:10:26,402 --> 00:10:29,902 When you first started to be able to run, video calls on a 186 00:10:29,902 --> 00:10:32,012 generic computer running software. 187 00:10:32,267 --> 00:10:36,689 Polycomm had software for awhile that was H.323 compliant. 188 00:10:36,689 --> 00:10:38,891 But it was clunky and it was hard to use. 189 00:10:39,281 --> 00:10:44,351 And web based video platforms really changed all that. 190 00:10:44,351 --> 00:10:48,761 And I really have to say, I have to emphasize that even the 191 00:10:48,821 --> 00:10:54,221 algorithms and code that we had zoom coming onto the scene, zoom. 192 00:10:55,186 --> 00:10:58,636 Change generationally before COVID zoom was around before 193 00:10:58,636 --> 00:11:00,416 COVID, several years before COVID. 194 00:11:00,896 --> 00:11:07,523 But when zoom came on the scene, their video algorithms were just a generation 195 00:11:07,523 --> 00:11:09,743 ahead of what else was available. 196 00:11:10,269 --> 00:11:15,168 The age the H.264 advanced video codec had come out, but zoom really took 197 00:11:15,168 --> 00:11:20,475 that and ran with it and provided a markedly better throughput markedly, 198 00:11:20,475 --> 00:11:22,305 better video markedly, more adaptable. 199 00:11:22,335 --> 00:11:24,405 It was just a real game changer in a lot of ways. 200 00:11:24,405 --> 00:11:26,686 And everybody has caught up or a lot of people have caught 201 00:11:26,686 --> 00:11:27,944 up to a certain extent. 202 00:11:28,334 --> 00:11:33,185 But those things made it possible to really do high quality ubiquitous, 203 00:11:33,215 --> 00:11:36,755 just kinda click a button and there you go, kind of video. 204 00:11:36,785 --> 00:11:39,504 And that really has changed the world of telehealth. 205 00:11:40,314 --> 00:11:40,824 And then, 206 00:11:40,920 --> 00:11:44,729 you can't underestimate the impact, that COVID-19 had on it because we had a 207 00:11:44,729 --> 00:11:48,411 solution there waiting, and then all of a sudden, boom, national, international 208 00:11:48,479 --> 00:11:50,244 situation where we needed tele-health. 209 00:11:50,744 --> 00:11:51,434 Cameron Hilt: Absolutely. 210 00:11:51,434 --> 00:11:51,734 yeah. 211 00:11:51,783 --> 00:11:52,773 Before the pandemic. 212 00:11:52,862 --> 00:11:55,982 How many people knew and utilize telehealth services. 213 00:11:56,012 --> 00:12:03,138 I was just on a student panel this week and I had a student who asked me 214 00:12:03,138 --> 00:12:09,991 did telehealth exist prior to COVID-19 and yes, it's had a very vast history. 215 00:12:09,991 --> 00:12:14,143 The father of telemedicine can be traced back to the seventies. 216 00:12:14,247 --> 00:12:18,447 People really didn't know that the services were being utilized and in 217 00:12:18,447 --> 00:12:19,797 what ways they're being utilized. 218 00:12:19,797 --> 00:12:21,398 But now it's commonplace. 219 00:12:21,431 --> 00:12:26,540 Dr. Jonathan Neufeld: I've said in other settings too that most, of 220 00:12:26,540 --> 00:12:31,663 course most people's view of telehealth is telehealth since March of 2020. 221 00:12:31,993 --> 00:12:36,319 And it, and most people think of it as, live video to your home. 222 00:12:37,099 --> 00:12:43,759 And in fact, before March of 2020, almost none of it was live video to your home. 223 00:12:44,239 --> 00:12:46,552 And we could do that, the technology existed, but you couldn't get 224 00:12:46,552 --> 00:12:48,232 paid for it most of the time. 225 00:12:48,290 --> 00:12:51,963 Just the year prior to that, I think it was Medicare started paying for 226 00:12:51,963 --> 00:12:53,433 mental health services to the home. 227 00:12:53,998 --> 00:12:55,678 Other than that Medicare didn't pay for it. 228 00:12:55,678 --> 00:12:58,768 And most commercial payers, didn't either, there's some dabbling here 229 00:12:58,768 --> 00:13:03,505 and there, and some Medicaid payers that were pretty progressive did. 230 00:13:03,559 --> 00:13:06,919 But you were going into an office somewhere to do a live video 231 00:13:06,919 --> 00:13:11,749 telehealth call until mostly until COVID-19 until the pandemic. 232 00:13:11,749 --> 00:13:14,869 And then all of a sudden, everybody realized, oh, this is telehealth. 233 00:13:14,869 --> 00:13:17,239 This is where my doctor sees me at home, sitting on my couch 234 00:13:17,239 --> 00:13:18,264 with my cell phone, it's wow. 235 00:13:19,134 --> 00:13:23,057 Yeah, that's cool, but we couldn't do that a month ago or, whatever. 236 00:13:23,597 --> 00:13:27,224 The other interesting thing that I think even folks in the field don't 237 00:13:27,434 --> 00:13:33,344 realize is that most of the telehealth that has happened since the beginning 238 00:13:33,464 --> 00:13:38,594 of the pandemic would not have been reimbursed before the pandemic 239 00:13:38,594 --> 00:13:42,574 would not have existed without the flexibilities during the pandemic. 240 00:13:43,006 --> 00:13:48,076 And it's why there's such pressure to make those changes permanent, 241 00:13:48,376 --> 00:13:53,860 because I we know what it's like to operate with one hand and one arm 242 00:13:53,860 --> 00:13:55,450 and one leg tied behind our back. 243 00:13:55,480 --> 00:13:57,537 It's okay, we can go back to that. 244 00:13:57,568 --> 00:14:01,108 But nobody wants to do that, but that's, those are the permanent laws. 245 00:14:01,168 --> 00:14:05,849 They're still on the books, when we go back from the COVID-19 relaxation. 246 00:14:05,892 --> 00:14:08,699 So yeah, it really is critical that we examine those rules and think 247 00:14:08,699 --> 00:14:13,109 about, okay, how do we want to support virtual care going forward, 248 00:14:13,139 --> 00:14:18,239 both as a policy decision, but also reimbursement at whatever payer levels. 249 00:14:19,239 --> 00:14:19,449 Cameron Hilt: Yeah. 250 00:14:19,449 --> 00:14:22,572 And I'm glad you brought that up, especially with, the most recent 251 00:14:22,572 --> 00:14:25,981 edition that we had of the physician fee schedule from Medicare. 252 00:14:25,989 --> 00:14:30,999 One of the big wins that we've seen through the course of the pandemic is, 253 00:14:31,095 --> 00:14:35,071 the lifting of geographic restrictions when it comes to telebehavioral health. 254 00:14:35,071 --> 00:14:39,283 But to your point, there's still lots of other specialties that 255 00:14:39,347 --> 00:14:40,965 we have a lot of evidence-based. 256 00:14:40,965 --> 00:14:45,852 So their effectiveness of being able to offer it through, Modality, but still, 257 00:14:45,852 --> 00:14:49,203 there are some of those restrictions that are in place that it makes it 258 00:14:49,203 --> 00:14:54,693 hard for a lot of healthcare providers who did all this work to implement 259 00:14:54,693 --> 00:14:59,730 this new service, potentially hired staff, got the technology on board. 260 00:15:00,060 --> 00:15:04,169 And now all of a sudden they're in this weird limbo I've done all this investment. 261 00:15:04,199 --> 00:15:08,931 Our patients want it now, our providers enjoy, providing this service, but 262 00:15:08,961 --> 00:15:11,331 now I don't know if I'm going to be able to get reimbursed for it. 263 00:15:11,391 --> 00:15:12,021 Long-term. 264 00:15:12,211 --> 00:15:12,631 Dr. Jonathan Neufeld: Yeah. 265 00:15:13,187 --> 00:15:16,337 Yeah, there, there is a lot of movement there. 266 00:15:16,337 --> 00:15:19,027 And I think that pressure is being felt. 267 00:15:19,032 --> 00:15:21,710 And to the extent that anything gets through Congress, this 268 00:15:21,710 --> 00:15:25,290 is definitely up there as one of the things that's critical. 269 00:15:25,380 --> 00:15:30,531 Telehealth has always been a remarkably bipartisan issue at the federal level. 270 00:15:30,531 --> 00:15:34,664 So to the extent that, anything can get done, both sides want it to happen. 271 00:15:35,222 --> 00:15:37,386 But, it doesn't guarantee anything. 272 00:15:37,434 --> 00:15:42,633 It still has to be acting, be passed as a piece of legislation that somebody is 273 00:15:42,633 --> 00:15:47,013 supporting and somebody is offering and somebody is going to get credit for that. 274 00:15:47,013 --> 00:15:49,895 And if we just keep wrangling about who's going to get credit for it, 275 00:15:49,895 --> 00:15:51,809 then, and it doesn't get done. 276 00:15:51,809 --> 00:15:54,943 So yeah, it's a, it can be a challenge, but I suspect. 277 00:15:55,843 --> 00:15:58,093 We're going to see that change happen this year. 278 00:15:58,602 --> 00:15:58,932 Cameron Hilt: Yeah. 279 00:15:58,932 --> 00:15:59,712 absolutely. 280 00:15:59,712 --> 00:16:03,274 And I think, especially if you can see some of those changes from the 281 00:16:03,274 --> 00:16:08,998 federal level, I know here in the Midwest, we tend to see a lot of our 282 00:16:08,998 --> 00:16:11,458 Medicaid's tend to mirror Medicare. 283 00:16:11,892 --> 00:16:14,126 After they've made some decisions. 284 00:16:14,126 --> 00:16:17,671 And especially if we can see some of those changes at a federal level, even 285 00:16:17,671 --> 00:16:22,157 if it may not be instantly at a state level hopefully we can see, some of 286 00:16:22,157 --> 00:16:24,624 those state changes in Medicaid as well. 287 00:16:24,679 --> 00:16:28,811 Cause I know that can be a huge barrier, especially if your main 288 00:16:28,811 --> 00:16:32,471 patient base is Medicaid to be able to have the same reimbursement 289 00:16:32,501 --> 00:16:34,031 that you may have through Medicare. 290 00:16:34,049 --> 00:16:34,439 Dr. Jonathan Neufeld: Yeah. 291 00:16:34,979 --> 00:16:35,309 Yeah. 292 00:16:35,344 --> 00:16:39,722 I've been very impressed with Medicare for the most part, actually CMS, I mean, 293 00:16:39,722 --> 00:16:41,852 they're aware they know the situation. 294 00:16:42,182 --> 00:16:47,301 They are a bit restricted because the original Medicare statute is in statute. 295 00:16:47,331 --> 00:16:49,821 If the original telehealth payment is in statute. 296 00:16:50,211 --> 00:16:52,554 And so CMS, can't just say we're not going to do it that way. 297 00:16:53,439 --> 00:16:57,330 Congress has to say, or at least give the administrator of 298 00:16:57,330 --> 00:16:59,598 CMS, the authority to do that. 299 00:16:59,649 --> 00:17:06,169 It is a pretty hard limitation, but CMS has been remarkably creative in 300 00:17:06,219 --> 00:17:11,559 wiggling around those restrictions or at least I don't want to make it sound 301 00:17:11,559 --> 00:17:15,539 nefarious, but they have figured out how to support an awful lot of virtual. 302 00:17:16,389 --> 00:17:20,539 In spite of the fact that an awful lot of it is restricted in the 303 00:17:20,539 --> 00:17:26,589 original legislation When the first Medicare coverage was put into place. 304 00:17:26,589 --> 00:17:31,460 One of the, in that 1996, 1997 act I don't know if you've heard the story of 305 00:17:31,460 --> 00:17:35,960 how OMB scored telemedicine and I don't know the numbers, but I definitely have 306 00:17:35,960 --> 00:17:40,130 the impression OMB scored it it's just, this was just going to be a bank Buster. 307 00:17:40,211 --> 00:17:43,811 If we let people from all over the country, see their doctor 308 00:17:43,811 --> 00:17:47,195 by telemedicine, this is just gonna put Medicare in the red. 309 00:17:47,195 --> 00:17:49,625 So they were very restrictive in what they allowed. 310 00:17:49,985 --> 00:17:52,668 And since then I did an analysis a while back. 311 00:17:53,168 --> 00:17:58,887 Since then Medicare, despite growing by double digit percentage, and in 312 00:17:58,887 --> 00:18:04,797 fact up until 2020 was growing at about a 30% or more per year rate. 313 00:18:05,307 --> 00:18:10,797 And so he had this logarithmic growth, but even so the peak of it was still 314 00:18:10,797 --> 00:18:15,777 less than 1%, less than a 10th of a percent of Medicare beneficiaries. 315 00:18:16,507 --> 00:18:18,127 Had any kind of a telehealth encounter. 316 00:18:18,127 --> 00:18:21,872 So it was really just a tiny trickle tiny rounding error at the bottom. 317 00:18:22,632 --> 00:18:27,507 And so those predictions about busting the bank never really came to fruition. 318 00:18:27,797 --> 00:18:30,957 I did, an interesting kind of comparison when I did some of that analysis. 319 00:18:31,071 --> 00:18:34,581 I wanted to find something to compare telemedicine to all of telemedicine 320 00:18:34,581 --> 00:18:39,521 in 2019, with Medicare, Medicare spent less on all of telemedicine in 321 00:18:39,521 --> 00:18:42,821 2019 that it spent on Holter monitors. 322 00:18:42,897 --> 00:18:43,677 There's cardiac monitor. 323 00:18:43,677 --> 00:18:44,337 You take home. 324 00:18:44,367 --> 00:18:45,087 It comes in a box. 325 00:18:45,087 --> 00:18:49,507 You'd wrap it up, put it on for a few hours, it sends a reading to your doctor. 326 00:18:49,857 --> 00:18:52,887 We spend more on that than telehealth and the whole country 327 00:18:53,337 --> 00:18:55,467 we being CMS and Medicare. 328 00:18:55,467 --> 00:18:59,867 So at the time when I wrote the article, I said, the Medicare telemedicine program is 329 00:18:59,867 --> 00:19:01,817 really nothing more than a pilot program. 330 00:19:01,901 --> 00:19:04,481 A couple of people pointed that out and said, Ooh, that's pretty strong 331 00:19:04,481 --> 00:19:07,518 statement, how do you, less than one 10th of a percent, how do you 332 00:19:07,518 --> 00:19:09,569 call that, real, a real program? 333 00:19:09,619 --> 00:19:12,469 Nobody wanted the pandemic to come that's for sure. 334 00:19:12,589 --> 00:19:15,969 But but it certainly has changed that, especially in 335 00:19:15,969 --> 00:19:17,029 the world of behavioral health, 336 00:19:17,529 --> 00:19:17,769 Cameron Hilt: Yeah. 337 00:19:17,769 --> 00:19:23,201 we now suddenly have, some of the biggest use cases that we've ever had 338 00:19:23,201 --> 00:19:27,403 for telehealth with what you just quoted with Medicare and seeing, after we've 339 00:19:27,403 --> 00:19:33,086 had these big peaks and now that we've seen tele-health utilization still remain 340 00:19:33,086 --> 00:19:37,935 significantly higher than it was prior to the pandemic we're really looking at that 341 00:19:37,935 --> 00:19:40,338 and seeing what the actual outcomes are. 342 00:19:40,338 --> 00:19:45,089 What does some of the emerging research coming out of the pandemic look like? 343 00:19:45,161 --> 00:19:46,391 When it comes to tele-health. 344 00:19:46,421 --> 00:19:50,168 And I think that will be a really fascinating thing to monitor over the 345 00:19:50,168 --> 00:19:54,327 next few years and just look back at moments like you just mentioned and 346 00:19:54,327 --> 00:19:58,751 just Based off of what we found, that seems just real far off the mark. 347 00:19:59,362 --> 00:20:03,812 Dr. Jonathan Neufeld: When the pandemic first started, a few months in 3, 348 00:20:03,812 --> 00:20:08,593 4, 6 months in everybody was taking a breath and realizing, okay We had 349 00:20:08,593 --> 00:20:11,833 done, we started doing telemedicine, just tons of telemedicine all over the 350 00:20:11,833 --> 00:20:15,923 country, a number of researchers and regulators and payers and others were 351 00:20:15,923 --> 00:20:20,783 starting to say, okay, great people are being seen, offices are operating. 352 00:20:20,783 --> 00:20:25,812 We're all doing telemedicine, but the big concern was, what about quality? 353 00:20:25,812 --> 00:20:28,436 Is all of this tele-health is going on. 354 00:20:28,509 --> 00:20:31,746 Is it, has it significant, significantly damaged the 355 00:20:31,746 --> 00:20:33,426 overall quality of medical care. 356 00:20:33,464 --> 00:20:34,668 And we worried about that for awhile. 357 00:20:34,668 --> 00:20:37,398 And a number of studies have tried to look at that. 358 00:20:38,088 --> 00:20:43,368 The challenge in my mind about that is that number one, we don't measure 359 00:20:43,368 --> 00:20:45,018 the quality of healthcare very well. 360 00:20:45,078 --> 00:20:50,478 Anyway, so it's hard to do a better job of measuring quality and tele-health, 361 00:20:50,478 --> 00:20:51,918 and we do measuring health care. 362 00:20:51,918 --> 00:20:56,046 Generally, you don't have a comparison an AB a legitimate comparison there. 363 00:20:56,080 --> 00:20:59,674 The other thing is that there's this sort of implication in that 364 00:20:59,674 --> 00:21:03,383 question that, yeah, we shouldn't do tele-health it's not as good a quality. 365 00:21:03,383 --> 00:21:05,603 We should just go into the doctor in person. 366 00:21:05,603 --> 00:21:09,293 Like we have been doing well when that's not possible anymore. 367 00:21:09,593 --> 00:21:12,843 And in the old days, it wasn't possible for other reasons, it's not that 368 00:21:12,843 --> 00:21:14,013 you just couldn't drive across town. 369 00:21:14,013 --> 00:21:16,183 It's like you couldn't get to a doctor. 370 00:21:16,203 --> 00:21:17,463 There was none in your region. 371 00:21:18,003 --> 00:21:21,153 The comparison is not, we should just fall back to in person, the 372 00:21:21,153 --> 00:21:22,713 comparison is we should do nothing. 373 00:21:22,752 --> 00:21:24,582 We should not see the doctor. 374 00:21:25,302 --> 00:21:27,883 And when you compare it to that, we haven't had to make that 375 00:21:27,883 --> 00:21:28,963 comparison for a while now. 376 00:21:28,963 --> 00:21:29,894 We've moved past that. 377 00:21:29,904 --> 00:21:32,814 It's a measure of how far we've moved past it but tele-health 378 00:21:33,084 --> 00:21:37,085 definitely beats nothing whether it's pandemic or it's just, far distance 379 00:21:37,281 --> 00:21:41,091 I think that what we're finding with regard to quality, at 380 00:21:41,091 --> 00:21:41,751 least where the world is. 381 00:21:42,696 --> 00:21:48,088 It's sorting itself out now is that yes, there are things you can't 382 00:21:48,088 --> 00:21:49,798 do in a telemedicine encounter. 383 00:21:50,218 --> 00:21:53,680 And there are especially things you can't do on a phone call with a 384 00:21:53,680 --> 00:21:58,690 patient, but you can do some things and those things that you can do; 385 00:21:59,190 --> 00:22:01,420 A, you can do more than you think. 386 00:22:01,510 --> 00:22:07,540 And B if you use telemedicine to do the things that you can do, you end up getting 387 00:22:07,540 --> 00:22:14,285 an awful lot of care, taken care of for way lower cost and way more convenient 388 00:22:14,315 --> 00:22:19,620 and great satisfaction because the patient is satisfied, with the convenience. 389 00:22:19,650 --> 00:22:23,040 They're satisfied with the care of course that they got care. 390 00:22:23,040 --> 00:22:26,580 But the thing that really kicks it up is that I didn't 391 00:22:26,580 --> 00:22:28,167 have to, take a day off work. 392 00:22:28,167 --> 00:22:29,427 I didn't have to drive across town. 393 00:22:29,427 --> 00:22:31,317 I didn't have to arrange for childcare. 394 00:22:31,317 --> 00:22:34,977 I didn't have to do all those other things that, that telemedicine 395 00:22:35,247 --> 00:22:36,597 makes it possible to avoid. 396 00:22:37,113 --> 00:22:37,413 Cameron Hilt: Yeah. 397 00:22:37,413 --> 00:22:38,823 And that's an interesting point. 398 00:22:38,823 --> 00:22:43,772 And I think a lot of times you hear this all or nothing approach, it's either 399 00:22:43,802 --> 00:22:46,692 all telemedicine or it's all in-person. 400 00:22:46,692 --> 00:22:49,824 There are certain specialties where it might make complete sense 401 00:22:49,824 --> 00:22:51,594 to do it all on telemedicine. 402 00:22:51,624 --> 00:22:54,904 There might be others that make complete sense to do it all. 403 00:22:54,954 --> 00:22:56,722 In the office and like thinking of. 404 00:22:57,457 --> 00:23:02,137 Certain scenarios where it makes more sense to provide that type of service. 405 00:23:02,167 --> 00:23:07,483 I'm thinking of, telestroke services in particular, a lot of times that has 406 00:23:07,483 --> 00:23:12,853 the most benefit and rural areas where patients don't have easy access to the 407 00:23:12,853 --> 00:23:16,963 neurologists, those hospitals may have difficulty recruiting and not to say 408 00:23:16,963 --> 00:23:20,776 that those don't have a place in an urban setting either, that tends to be 409 00:23:20,776 --> 00:23:22,859 the most common place that you find it. 410 00:23:22,859 --> 00:23:26,326 Because perhaps if you live in an urban center, you might have more 411 00:23:26,326 --> 00:23:30,826 access to a neurologist and be able to actually see that individual in person. 412 00:23:30,848 --> 00:23:35,918 Really being able to understand and know when are the times that this patient 413 00:23:35,918 --> 00:23:40,028 needs to come in person and what are times where this can be done over 414 00:23:40,028 --> 00:23:43,999 telemedicine and really understanding should it be a hybrid approach or 415 00:23:43,999 --> 00:23:47,149 should it be an all or nothing, but it doesn't have to just be all or nothing. 416 00:23:47,510 --> 00:23:51,713 Dr. Jonathan Neufeld: And because telemedicine in primary care specifically 417 00:23:51,713 --> 00:23:56,033 primary care, has been what we have come to see now in the pandemic. 418 00:23:56,129 --> 00:23:58,649 The thing that really happened that hadn't been happening before 419 00:23:58,649 --> 00:24:00,179 is telemedicine for primary care. 420 00:24:00,240 --> 00:24:03,854 Obviously we had other specialties too, and all of healthcare moved there 421 00:24:03,864 --> 00:24:07,404 but we tend to think now in terms of primary care and there's questions about 422 00:24:07,614 --> 00:24:11,154 how much telemedicine should there be versus in-person, what's the ideal mix. 423 00:24:11,514 --> 00:24:13,399 And I have some comments about that too, but. 424 00:24:13,899 --> 00:24:17,679 When you look at more historical or you go back a few years and 425 00:24:17,679 --> 00:24:20,379 you think about what are the real successes before the pandemic? 426 00:24:20,799 --> 00:24:22,959 You mentioned telescope, which is definitely one of them. 427 00:24:23,559 --> 00:24:32,979 And the fact is that without telestroke, without some rational and even aggressive 428 00:24:32,979 --> 00:24:38,529 application of telestroke care, there is no way that we're going to have stroke 429 00:24:38,529 --> 00:24:41,589 outcomes at every hospital in the country. 430 00:24:42,459 --> 00:24:44,679 That meet the standard of care. 431 00:24:44,796 --> 00:24:48,456 Physically, it could happen, but we have to train an awful lot of neurologists 432 00:24:48,696 --> 00:24:52,116 and an awful lot of them would have to be sitting around on their hands 433 00:24:52,206 --> 00:24:54,066 for an awful lot of their time. 434 00:24:54,426 --> 00:24:58,416 And that it's just not going to economically or professionally 435 00:24:58,416 --> 00:24:59,856 make any sense at all. 436 00:25:00,386 --> 00:25:03,116 There aren't enough stroke cases to use somebody like 437 00:25:03,116 --> 00:25:04,586 that full time in a rural area. 438 00:25:04,976 --> 00:25:08,246 And so you have to, one of the things telemedicine is 439 00:25:08,246 --> 00:25:10,256 great at aggregating demand. 440 00:25:10,286 --> 00:25:11,816 You have to aggregate the demand. 441 00:25:12,581 --> 00:25:17,471 To the point where that one neurologist or that team of neurologists can be 442 00:25:17,471 --> 00:25:22,871 serving a much larger geographic area or multiple centers in an urban area, 443 00:25:22,871 --> 00:25:28,301 whatever it takes to aggregate demand to the point where you can then staff 444 00:25:28,411 --> 00:25:36,405 24/7 neurology and have somebody calling and have those people busy 24/7 whatever 445 00:25:36,405 --> 00:25:38,775 it takes to make it a viable service. 446 00:25:38,860 --> 00:25:41,560 That aggregation of demand is another part of tele-health. 447 00:25:41,560 --> 00:25:42,760 It doesn't get talked about a lot. 448 00:25:42,760 --> 00:25:48,866 We talk about aggregating geographically, but also over time and, making it possible 449 00:25:48,866 --> 00:25:55,170 to sustain a practice for a sub-specialty and allow that sub specialist to, then 450 00:25:55,500 --> 00:25:59,198 they can actually start to migrate out of the urban areas because they can 451 00:25:59,198 --> 00:26:02,691 draw a map on, draw a line on the map and say, okay, that's my service area. 452 00:26:02,781 --> 00:26:03,921 And I'm going to virtually connect to all. 453 00:26:04,581 --> 00:26:07,911 I don't have to live in an area where there are enough 454 00:26:07,911 --> 00:26:10,462 patients to support my practice. 455 00:26:10,582 --> 00:26:14,212 I can live anywhere and just find a geographic area that 456 00:26:14,212 --> 00:26:15,352 will support my practice. 457 00:26:15,378 --> 00:26:18,844 And I'm personalizing it, but it's more, we do it more realistically in 458 00:26:18,844 --> 00:26:24,544 groups, but still that aggregation of demand is a huge benefit for those 459 00:26:24,844 --> 00:26:26,934 subspecialty practices like tele-stroke. 460 00:26:27,451 --> 00:26:31,236 That were, the rockstars before the pandemic and had been 461 00:26:31,236 --> 00:26:34,921 showing us an absolutely critical area that we need to move in. 462 00:26:34,972 --> 00:26:36,112 Even before the pandemic 463 00:26:36,624 --> 00:26:41,154 Cameron Hilt: being able to capture and serve a larger area through the 464 00:26:41,154 --> 00:26:45,729 utilization of telehealth and, see that in variety of different disciplines. 465 00:26:45,729 --> 00:26:50,225 And, even with, within the context of Indiana, we have several mental 466 00:26:50,225 --> 00:26:51,995 health, professional shortage areas. 467 00:26:51,995 --> 00:26:57,346 And we have a few behavioral health providers that cover big chunks of 468 00:26:57,376 --> 00:27:01,441 Indiana, even though they don't live in those areas, but because they're 469 00:27:01,441 --> 00:27:05,076 offering it through tele-health, they can have that larger service area versus 470 00:27:05,076 --> 00:27:09,696 just being restricted to the one city that they're geographically located at. 471 00:27:09,705 --> 00:27:14,838 Even with that, being able to serve a larger patient population, but also for 472 00:27:14,838 --> 00:27:19,278 that hospital or clinic that's providing the services, opening up the number of 473 00:27:19,278 --> 00:27:23,610 patients that they can bring in for even their own business our own sustainability 474 00:27:23,610 --> 00:27:25,836 of their programs, which is huge as well. 475 00:27:25,836 --> 00:27:30,669 But with that, for some of our listeners that are just curious with tele-health, we 476 00:27:30,686 --> 00:27:35,098 talked about a few different disciplines, but just, in general, what are some 477 00:27:35,128 --> 00:27:38,925 of, The we've already talked about strengths, but what are maybe some of the 478 00:27:38,925 --> 00:27:40,955 weaknesses or limitations of telehealth. 479 00:27:41,408 --> 00:27:45,616 Dr. Jonathan Neufeld: The biggest challenges I think that telehealth 480 00:27:45,616 --> 00:27:50,106 faces, and this is this is a, it's not really a weakness of telehealth per se. 481 00:27:50,136 --> 00:27:54,766 But one of the biggest challenges is, to do what you're already doing, or just 482 00:27:54,766 --> 00:27:56,685 mimic what you're already doing virtually. 483 00:27:56,696 --> 00:27:59,516 Some of the more progressive organizations and providers are starting 484 00:27:59,516 --> 00:28:03,456 to bump into this and realizing, we gotta take this to another level. 485 00:28:03,666 --> 00:28:08,296 Telehealth doesn't just enable us to replicate the in-person encounter 486 00:28:08,356 --> 00:28:10,006 virtually and doing it at a distance. 487 00:28:10,033 --> 00:28:14,760 It does do that, but if we do that, then we're leaving an awful 488 00:28:14,760 --> 00:28:16,180 lot of the value on the table. 489 00:28:16,680 --> 00:28:22,080 Tele-health doesn't really come into its own until you start doing what 490 00:28:22,080 --> 00:28:27,520 I call refactoring the encounter or refactoring the contact between 491 00:28:27,820 --> 00:28:29,229 the provider and the patient. 492 00:28:29,229 --> 00:28:31,299 And I don't mean just an individual provider, but in 493 00:28:31,299 --> 00:28:33,849 the clinic and the patient or between the group and the patient. 494 00:28:33,864 --> 00:28:38,639 So that patient can get various components of the services they 495 00:28:38,639 --> 00:28:41,240 need through various modalities. 496 00:28:41,740 --> 00:28:46,053 So if all you need is lab results, you get a phone call about that, 497 00:28:46,083 --> 00:28:49,383 or you go online and you check that asynchronously, or you get a message. 498 00:28:49,383 --> 00:28:50,403 Hey, your results are available. 499 00:28:50,403 --> 00:28:51,136 You can check now. 500 00:28:51,145 --> 00:28:54,535 And if what you need is a followup or you need some sort of an intake and we 501 00:28:54,535 --> 00:28:57,975 just need to exchange some information, we can do that online with a video. 502 00:28:58,315 --> 00:29:01,255 We can do an awful lot virtually. 503 00:29:01,405 --> 00:29:04,495 And then when it comes to the point where we need to see you to take your 504 00:29:04,495 --> 00:29:08,545 appendix out, or to provide that in a injection or do whatever we have 505 00:29:08,545 --> 00:29:11,665 to do physically, then you come in and you, and we do that physically. 506 00:29:11,935 --> 00:29:17,335 It's a variation of the old stepped care type of idea where you want 507 00:29:17,335 --> 00:29:20,335 to engage at the least restrictive. 508 00:29:20,395 --> 00:29:23,815 And I would add most cost-effective level. 509 00:29:24,565 --> 00:29:27,985 Possible for every service that has to happen. 510 00:29:28,225 --> 00:29:32,125 Now, if the service is an in-person encounter and you don't differentiate 511 00:29:32,125 --> 00:29:34,585 it any further than that, then yeah. 512 00:29:34,585 --> 00:29:36,955 You're going to be limited that you have to do a lot of those 513 00:29:36,955 --> 00:29:38,685 in person, but if you can. 514 00:29:39,160 --> 00:29:43,750 Break down that encounter breakdown, that level of service into a few of its 515 00:29:43,750 --> 00:29:50,482 components, like teaching and information exchange and lab results, explanation. 516 00:29:50,692 --> 00:29:53,662 And there are a lot of those things that don't have to happen 517 00:29:53,662 --> 00:29:55,132 in person at the doctor's office. 518 00:29:55,442 --> 00:30:00,342 The weakness of tele-health is using it to do what we've always done by video. 519 00:30:00,912 --> 00:30:05,112 The strength is when we start to rethink what we're doing by video, and what 520 00:30:05,112 --> 00:30:10,392 we're doing to deliver care, what it takes to deliver care and using the 521 00:30:10,392 --> 00:30:16,062 virtual channels that we have to do the things that they do well, and then use 522 00:30:16,062 --> 00:30:19,212 the in-person channels that we have to do the things that are necessary to do, 523 00:30:19,522 --> 00:30:20,565 Cameron Hilt: That's a great point. 524 00:30:20,630 --> 00:30:27,194 Using tele-health is going against the status quo of the way that healthcare has 525 00:30:27,194 --> 00:30:29,784 been done and delivered for centuries. 526 00:30:29,811 --> 00:30:36,573 So really being able to think of now that we have this new way, 527 00:30:36,573 --> 00:30:38,111 that we can deliver this care. 528 00:30:39,081 --> 00:30:42,081 Are we actually thinking of it as a unique offering? 529 00:30:42,141 --> 00:30:45,531 Or are we just trying to do just like you said, are we just trying 530 00:30:45,531 --> 00:30:49,011 to provide the same service now it's just on video and not in person. 531 00:30:49,023 --> 00:30:54,203 Versus really trying to think through how does us offering this service 532 00:30:54,203 --> 00:30:59,273 through tele-health make this unique, how can we make this service better? 533 00:30:59,273 --> 00:31:02,423 Because we're providing it through tele-health or better fit 534 00:31:02,423 --> 00:31:05,687 for the patient or the provider versus, Kind of checking my box. 535 00:31:05,687 --> 00:31:06,707 I did my visit. 536 00:31:06,887 --> 00:31:07,667 I'm good to go. 537 00:31:07,667 --> 00:31:08,417 It's the same. 538 00:31:08,435 --> 00:31:11,657 And so really challenging some of that status quo. 539 00:31:11,687 --> 00:31:15,576 But because it's new for a lot of people the tendency is 540 00:31:15,576 --> 00:31:17,389 just to follow what you know. 541 00:31:17,449 --> 00:31:21,979 So if that's how you've provided care for your entire career, and now all of 542 00:31:21,979 --> 00:31:25,909 a sudden you have to learn how to do it over a tele-health platform, there's 543 00:31:25,909 --> 00:31:27,517 a learning curve attached to that. 544 00:31:27,541 --> 00:31:27,951 Dr. Jonathan Neufeld: Yeah. 545 00:31:27,951 --> 00:31:31,141 There's a lot of change and it is not simple. 546 00:31:31,151 --> 00:31:35,231 I don't ever want to give the impression that, oh, all we have to do is X. 547 00:31:35,231 --> 00:31:36,577 And then, that'll solve problems. 548 00:31:36,577 --> 00:31:42,787 Healthcare is complicated and delivering individualized healthcare is challenging. 549 00:31:42,787 --> 00:31:47,287 Even in the best of circumstances, we've developed our skillsets 550 00:31:47,347 --> 00:31:49,357 and our ways of providing care. 551 00:31:49,371 --> 00:31:51,536 Just on the assumption that the patient is here. 552 00:31:52,856 --> 00:32:00,883 And it will take a while to Recode reorient to the ways that we can provide 553 00:32:00,883 --> 00:32:02,713 health care if the patient isn't here. 554 00:32:03,043 --> 00:32:05,146 It's also important to underscore the fact that. 555 00:32:05,646 --> 00:32:10,377 Healthcare also develops according to what's reimbursable because 556 00:32:10,377 --> 00:32:13,226 ultimately, you can provide an awful lot of healthcare, but if 557 00:32:13,226 --> 00:32:15,236 you don't get paid for it, you're not going to be doing it for long. 558 00:32:15,836 --> 00:32:20,726 And so telehealth has this, like any, I think probably any part of 559 00:32:20,726 --> 00:32:26,816 healthcare, it's absolutely dependent on the circulatory system that runs 560 00:32:26,816 --> 00:32:30,776 underneath it, that the infrastructure underneath it is the payment system. 561 00:32:30,776 --> 00:32:34,180 And if that in-person encounter is what has been conceptualized as this 562 00:32:34,180 --> 00:32:37,908 is what we pay then you have to kind of stuck trying to replicate the 563 00:32:37,908 --> 00:32:39,528 in-person encounter to get paid. 564 00:32:40,218 --> 00:32:44,027 So it's going to take some creativity on the part of payers as well, or 565 00:32:44,094 --> 00:32:48,034 some more vertically integrated capitation and quality-based payment 566 00:32:48,034 --> 00:32:52,234 arrangements that allow providers and organizations to be a lot more creative 567 00:32:52,624 --> 00:32:54,734 about how they provide services. 568 00:32:55,341 --> 00:32:55,551 Cameron Hilt: Yeah. 569 00:32:55,551 --> 00:32:59,481 And I'm just gonna take a second, just for some of our listeners who may not 570 00:32:59,481 --> 00:33:04,861 know some of those innovative or different kind of value-based care payment models. 571 00:33:04,864 --> 00:33:08,679 Tell us a little bit about capitation payments and what that model looks 572 00:33:08,679 --> 00:33:10,347 like in a healthcare practice. 573 00:33:11,005 --> 00:33:11,335 Dr. Jonathan Neufeld: Yeah. 574 00:33:11,403 --> 00:33:16,177 So a capitation payment is just a per member per month amount 575 00:33:16,327 --> 00:33:19,597 that a provider gets to provide a certain range of services. 576 00:33:19,807 --> 00:33:23,601 It could be, any healthcare they need all the way up to and including hospital care, 577 00:33:23,601 --> 00:33:28,683 but usually it's broken into outpatient and then other services, inpatient and 578 00:33:28,683 --> 00:33:34,730 others are paid separately, but a primary care group or an ACO or some organization 579 00:33:34,730 --> 00:33:38,150 may have primary responsibility for all the outpatient health. 580 00:33:39,020 --> 00:33:42,450 It might improve behavioral health and might not, but and then get 581 00:33:42,450 --> 00:33:45,670 a single payment per person. 582 00:33:45,684 --> 00:33:49,824 And then the provider it's up to them to provide the care that's necessary 583 00:33:50,134 --> 00:33:51,604 and that's way over simplified. 584 00:33:51,633 --> 00:33:56,583 But the idea is that it motivates the provider to both 585 00:33:56,583 --> 00:33:58,753 be proactive and efficient 586 00:33:59,083 --> 00:34:03,831 . So they want to, not just test everybody all the time and they don't want to 587 00:34:03,831 --> 00:34:06,608 just waste care when it's not needed. 588 00:34:06,658 --> 00:34:09,928 But also at the same time, if they just did a test last month and 589 00:34:09,928 --> 00:34:12,658 they need it again this month, where they need that information. 590 00:34:13,378 --> 00:34:16,138 They get more efficient at finding the old test and saying, oh, okay, 591 00:34:16,138 --> 00:34:17,338 we've already got this information. 592 00:34:17,338 --> 00:34:18,628 We don't need to do it again. 593 00:34:18,988 --> 00:34:24,766 Or they get more effective at saying let's reorder these services or let's figure out 594 00:34:24,766 --> 00:34:30,586 how to provide these in a more efficient way as well as let's do it now instead 595 00:34:30,586 --> 00:34:34,006 of a year from now, when it's going to be a much more complicated process 596 00:34:34,006 --> 00:34:35,356 or the person going to be much sicker. 597 00:34:35,356 --> 00:34:39,236 The outcomes will be much worse . The provider is motivated because of that 598 00:34:39,266 --> 00:34:43,036 overall payment that doesn't change unless, their population changes. 599 00:34:43,036 --> 00:34:46,426 But basically I'm going to get the same amount of money for this person. 600 00:34:47,416 --> 00:34:52,376 It's way cheaper if I keep them well, than if I let them get sick and then intervene. 601 00:34:52,401 --> 00:34:55,786 That's the holy grail of capitation is that everybody's motivated 602 00:34:55,786 --> 00:34:59,636 to really provide high-quality preventive and interventionists 603 00:34:59,656 --> 00:35:02,660 care in the most cost efficient way. 604 00:35:02,900 --> 00:35:08,443 And most cost efficient usually works out to be best for the patient as well. 605 00:35:08,923 --> 00:35:11,103 Cameron Hilt: you for that explanation, Jonathan. 606 00:35:11,209 --> 00:35:11,449 Yeah. 607 00:35:11,479 --> 00:35:16,928 it really will be interesting to see, As the year progresses and wherever the 608 00:35:16,928 --> 00:35:20,787 pandemic lands and some of the public health emergencies, as well as some of the 609 00:35:20,787 --> 00:35:26,114 waivers that have been extended during the course of the public health emergency, it 610 00:35:26,114 --> 00:35:30,533 will be interesting to see, some of these different innovative payment models that 611 00:35:30,533 --> 00:35:36,044 will come and hopefully, we'll see some of these waivers begin to become permanent 612 00:35:36,044 --> 00:35:37,838 past the public health emergency. 613 00:35:37,858 --> 00:35:41,231 I want to thank you so much for coming onto our show. 614 00:35:41,255 --> 00:35:42,775 And I want to give you a little bit of time. 615 00:35:42,775 --> 00:35:45,415 I know you have a upcoming conference. 616 00:35:45,452 --> 00:35:48,662 So go ahead and just give our listeners some details. 617 00:35:49,221 --> 00:35:53,491 Dr. Jonathan Neufeld: Yeah it's a ways off yet in May end of May 23rd to 25th. 618 00:35:53,569 --> 00:35:54,829 And it's in Minneapolis. 619 00:35:55,069 --> 00:36:02,269 We are fingers crossed, but very excited to be back in person for the last two 620 00:36:02,269 --> 00:36:05,207 years, we haven't been able to have an annual conference and we have a very. 621 00:36:05,207 --> 00:36:09,013 As you mentioned before, and as I said, a very collaborative and collegial group up 622 00:36:09,013 --> 00:36:12,373 in the great Plains states, Northern great Plains states that love to get together 623 00:36:12,373 --> 00:36:14,293 and share ideas and solve problems. 624 00:36:14,743 --> 00:36:18,943 So May 23rd to 25th at the Radisson Blu mall of America. 625 00:36:18,973 --> 00:36:24,408 So I'm going to have a day and a half and have some fantastic keynote 626 00:36:24,438 --> 00:36:28,921 plenary speakers already lined up and people can find out more about 627 00:36:28,921 --> 00:36:34,248 it at gptrack.org/conference that's where people can find out more 628 00:36:34,748 --> 00:36:35,738 Cameron Hilt: Thank you, Jonathan. 629 00:36:35,738 --> 00:36:41,276 And with our show notes, we'll make sure that we also share the GP track website. 630 00:36:41,276 --> 00:36:44,866 So any individuals who are interested can signup for your conference 631 00:36:44,866 --> 00:36:48,616 thanks so much for joining us and thank you all for listening today. 632 00:36:49,341 --> 00:36:49,641 Dr. Jonathan Neufeld: great. 633 00:36:49,641 --> 00:36:50,271 Thank you, cam. 634 00:36:52,939 --> 00:36:55,129 Caroline Yoder: I want to thank you for listening to a virtual view. 635 00:36:55,608 --> 00:36:59,058 You can find more information about today's episode in the show notes below. 636 00:36:59,407 --> 00:37:02,887 If you would like to support our podcast, please rate and review us on your favorite 637 00:37:02,887 --> 00:37:07,243 podcast platform do you have any questions or topics you'd like us to discuss? 638 00:37:07,556 --> 00:37:13,256 If so, contact us at info at UMTRC.Org or through the form found in the show notes. 639 00:37:13,956 --> 00:37:16,356 Also, we'd like to give a special thanks to our editor. 640 00:37:17,356 --> 00:37:21,316 Finally a special thanks to the health resources and service administration. 641 00:37:21,316 --> 00:37:22,366 Also known as HERSA. 642 00:37:22,876 --> 00:37:26,066 Our podcast series a virtual view is sponsored in part by HERSA's 643 00:37:26,086 --> 00:37:29,716 telehealth resource center program, which is under HERSA's office of 644 00:37:29,716 --> 00:37:32,576 the administrator and the office for the advancement of telehealth. 645 00:37:32,935 --> 00:37:36,415 The content and conclusions of this podcast are those of Cameron hilt of the 646 00:37:36,415 --> 00:37:41,174 UMTRC and should not be construed as the official policy of, or the position of 647 00:37:41,246 --> 00:37:45,416 nor should any endorsements be inferred by . HERSA, HHS, or the U S government. 648 00:37:45,806 --> 00:37:47,336 Thanks for listening and have a great day.