Delivered January 12, 2021

Thank you, Ann, for the kind introduction.

And thank you to the American Telemedicine Association for convening this remarkable virtual conference, on the future of virtual care.  Today is the first of four compelling days of discussion, happening every Tuesday for the next four weeks, on the telemedicine that has become so vital to the future of health and healthcare in the face of a global pandemic.

Today, I’ll briefly recount

• how far we’ve come in this virtual care revolution,
• consider what needs to be done to solidify these gains, and
• look to future challenges and make a few suggestions.

Dad’s Story

I begin with a story.  When I was a young boy about 8 or 9 years old, the telephone would ring in my parent’s bedroom – just next to mine — in the middle of the night, at least three, sometimes four nights a week.  You see, dad was a beloved doctor, trained in what was then still the young specialty of cardiology. At the time, there were few cardiologists in Tennessee, a rural state, and all of them, like dad, practiced in the bigger cities.

At 2 a.m., my dad turns over, answers the phone, calmly speaks with a nurse or a doctor in a small town 100 miles away, who tells him she is with patient with acute, chest pain — possibly a heart attack.

Dad places the phone on a clunky, antiquated device sitting on his bedside table, and a minute later, out flows a continuous strip of paper with an EKG scribbled along its length.  Dad makes the diagnosis, tells the nurse there is no evidence of ischemia, counsels her which medicines to give, and reassures the patient, their family, and the nurse. He goes back to sleep.

Dad, 60 years ago, was on the pioneering front of using telemedicine, using virtual care, using remote technology and monitoring, to connect to patients all over the middle third of the state.

In my own practice as a heart transplant surgeon, I used telemedicine extensively to manage the chronic immunosuppressive care of my heart recipients all over the country… for months after their transplants.

And as the only doctor in the Senate in Washington, I focused on the health of Native Americans on reservations.  We made major investments in programs establishing expensive T1 lines (remember this was before the internet) which allowed us to provide real-time telehealth to vulnerable populations in remote areas – to suffering patients who otherwise would have no access to care.

And today, as a partner and board member, I am heavily involved with Teladoc Health, Livongo, and a virtual dental care company, Smile Direct Club.

And in my 60-year journey with telemedicine, I have never been more optimistic about our future as I am today!

Recent history

We are at an inflection point. And inflections bring new challenges, and inflections demand changed perspectives – changed understanding, and changed behaviors on our parts.

The sheer scaling of telehealth services that took place across the country over the course of the pandemic has been astounding.   It’s said that ‘necessity is the mother of invention.’  The explosion of virtual care, I’d argue, is the single most transformative – and most constructive – advancement to emerge from the COVID-19 crisis.

Most importantly, the pandemic created a seismic shift in the culture of telehealth.  Before we – those of us together today — knew its power, its usefulness and potential – but others, patients, and doctors and hospitals, had been slow to adopt.

This culture of hesitancy, of doubt, of fears around privacy, of inadequate reimbursement, of the unknown was replaced by a culture of confidence and trust, a culture which values convenience, affordability, and rapid access to quality care.  All this in the safe environment of home, eliminating the risk of COVID spread.

The culture and use of virtual healthcare — delivered from a remote location by text, phone, or video – has been accelerated by five years or more.

• Washington-based Providence went from 700 video visits a month to 70,000 a week at the peak of the crisis.
• Pittsburgh’s UPMC saw video visits, which were averaging 20-30 a day pre-pandemic, grow to 6,000 a day at the pandemic’s height.
• Kaiser Permanente — which already had a relatively large telehealth presence with about 15% of scheduled outpatient visits conducted virtually — saw that figure skyrocket to 80% in the early spring.
• The Centers for Medicare and Medicaid Services (CMS) shared that between mid-March and mid-October over 24.5 million out of 63 million Medicare enrollees – more than a third – received a telemedicine service.
• And we at Teladoc Health have seen utilization stabilizing at a level 40 percent higher than before COVID.

Now, providers are planning and financially budgeting for a larger percentage of virtual care, between 10 – 30%.

With the culture change, providers are increasingly comfortable conducting virtual visits and are seeing the benefits. A recent American Medical Association survey of nearly 1600 physicians and other health professionals found that:

• 60% reported that telehealth has improved the health of their patients.
• 80% indicated that telehealth improved the timeliness of care.

Similarly, Americans are increasingly at ease with virtual visits, with one recent HIMSS survey showing:

• 77% of consumers willing to use some form of telehealth post-Covid, and
• 41% preferring to use telehealth to meet with at least one of their providers after the pandemic.

And with all this cultural acceptance, we are seeing the benefits, such as:

• greatly enhanced mental and behavioral health access,
• substantially improved patient convenience and experience,
• improved patient adherence,
• and expanded reach to regions with provider shortages … to name just a few.

Recent Policy

So how do we not lose the gains made when this public health emergency comes to an end?

I think all of us recognize that this rapid progress was made possible by emergency regulatory measures that speeded access and reimbursement for telehealth services — making physician adoption feasible, and removing traditional bottlenecks in administrative decision-making.  These included:

• Medicare payment parity — something many private insurers also adopted
• Waiving Medicare geographic restrictions
• Expanded Medicaid coverage, including coverage of audio-only care
• Expanded covered providers – with CMS adding 144 additional services to be furnished via telehealth
• Relaxed physician interstate licensure – waiving Medicare and Medicaid’s requirements that practitioners be licensed in the state where they are providing services
• Relaxed HIPAA data privacy rules, allowing providers to use non-HIPAA compliant telehealth platforms, like FaceTime and Skype.
• And private insurers following the federal government’s lead by waiving cost-sharing and expanding telemedicine programs.

The Centers for Medicare and Medicaid Services, the Administration, and the private sector should be commended for responding so quickly and so comprehensively to meet the rapidly changing needs of our healthcare communities during the pandemic.

But now we must make these gains permanent.

I know many of my former Congressional colleagues – Democrat and Republican – are in favor of doing just that. I had hoped to see more of these policies included in the year-end spending and Covid-19 relief package.

And some were added:

• Increasing funding for the Federal Communications Commission’s telehealth work and expansion of broadband, and
• Medicare coverage for tele-MENTAL health services.

But I agree with Ann Mond Johnson that, “the noticeable lack of permanent reform or a guaranteed extension of the telehealth flexibilities in this relief package is disheartening for the millions of Americans who relied on telehealth to access care, and our healthcare providers still on the frontlines of the pandemic.  We believe arbitrary restrictions on telehealth must be permanently removed to make way for a modernized and more accessible healthcare system.”  Ann and the ATA are spot on.

Proposed policies for the future

So where will we go from here?

I served 9 months in an equally split, 50 to 50, Senate.  With a razor-thin Democratic majority in the Senate that is vulnerable to filibuster, I’m frequently asked where we might see bipartisan agreement in health policy in 2021.  Telehealth is unquestionably at the top of that list.

To continue this progress,

• we need to permanently allow telehealth access regardless of patient and provider location,
• we need to codify the broader range of practitioners — such as physical therapists, occupational therapists, and speech language pathologists – to provide Medicare telehealth services.

Federally Qualified Health Centers and Rural Health Clinics—community-based health care providers that support underserved populations—should be authorized to continue to offer telehealth after COVID.

Congress should also address cross-state licensing barriers – a more challenging area to navigate.

And with reimbursement, treat all forms of communication equally, if providers can meet the same standards of care.

While the Administration has done a good job, there is a risk that broad telehealth deployment—if not carefully designed—could replicate the barriers of the traditional bricks and mortar health system that produce disparities.

One glaring example is a bias in some of the new authorizations for two-way video communications. If we discriminate against telephone (without video) users, for example, we will leave behind:

• rural communities without access to broadband, as well as
• minority and other lower-income populations that may not have more expensive smart phones with two-way video capabilities.

Finally, while I believe most regulatory changes made to advance telehealth and virtual care during these extraordinary times should be made permanent, parity in payment is one that should be revisited following the crisis. Undoubtedly, payment parity was necessary to motivate physician participation. But since many overhead costs are eliminated in virtual transactions and thus result in overall cost savings, these savings should flow to the patient as well as the provider.

Challenges for the future

Looking to the future, it cannot be denied that the culture of health delivery is radically shifting.  Some will say 2020 was the year that changed everything, but in reality, 2021 will be.  It will be this year when we will find out what has staying power … what will truly be our new healthcare reality.

So, inflections bring challenges: how can you best prepare for them?

1. Digital: Devote 15% of your budget to a digital backbone.  Capture and claim this coalescence of digital and telemedicine.  This is your opportunity to fill the digital infrastructure gaps in the patient journey. Telemedicine pre-Covid moved at the snail’s pace of traditional doctor-patient interactions. That is the past. 2021 and the future will require you understand – and assimilate — with true digital health, which moves at the speed of computers.
2. Integration: Telemedicine, in the past, was much about automation – today it’s about integration –– of the entire patient experience. And not just at a point in time, or over the course of an acute illness – but longitudinally over the course of chronic disease, and even a lifetime.

An example:  In August, Teladoc acquired chronic care management platform Livongo. The whole purpose was to provide “whole person” care that will change how customers access care over time. It brought together Teladoc’s traditional telehealth platform with Livongo’s longitudinal digital coaching services, using data for greater insights about a person’s health. Allowing more “wholistic” and more seamless care.

3. Partner: Partner with health systems.  Health systems are today highly motivated to incorporate telemedicine.  Their goal is to intelligently orchestrate digital demand and health system capacity across all lines of care, using virtual health/telemedicine to do so. You must insert yourself in that process and claim the ground.  Be an inextricable part of the solution. A solution of value-based care.

And partner with the new care delivery models.  2021 will be the year of an exploding number and variety of new care delivery models aimed at the home.  For example, two of my companies, Aspire Health and Ready Responders grounded their home-centeredness on telemedicine – the first, in community-based palliative care and the latter in urgent care delivered in the home.

4. Interoperability. Align yourself with interoperability, so all the information traditionally surrounding a physical visit is digitally – or instantaneously – accessible and shareable in the virtual space. Be an integral part of the newly created seamless digital backbone for all interactions – in-person and virtual — by devoting resources to interoperable information technology, machine learning and big data.
5. Continuous patient engagement. We can make diagnoses and we can monitor, and we can treat.  But if we do not engage the patient over time, it means nothing. Telemedicine must move beyond just a physician on a video, or a nurse on the phone.   Otherwise, we are just a commodity, and the world will treat us as a commodity.

You will need to incorporate disparate data sets and use computer learning and artificial intelligence to streamline the patient experience.  Today’s patient journey is discontinuous and fragmented and chaotic and nonlinear. It is frustrating. It is characterized by inefficient front-end access, lack of individualized care navigation.

Telemedicine cannot just be the endpoint to which a patient is referred – it must be an integral part of the triaging of patients to the appropriate setting across any line of care or business based on health care needs, insurance/coverage financial situation and health system capacity.

6. Standards of care. We need to answer questions, and create standards of virtual care, that establish what is the right mix between office visits and virtual visits for various health conditions and care bundles. The lack of published research on which clinical circumstances command in-person attention and which cases are appropriate for a virtual visit warrants attention. For example, we do not yet understand how a patient’s demographic and medical history impact their optimal cadence of face-to-face visits versus virtual visits.

These are all questions we together much tackle as we move forward into the next frontier of virtual care.

Thanks, and opportunity

To all of you, thank you for your tireless efforts to find new ways to innovatively, and safely, care for Americans in this time of pandemic.

In this moment of crisis lies a crucial opportunity to build a stronger and more resilient healthcare system – a system that is value-based and centers on the patient journey.

We saw what telehealth can do in terms of getting much needed care to patients outside of the hospital setting.

We saw how quickly it can be ramped up and accelerated within health system settings.

And perhaps most interestingly, we saw how the removal of antiquated regulations, such as the permission to allow access regardless of patient and provider location, can open the way for greater accessibility.

We should not let these gains be rolled back when this public health emergency comes to an end. With an eye towards quality, value, and enhanced patient experience, we can use this opportunity to usher in the health care systems of the future.

Joining your voice with the American Telemedicine Association and other health systems and providers to let our lawmakers know the value clearly and consistently you have seen play out in real time on the frontlines will be essential to getting telehealth policy right.  It will ensure it continues to be a bipartisan issue … and a continual drumbeat for action will make clear the urgency of making these advances permanent.

Thank you again to the American Telemedicine Association for allowing me to kick off the EDGE Policy Conference this morning.

Lastly, if you have questions for me, please post them to Disqus, the Edge comment tool that you log in and access from my session page and I will be following up later this week with my thoughts and feedback.

Thank you again.

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Senator William Frist, MD, is a nationally recognized heart and lung transplant surgeon, former U.S. Senate Majority Leader, founding partner of Frist Cressey Ventures and chairman of the Executives Council of the health service investment firm Cressey & Company. He is actively engaged in the business as well as the medical, humanitarian, and philanthropic communities. 

Twitter: @bfrist

Facebook: @SenatorBillFrist

LinkedIn: @billfristmd

Instagram: @senatorbillfrist

Editor’s Note: Access to Senator Frist’s session and ability to connect via Disqus is only open to ATA EDGE Policy Conference Registrants. For full access to Senator Frist’s opening keynote and the conference program, please visit ATAEDGE.ORG.