Reimbursement and financial considerations for Telehealth
Reimbursement for telemedicine has been challenging and tends to be fragmented depending on type of care provided, patient location and type of medical care insurance. The Centers for Medicare and Medicaid Services historically had a narrow definition for telemedicine for purposes of reimbursement as requiring a two‐way, real‐time interactive communication between the provider and a patient at a distant site, but that is changing with expansive new regulations issued in 2019 that broaden the definition and potential for reimbursement [31]. While historically, payment was only provided for synchronous telemedicine visits, Medicare/Medicaid is expanding coverage to asynchronous visits (store‐and‐forward) and other types of telehealth, which may pave the way for private payers who often follow suit. One problem to consistent reimbursement is a lack of statewide policies that cover synchronous, asynchronous and remote patient monitoring services, and a lack of policies that dictate reimbursement of telehealth services at the same rate as similar care delivered in‐person [13].
Though standard and consistent reimbursement are critical for a successful telehealth program, other financial considerations need discussion. One of the primary patient benefits of telemedicine is the cost savings for travel, food and accommodation at the site of care, especially for patients from remote rural areas or from long distance (i.e., Hawaii, Alaska). This cost savings to patients may result in a willingness to pay out of pocket for telehealth if the patient total travel cost savings with telehealth are greater than the cost of in‐person care. Additionally, healthcare systems may be willing to subsidize telehealth as a mechanism for bringing more patients into their system and potentially increasing the volume of in‐person care [18]. Telehealth programs that provide consultation between specialists and community generalist providers have been shown to benefit patients and reduce cost [5]. In a study to understand the factors common to hospitals that offer telehealth, the authors found that in competitive markets, telehealth is a way to distinguish the hospital from others in the region. Another important result of this study, albeit not surprisingly, was that more hospitals adopted telehealth in states where private payers are required to reimburse telehealth services at the same rate as in‐person services [24].
Challenges to Telehealth adoption
Despite the known benefits of telehealth, many barriers exist to its adoption by healthcare organizations and systems. Some of these barriers relate to a perceived lack of resources such as financial cost to set up a telehealth program and the technology required for remote clinic visits or transfer of diagnostic data with an unclear return on investment (ROI). Indeed, telehealth outcomes are, by nature, difficult to measure and few traditional cost‐benefit analyses have been done [12]. Some of the reported barriers about the perceived burden of telehealth are related to human factors, such as the extra work required by providers who may lack familiarity with telehealth and its related technology and thus become resistant, or privacy concerns about patient health information being shared remotely. A recent telemedicine intervention for shared survivorship care for childhood cancer survivors between oncology and primary care reported the service was beneficial overall to providers and patients, but the technology glitches and extra time needed were frustrating for all parties [32]. Some of the barriers are regulatory or legal in nature with concerns about credentialing and licensing across state lines and potential liability for care delivered via telehealth. Some of the barriers are related to unclear evidence for outcomes and a lack of willingness to invest in programs that do not have easily measured metrics to share with the institutions’ decision makers [15,26]. Reimbursement of providers delivering care via telemedicine is critical and remains one of the major obstacles for implementation of a successful telehealth program [13].
One important way to overcome barriers for adopting a telemedicine program is to invest in the development of outcome measures for telehealth. Providing the evidence that telemedicine significantly improves patient outcomes is key to convince organizational decision makers to develop a telemedicine program, and the argument would be even stronger if improved patient outcomes are seen without taxing the financial resources of the institution. Outcomes evidence that supports telehealth can also lead to better reimbursement, increased willingness of providers to engage in this healthcare delivery model and patient acceptance of telemedicine care. The National Quality Forum has developed a framework to support measure development in telehealth and can be used as a model for telehealth outcomes research. The framework includes the following domains: access to care (for patient/family/caregiver, care team, to information), financial impact/cost (to patient/family/caregiver, care team, health system/payor, society), experience (patient/family/caregiver, care team, community), and effectiveness (system, clinical, operation, technical). By using a standardized framework for outcomes measurement, telehealth outcomes will make a case for further program development [17].
What we know about current models for hct survivorship
In the US alone, there are approximately 180 transplant programs. These centers are unique in several aspects: number of transplants performed per year, the type of transplants performed, the type of institution performing the transplant, the geographic area served by the transplant center, the socioeconomic status of the population served, as well as the existence of a LTFU transplant survivorship care clinic or not. All these factors contribute to outcome differences reported among the centers.
In a recent survey of 200 HCT transplant programs in the US and Canada, among the 77% that responded only 45% indicated the presence of a dedicated LTFU clinic [33]. Most programs with an established LTFU clinic reported benefit in regards to delivery of preventative guidelines for surveillance and management of late transplant effects care as recommended by the American Society of Blood and Marrow Transplantation, currently named as the American Society of Transplantation and Cellular Therapy (ASTCT).
A survey of 441 HCT survivors in Australia found that 62% of them preferred a single provider for their LTFU care rather than a shared‐care model [22]. Furthermore, most of these survivors preferred having their transplant physician, rather than their local hematologist or general practitioner, to provide their LTFU care. When asked about preferences for the location of LTFU care, 74% preferred follow‐up at the transplant center or through a satellite clinic closer to their home attended by the transplant physician (27%) or through telemedicine service linked to the transplant center (21%). In this study, survivors preferring telehealth in LTFU care tended to have higher educational status, increased sexual morbidity, and participated less in exercise (possibly reflecting less motility).
In other studies, a dedicated, multidisciplinary LTFU clinic appeared to be associated with improved overall survival [34] and overcame the adverse impact of geographic distance from the transplant center to the patient’s residence [35]. This is significant as previous studies showed that rural residence and long driving distance was associated with worse survival following autologous [36] and allogeneic HCT [37].
Access to a dedicated, multidisciplinary LTFU clinic would appear optimal for all transplant survivors, but this is