Editor’s Note: Spurred by the COVID-19 pandemic and the adoption of innovative technologies, the U.S. health care system is transitioning to a new era of digitally enabled care characterized by delivery models that fully integrate in-person care and virtual care. However, the full spectrum of benefits generated by virtual care is often misunderstood due to the lack of a comprehensive value framework. In a new white paper, summarized below, the American Medical Association (AMA) and Manatt Health developed a framework to assess the total range of benefits that virtual care generates.
The white paper proposes a new framework to better understand the comprehensive value of digitally enabled care models. The framework accounts for the various ways in which virtual care programs may increase the overall “return on health” by generating positive impacts for patients, clinicians, payers and society going forward. The white paper offers real-world and illustrative case studies featuring early adopters of the digitally enabled hybrid model that demonstrate how the framework can be applied. Real-world case study participants include VCU Health, Cityblock, Massachusetts General Hospital and Ochsner Health. The paper also highlights opportunities for a broad range of health care stakeholders to realize the full potential of digitally enabled care in the future. To read the full white paper, click here.
A Framework for Measuring the Value of Digitally Enabled Care
The COVID-19 pandemic spurred a dramatic increase in virtual care adoption and use. This evolution to digitally enabled care will fundamentally transform the value equation for health care professionals and payers. Instead of focusing narrowly on whether a specific type of visit can be delivered virtually, attention is shifting to how innovative technologies can be used to enhance overall episodes of care, blending a virtual and in-person experience in ways that improve access and experience for some patients while maintaining or improving quality and reducing long-term costs.
As the shift toward digitally enabled care continues, it will be critical to have a framework to guide clinicians, virtual care leaders, payers and other health care stakeholders in assessing value created for patients and for themselves. The ability to define and measure specific value streams will be necessary for designing new care models, making program prioritization decisions, and determining appropriate coverage and payment policies in the future.
To move beyond dollars and cents in realizing the value of virtual care, the following framework, which was developed based on a review of existing literature and interviews with more than 20 national experts, illustrates the benefits of virtual care according to six value streams: clinical outcomes; quality and safety; access to care; patient, family and caregiver experience; clinician experience; financial and operational impact; and health equity. The framework also incorporates environmental variables that impact the six value streams: practice type, payment arrangements, patient population, clinical use case and virtual care modality. These environmental variables enable the framework to be adapted to different contexts and acknowledges that different health care organizations will have unique clinical, business or infrastructure demands that fundamentally shape their approach to virtual care.
A Framework for Measuring the Value of Virtual Care
The Six Virtual Care Value Streams
The six value streams define the various ways in which virtual care models can generate value. Each value stream is comprised of several sub-streams that provide further specificity regarding how value can be created and measured.
Value Stream #1: Clinical Outcomes, Quality and Safety
Improvement of clinical outcomes, quality and safety is often the most important goal among clinicians who implement virtual care. When implemented effectively, virtual care programs may enhance clinical outcomes, improve quality of care, increase patient safety and improve clinical processes. Clinical and safety measures have historically been designed to measure the clinical effectiveness of in-person care, though they are increasingly used to assess effectiveness across modalities (in-person care, parallel care, digitally enabled care).
Value Stream #2: Access to Care
Virtual care programs may reduce barriers that delay patients’ access to timely care. This value stream seeks to measure the impact that a virtual care program may have on access to care by assessing a program’s impact on availability, appropriateness and affordability of care.
Value Stream #3: Patient, Family and Caregiver Experience
Virtual care programs have the potential to enhance the overall care experience for patients, as well as their families and caregivers. This value stream seeks to measure the impact that a virtual care program may have on the patient, family and caregiver experience with a focus on the clinical and technology experience.
Value Stream #4: Clinician Experience
The adoption of virtual care can enhance the experience of clinicians and care teams by enabling them to connect and care for patients more easily, allowing for more flexible work schedules and helping clinicians connect more quickly and easily with their colleagues. This value stream seeks to estimate the impact that a virtual care program may have on clinicians’ technology and work experience delivering virtual care.
Value Stream #5: Financial and Operational Impact
Health care organizations, such as hospitals/health systems, clinician groups or independent practices, will be reluctant to adopt virtual care unless it is financially viable, and payers will be reluctant to pay for it unless it is cost-effective. This value stream seeks to estimate the impact that a virtual care program may have on financial and operational variables, including direct revenue, indirect revenue, direct expenses and operational efficiencies.
Value Stream #6: Health Equity
Health equity is a cross-cutting component of this framework that seeks to understand the impact of a virtual care program across the other value streams for historically marginalized patient populations.
The AMA defines health equity as “having the conditions, resources, opportunities, and power to achieve optimal health.” The AMA aligns with the definition proposed by Dr. Camara Phyllis Jones, that achieving health equity requires three strategies: (1) valuing all individuals and populations equally; (2) recognizing and rectifying historical injustices; and (3) providing resources according to need. Unless digitally enabled care models are designed with health equity at the forefront, they can miss opportunities to advance health and can exacerbate inequities impacting historically marginalized populations.
Applying the Framework to New Digitally Enabled Care Programs
The AMA recently published the Telehealth Implementation Playbook, Telehealth Quick Guide and Remote Patient Monitoring Implementation Playbook to aid practices considering adopting new virtual care programs. The Telehealth Implementation Playbook proposes 12 distinct steps that practices can take to support efficient, successful implementation of telehealth programs. The framework proposed in this report can support those practices in completing four of those 12 steps: Defining Success, Making the Case, Evaluating Success and Scaling.
- Defining Success: The framework can help practices define the short- and long-term impact goals and associated metrics that will guide the design and implementation of the virtual care program.
- Making the Case: The framework can also be leveraged to develop a value impact estimate of a newly planned program to inform resourcing and investment decisions.
- Evaluating Success: After program launch, practices can use the impact goals identified in the Defining Success step to measure the impact of the implemented program. The framework can be used both to identify successes and determine areas for improvement.
- Scaling: If a practice has found its virtual care program has delivered value for the organization and decides to scale the program up to serve more patients or cover more clinical areas, the framework can be used again to project potential future value generated by a larger program.
Opportunities for Health Care Stakeholders to Realize the Full Potential of Virtual Care
There are actions that health care stakeholders, including payers and policymakers, can consider taking to encourage and enable the adoption of virtual care among clinicians, hospitals, clinics and other types of providers and overcome the challenges that are currently slowing the evolution to digitally enabled care models.
Unpredictable Virtual Care Coverage and Payment Environment
The lack of reliable coverage and payment for virtual care delivery remains a major impediment for clinicians seeking to build digitally enabled care models. Though most payers temporarily expanded their telehealth coverage and payment policies during the COVID-19 pandemic, many have not been clear about which policies will be made permanent.
Payers and policymakers can help overcome health care professionals’ concerns by supporting long-term fair and equitable payment that supports sustainability for proven virtual care services in fee-for-service (FFS) environments.
Supporting Virtual Care in Both Fee-for-Service and Value-Based Payment Environments
Though the health care payment system continues to shift from FFS to value-based payment models, most health care professionals will “live in both worlds” for the foreseeable future. Given this, it will be important to pay for and support virtual care across payment arrangements to enable the development of digitally enabled care models.
As noted above, it will be important for payers and policymakers to support long-term fair and equitable payment for clinicians to sustain virtual care services in FFS environments. In addition, as value-based models become more prominent, there should be significant flexibilities allowed for incorporating the full range of virtual care modalities (including those outside of video) into digitally enabled care models.
Insufficient Health Services Research Regarding Value of Virtual Care
Given the novelty of many virtual care modalities and the slow adoption of these tools prior to the COVID-19 pandemic, there is a lack of conclusive evidence regarding the clinical impact (e.g., quality and outcomes), financial impact (e.g., impact on total cost of care) and other impacts (e.g., impact on physician burnout) that virtual care capabilities generate with reference to specific contexts and care models. Further clinical and health services research is needed to establish and grow this body of evidence.
Policymakers should provide funding and support to organizations, such as the NIH Institutes and the Agency for Healthcare Research and Quality (AHRQ), to further define the value of virtual care across a range of environmental contexts, use cases and care models.
Limited Existing Metrics to Account for the Future of Virtual Care
A robust framework for measuring the value of virtual care should be based on measures that are tailored to the virtual care context. This will require adjustments to existing measures that were developed in relation to traditional in-person care delivery models and the development of new measures.
To further aid clinicians and other stakeholders in measuring the value of virtual care in the future, quality measure developers and stewards should consider updating and, where possible, streamlining these metrics to better measure the value of virtual care and recognize the massive shift toward this new mode of care delivery that has occurred recently.
Limited Ability for Physicians to Practice Virtual Care Across State Lines
A major attribute of virtual care is the ability to treat patients anytime, anywhere; to that end, virtual care can be a critical tool to address severe physician shortages in many regions of the United States. However, professionally licensed clinicians in most cases are limited to practicing in the state(s) where they are licensed. Policies governing telehealth and physician licensure vary widely across the country. Some states provide exceptions to allow for cross-border delivery of health care in limited circumstances, while others ban it entirely.
To better enable physicians to practice across state lines in the long term, states can consider joining the Interstate Medical Licensure Compact (IMLC), which offers an expedited licensing pathway for physicians who seek to practice in multiple states. In addition, policymakers can continue to seek solutions that enable physicians to practice across state lines safely and appropriately and in accordance with state oversight of physician licensure and telehealth.
Critical Need to Center on Historically Marginalized Patients in Design, Evaluation and Implementation of Virtual Care
Communities historically marginalized by the health care system, including Black, Indigenous, People of Color, Immigrant, LGBTQ+ and People With Disabilities, have experienced the perpetuation and exacerbation of inequities in their access to care and the quality of care they receive. It is critical to take an upstream approach to understanding the drivers of these inequities in access and quality, including technology device access, connectivity and poor usability. First and foremost, we must name and address the root causes of these inequities: exclusionary design that fails to center virtual care solution development on historically marginalized communities upfront, as well as the impact of systemic racism and oppression on resource allocation to marginalized groups that has resulted in inequitable infrastructure development and economic and social system exclusion.
To ensure that health equity is at the center of future virtual care research design, evaluation and implementation, health care stakeholders and advocates can take the following steps:
- Engage historically marginalized patients and innovators early, up front and often, and invite them to reframe the definition and assessment of the “value” associated with virtual care.
- Draw on community-provided data in order to present a comprehensive and holistic picture of the inequities in virtual care access and quality.
- Discuss and address the upstream causes that drive the inequities in virtual care access and quality.
- Provide a complete set of recommendations for policymakers, payers and other influencers of the health system to advance equity in virtual care at both the driver and upstream levels.
- In parallel with upstream-focused advocacy, address immediate social needs through collaboration with community-based services and resources (e.g., community health centers, YMCAs, libraries, community health workers), the technology industry, and other resource providers to support access to and use of technology and broadband connectivity.
- Highlight and support emerging innovations created by proximate leaders from marginalized communities focused on virtual care that centers on equity for those communities.