“What happens when there is a massive shift of where the beginning of a journey occurs…that sort of affords the opportunity for everyone after that to be disintermediated.” So says Zachariah “Z” Reitano, co-founder & CEO of Ro, arguably one of the most successful OG virtual-first care companies which has been providing telehealth-plus-testing-plus-pharmacy-delivery (and now a whole lot more) via its Roman and Rory brands since 2017.

As health tech companies – and now, more and more incumbent orgs and retail health providers – evolve their own “omnichannel” strategies, we talk to Z about Ro’s direct-to-patient care model, and what we can learn from its successful operation and expansion as one of the first “digitally native” healthcare providers.

To Z, the technology is just an enabler to a larger shift in how people are ultimately gaining more control over their health. Technology can turn luxuries into commodities, he says, and, at Ro, that’s translating into a concept they’re calling “goal-oriented healthcare,” which is basically providing the “luxury” of giving a patient what they want, when they want it; easily, conveniently, and affordably.

In short, Z explains: “Patients come to us, and they say what they want to achieve: ‘I want to lose weight…I want to have a child…I want to improve my mental health…I want to improve my skin…I want to have better sex.’ And then, we help them from beginning to end in the most convenient and effective way possible.”

The role of digital in all this is critical. It allows for costs to be stripped out, for providers to be able to practice at the top of their licenses, and for data to be shared between provider and patient asynchronously (aka conveniently.) But, it sounds like what’s most exciting about ‘virtual-first’ to Z is the “first” part – having the opportunity to initialize the relationship with the patient, then “raise the standard of where we guide people afterwards, and have the opportunity to disintermediate and really heavily influence the entire patient journey.”

Oooohh – can’t hear enough about this! Tune in to find out more about how Z sees virtual-first care as changing patients’ relationships with the healthcare system AND, because we had to talk a little policy too, get his thinking on how barriers like state licensure that are often looked at as constraints to ‘virtual care at-scale’ might also be evolving to help enable that shift.

* Special thanks to our series sponsor, Wheel – the health tech company powering the virtual care industry. Wheel provides companies with everything they need to launch and scale virtual care services — including the regulatory infrastructure to deliver high quality and compliant care. Learn more at www.wheel.com.

Thirty Madison and Nurx are merging and here’s what Steve Gutentag, CEO of Thirty Madison and the soon-to-be-combined entity, is saying about the deal!

This is a merger of two well-funded, direct-to-consumer, virtual-care-plus-pharmacy startups that deliver specialty and expert care and prescription drugs to a combined 750,000 active patients, with or without insurance. To-date, Nurx has raised a total $110 million, and Thirty Madison closed a Series C in June 2021 that brought their total funding to $210 million with a then-valuation of over $1 billion.

Thirty Madison currently deals with migraines, allergies, GI issues, and men’s hair loss, while Nurx (once referred to as “the Uber of birth control”) brings a predominantly women’s health-focused portfolio of chronic condition care focusing on sexual health, contraception, STIs, and dermatology.

So, what makes sense about this combination? And, what’s the big-picture plan for differentiation against rivals like Hims&Hers or Ro’s Rory or Roman brands – OR, the myriad virtual-first primary care clinics that have popped up in-person and online and offer more traditional routes to care for these same such conditions?

Steve talks extensively about the chronic care focus of both businesses, how each is providing access to specialists and experts patients wouldn’t otherwise be able to see, and how both companies’ tech platforms are built to scale along with the addition of new conditions. Still…why bring together care for this assortment of conditions instead of, say, either Thirty Madison or Nurx looking to find a merger partner who could expand their platform into high-demand chronic care areas like diabetes management, heart health, or mental health care? Is that what’s next, after the paperwork on this merger is signed? Tune in for more on Steve’s plans for the future of the NEW Thirty Madison and how “longitudinal care models” factor into its strategy to win over more patients AND their employers and payers.

By JON BLOOM

The rate of adoption for virtual care and remote monitoring solutions has skyrocketed over the last year as access to in-person appointments has been limited, but despite the uptick, we’re still drastically underutilizing their potential. These solutions often focus on treating a singular episode or chronic condition, when in fact they can open the door to more wide-ranging proactive monitoring and care that can have huge benefits in the long term. 

By simply offering a touchpoint for patients to interact with the health care system through solutions like remote monitoring, providers can detect and address all sorts of problems before they escalate and require more intense, expensive interventions, even if the problem isn’t related to the primary purpose of the solution. 

The downstream effects of these solutions are significant, both in terms of reducing the financial strain by eliminating unnecessary ER visits and hospitalizations, and in the long-term patient outcomes that are improved by catching problems early. 

For example, a study from October we conducted with the Mid Atlantic Permanente Group found that one prevention program for patients at risk of diabetic foot complications also saw reductions in all-cause hospitalizations by 52 percent and emergency department visits by 41 percent. Despite the fact that the subject solution was originally designed specifically to help prevent diabetic foot complications, the touchpoint was able to have a profound impact on overall health and total cost of care. 

This follows previous research on other condition-specific remote patient monitoring solutions that showed similar reductions in all-cause hospitalizations and mortality, further supporting the idea that these solutions can have broader impacts than just helping treat the condition they’re designed for. 

These findings are especially significant considering many of these solutions, like the one studied in the October research, are often deployed to underserved populations who tend to be less likely to schedule care on their own, whether that be for a well visit or because they’ve noticed a change in their health. By putting devices in their homes and removing the burden of seeking care, we can move toward a future in which patients are able to get the care they need even if they don’t know they need it or don’t know how to get it. 

Consider, for example, a patient who lives in a rural area far from their doctor, or one who may lack transportation, or have limited mobility. Regular tracking of any of their chronic conditions can be made much easier with telehealth or remote monitoring. And these check ins are often critical in catching potential problems early, whatever they may be, so they can be treated with simpler, lower-cost interventions. 

As we look to the years ahead and ways we can repair the health care gaps the pandemic has further unearthed, we should focus on expanding the types of virtual solutions that can have benefits well beyond simply addressing singular issues. One of the “miracles” of digital health is expanding known care models to patients previously unable to use them. To have these broad effects, the important thing is not necessarily what’s being measured, but that the care model is so easy to use that patients can sustain long-term engagement. There are two ways this improves outcomes: the first is that patients who use one healthy regimen regularly are more likely to adopt other healthy regimens, e.g. walking more often or taking medications as prescribed. The second is the creation of a new high-quality relationship, which can help to reveal problems outside of what is specifically monitored.

The global pandemic has provided many lessons about how we can do health care better in the future, but relatively few solutions can be implemented with technology that already exists, helps dramatically cut costs, and improves outcomes for huge swaths of patients in need.

Dr. Jon Bloom is a board-certified physician and CEO of Podimetrics, a care management company with the leading solution to help prevent diabetic amputations.

It’s the telehealth market reality check you’ve been waiting for! “Rogue” digital health consultant Dr. Lyle Berkowitz unpacks the numbers and the market potential for virtual care from the unique vantage point of a primary-care-physician-turned-health-tech-entrepreneur with nothing to lose. Having been 1) a clinician, 2) the Director of Innovation at Northwestern Medicine, 3) the founder of a health tech startup (Health Finch) that successfully exited to Health Catalyst, and 4) the former Chief Medical Officer at one of telemedicine’s biggest players, MDLive, few can boast such a wide-reaching, deep understanding of the inner workings of both the innovation and incumbent sides of the virtual care market — AND have a willingness to talk about it all with complete candor!

This is an analyst’s perspective on the telehealth market — with a twist of insider expertise — so expect to hear some good rationale behind predictions about how much care will remain virtual once hospitals and doctor’s offices return to normal, how “real” health system enthusiasm is for building out telehealth capacity to execute on the “digital front door” idea, and whether or not all these well-funded telehealth startups will have what it takes to win market share from traditional care providers.

BONUS on Primary Care: Is this the area of medicine that’s going to be the “battleground” where digital health and virtual care companies will be going head-to-head with incumbents for market share? Lyle says 50-plus percent of primary care “can and should be automated, delegated, virtualized, etc.” and boldly predicts that in 10-20 years we won’t even have primary care physicians anymore. Tune in to find out why starting at the 8:00 minute mark, where we shout out Crossover Health, Oak Street Health, Iora Health, and more.

Telehealth die-hards, don’t think for a second I’d miss this chance to also get some input on Teladoc-Livongo, Amwell, Doctor On Demand, SOC Telemed, the impending IPOs there, digital first health plans, virtual primary care, health systems (who Lyle hopes “don’t shoot themselves in the foot” with their opportunity to jump into the space) and, ultimately, who’s really going to ”WIN” in virtual care moving forward. For this, jump in at 17:00 minutes and hold on!

By JULIA HU

Though it will be impossible to overstate the devastation that the COVID-19 pandemic is leaving in its wake, we can also acknowledge that it has pushed humanity to creatively adapt to our new, socially-distanced reality—necessity is the mother of invention, as they say. Telehealth is not a new invention, but the necessity of keeping people physically apart, especially those particularly vulnerable to COVID, has suddenly put virtual health care at the center of our delivery system. 

Patients and providers quickly pivoted to at-home care as in-person visits were limited for safety, and use of telehealth spiked early in the outbreak. One survey of over 500,000 clinicians showed that by April—only about two weeks after the first stay-at-home orders were issued in the U.S.—14 percent of their usual number of pre-pandemic visits were being conducted via telemedicine. For many, that involved using unfamiliar technology and a big shift in procedures for providers. Congress recognized the need to support providers through this transition and allocated $500 million for waiving restrictions on Medicare telehealth coverage as part of the emergency funding bill that passed in March. 

But, as restrictions have begun to lift and hospitals and medical offices are beginning to reopen for non-emergent care, we have seen the use of telemedicine start to taper off. The same 500,000 clinicians were surveyed  in June, revealing that telemedicine was used for only 8 percent of the usual pre-pandemic number of visits. Providing quality, virtual health care won’t be as easy as flipping a switch, but we currently have an unprecedented opportunity to carry forward the best version of virtual care and create a more holistic health care system. As we work toward that goal, there are three components our virtual care system needs in order to be sustainable, feasible, and manageable for both patients and providers. 

Patients and providers need a range of services to be available virtually. 

When people talk about virtual care and COVID-19, they are most often referring to a telemedicine experience where a patient interacts with a provider through some type of video conferencing. Those visits are extremely useful for conducting certain types of appointments, including dermatological exams, triaging symptoms to determine best next care steps, and counseling or therapy appointments. 

But, not every virtual care interaction needs to include a video visit with a provider. Asking physicians to keep up a full schedule of virtual visits as they simultaneously work to safely reopen their in-person practices is unreasonable. Physicians are already experiencing some of the highest rates of burnout of any profession, and COVID-19 has only exacerbated that trend. 

Some virtual care, including certain check-up visits or assessments, can be conducted telephonically, giving more flexibility to both patients and providers when video conferencing is not needed. Digital health coaching tools offer another type of virtual care that can help relieve providers from some of that burden by managing patients’ routine care needs in-between either telemedicine or in-person appointments.

This is especially true for chronic condition prevention and management, which requires 24/7 support. Digital coaching can be available at any hour, outside of a physician’s normal 9-5 schedule. It also can help manage symptoms for certain behavioral health issues related to stress or anxiety. 

We need to carry forward the full suite of services that virtual care can provide. This will help physicians better manage their caseloads, give patients access to a variety of services right from their homes, and build more flexibility into our entire delivery system.

Our virtual care system should embrace Remote Patient Monitoring Tools with connected devices.

Remote Patient Monitoring (RPM) allows both patients and providers to access real-time monitoring of key biometrics, such as blood glucose for a patient with diabetes, blood pressure for someone with hypertension, or weight for someone with heart failure. RPM typically uses a connected device, such as a glucose monitor or a blood pressure cuff, that records and sends data. 

RPM benefits physicians by providing them with up-to-the minute information about their patients, alerting them when biomarkers indicate potentially serious issues, and helping them manage their patient population without having to conduct telemedicine or in-person visits. Because RPM is reimbursable through Medicare, it can also help drive revenue for practices, an especially important component for those struggling financially because of reduced patient volumes due to COVID-19.

RPM also benefits patients. It helps ensure that their care is being personalized to their unique health situation, and allows for quick identification and intervention of possible acute or emergent issues. By accessing RPM data, patients can also better understand how their behaviors impact their health. 

Incentive structures, including reimbursement policies, need to be aligned to support these virtual care models.

To sustain quality, virtual care beyond the pandemic, we need to align incentive structures to support its continued adoption. There is much agreement, including among Members of Congress and CMS leadership, that some of the Medicare restrictions on telehealth that were loosened to address the COVID-19 crisis should be permanently extended. Key among them are: allowing providers to provide virtual care across state lines, expanding Medicare and Medicaid reimbursement for a wider breadth of virtual services, and allowing doctors to conduct virtual visits using familiar technology, like FaceTime or over the phone.

Without the certainty that virtual care services will be adequately reimbursed, there is a risk that many physicians will abandon investment in the technology needed to provide those services. We need to act now to make sure that doesn’t happen, and that virtual care becomes an integral part of our larger delivery system moving forward. 

We also have a unique opportunity in this moment to shape our future virtual care system with value-based principles in mind. Aligning incentives between quality and cost can help ensure that virtual services meet the needs of patients, while helping reduce the overall cost of care.

Virtual care will remain especially important as our country continues to face rising COVID-19 cases, giving us the window of opportunity to cement quality, virtual care as a permanent piece of the delivery system. The benefits of building a more holistic system that weaves together virtual and in-person care will extend far beyond the current pandemic. From increasing access for patients, to filling critical gaps in care, to helping providers prioritize their caseloads—virtual services can help shape a better system. But we must act now to bring that vision to life.

Julia Hu is the Founder and CEO of Lark Health.

Imagine three months from now when the predicted ‘second wave’ of COVID-19 is expected to resurge and we’re still without a vaccine. Telehealth has become the entry-point to care, widely adopted by patients both young and old. Now, when an elderly diabetic patient wakes up in the middle of the night with a dull ache on her left side and back, she doesn’t ignore the symptom, like she may have during the first COVID outbreak. Instead, she logs online to her local hospital’s website from a cell phone and accesses a simple questionnaire to report her health history and presenting symptoms. The whole process takes just a couple of minutes and she immediately hears back from her health provider with the suggestion to schedule an in-person appointment for further testing to rule out any kidney issues. 

This patient doesn’t become one of the nearly 50% of Americans who delayed care during the initial COVID pandemic. She was able to access care without having to download an application or wait to schedule a virtual appointment during normal business hours. She receives virtual asynchronous care on-demand, coordinated to sync with her electronic health record. The next day, she receives a follow-up call from her primary care doctor to ensure her symptoms were alleviated with the over-the-counter pain medication she was prescribed. 

I applaud the article written by Paul Grundy, MD, and Ken Terry, “Primary Care Practices Need Help to Survive the COVID-19 Pandemic,” in which they called on Congress to make health policy decisions that will provide immediate financial relief for primary care practices. We must mitigate the real risk we face: the highly possible shutdown of our healthcare system. Amid the coronavirus pandemic, the U.S. healthcare system has taken an enormous financial hit and primary care practices have been especially affected and are struggling to survive. As the authors point out, telehealth has taken the spotlight to fill the acute need for an influx of patients needing to access care under social distancing practices. Telehealth can increase access to care, relieve provider burden, reduce costs to systems, and improve patient outcomes. However, this is only possible with on-demand telehealth, or asynchronous care. 

If COVID-19 has a silver lining, it is that forced social distancing has accelerated telehealth adoption by as much as 20 years, according to Deloitte. And while no one is certain when or how the crisis will end, one thing is abundantly clear: widespread use of telehealth is here to stay. Or, as CMS administrator Seema Verma said, “The genie’s out of the bottle on this one.”

That said, in the rush to implement telehealth solutions, CMS and many providers—failed to include asynchronous virtual care as a viable alternative to in-person care. Now though, we have the opportunity to develop a more thoughtful strategy going forward––one that can brace our system at a time when it needs the support.

First, we must establish a broader definition of “telehealth” that includes modalities other than video visits. Non-video forms of virtual care also deliver value for both patients and providers. In some cases, they may go further than video can to increase access and affordability and to protect a patient’s continuum of care. 

Take asynchronous virtual care delivery, for example. 

According to the FCC, approximately 21 million people lack broadband access, which makes video-based telehealth unavailable to large portions of the U.S. Asynchronous telehealth solutions don’t require high-speed internet or even a 4G mobile connection to deliver care. The store-and-forward nature of these platforms means very little data is required to exchange the crucial information needed to provide a complete episode of care.

Asynchronous telehealth platforms that fully integrate into clinical workflows ensure a patient’s electronic health record is intact. This is especially important during times of crisis when a patient seeks care remotely to avoid possible infection. If he or she receives care that isn’t reflected in their record, important information is lost and can impact the quality of care they receive in the future.

Because store-and-forward telehealth platforms boost clinical efficiency by saving provider time over in-person or video visits, they provide cost savings for all involved—healthcare systems, payers, and patients. When some of those savings are passed on to patients, reducing their overall out-of-pocket costs, those patients are less likely to avoid care due to financial concerns that include the threat of surprise bills.  

It is likely, if not inevitable, that how patients access care has been changed forever by COVID-19. Telehealth will continue to play a major part in how patients get care, but virtual care has much more to offer than video visits. Regardless of the modality, if a provider is able to deliver an episode of care that is held to the same standard and quality of in-person care, that visit should be reimbursed at a level that is fair to all parties involved. 

CMS has a real opportunity to help strengthen our injured healthcare system. In addition to patients who have access challenges, providers and systems are struggling financially. If patients put off visits because securing a video or in-person appointment is a challenge, we are going to see fewer ambulatory and non-acute patients, which has an immediate financial impact on systems and could lead to more chronic and emergent conditions that could have been avoided. 

Now is the time for Congress to take action and adjust the CARES Act to include ALL types of telehealth solutions, including virtual care like asynchronous telehealth, and to compensate providers for using it accordingly. These telehealth policy changes should be permanent – our new normal. Perhaps then we will look back at the COVID era as a pivotal time in our nation’s history when healthcare changed for the better. When we considered new entry points to care that are effective, reduce burden on clinicians, and offer more immediate care beginning with triage for patients. It’s the silver lining in this cloudy mess. 

Ray Constantini, MD is the CEO and Co-Founder of Bright.md.