About 25 years ago, two physicians coined the term “hospitalist” to refer to a doctor who focuses largely on inpatient care. Given the explosive rise of telemedicine over the last six months, some say we’re at the dawn of another new medical field: that of the “virtualist.” And despite the volume of unanswered questions about the move to virtual healthcare, telemedicine provider Teladoc Health’s $18.5 billion megadeal to acquire diabetes coaching firm Livongo just might hasten the arrival of this new era.
“Through this coordinated effort with Livongo, we believe that we are going to be able to deliver a focus on whole-person care going forward,” said Dr. Lewis Levy, chief medical officer for the combined company, now known simply as Teladoc.
“Whole-person care” is Teladoc’s terminology for a comprehensive, multidisciplinary brand of virtual care that includes everything from ad-hoc primary care by board-certified physicians to long-term chronic disease management by health coaches to physical therapy and mental health services.
The deal helps Teladoc broaden its portfolio to provide that breadth of health support, while Livongo’s coaching sessions gain reach courtesy of Teladoc’s 70 million international customers. Billed as a “merger” when it was announced last month, the cash-and-stock arrangement actually gives Teladoc a 58% stake in Livongo. Considered a blockbuster by digital health standards, the deal’s value is significantly higher than any other seen in digital health to date, per venture fund Rock Health.
Levy spoke this week to physicians at Mount Sinai’s Icahn School of Medicine as part of a virtual lecture series, organized by the school’s master of science program in healthcare delivery, about designing a hybrid care model for the post-COVID world.
It’s entirely possible that in-person care may become an outlier within that model, or at least not the default anymore. This could happen as the medical establishment begins flipping the typical question of “which type of medical situation is appropriate for virtual care?” to “which type is fitting for in-person care?”
“Rather than responding, ‘Well, what do you mean, appropriate for in-person care; wouldn’t that be everything?’ I don’t think so,” Levy explained. “Going forward, people will definitely start asking the question, ‘Why does this person need to come in? And is this really making the best use of the provider’s and the patient’s time in terms of the outcomes that we’re looking to achieve?’”
During the pandemic, people avoided the doctor’s office to prevent transmission of the virus, and physician office visits subsequently fell by as much as half. Meanwhile, remote engagement – once an unattractive afterthought for many HCPs – skyrocketed among providers, as health systems promoted video visits as alternatives to in-office ones and health plans lowered co-pays to make such visits more affordable. For their part, federal officials expanded Medicare coverage for virtual visits and smoothed out regulations for interstate licensing.
Many studies have suggested that, long after the crisis subsides, telemedicine will remain a fixture of the health system. The question is: To what extent? While doctors say they’re not automatically assuming brick-and-mortar to be the norm anymore, those familiar with both insist that the care model of the future is definitely not moving toward an all-or-nothing proposition.
“It’s important not to think of virtual care as an and/or to in-person care because it’s not an apples-to-apples comparison,” cautioned Dr. Tania Elliott, former medical director at telemedicine provider Doctor on Demand and an associate attending physician at NYU Langone Health. “The ideal patient care experience should be a seamless transition from virtual to in-person with clinicians who have visibility into your whole health picture.”
Virtual care, Elliott added, helps to remove much of the “friction” related to care access, allowing for more frequent touchpoints with the patient. And exclusively virtual care provider groups like Teladoc seem “well-positioned” to interact with patients for an expanded, complementary scope of services, from wellness to counseling to chronic disease management.
“It is important, though, to ensure that these groups also create a partnership with other clinicians on the patient’s care team and have visibility into other services that the patient may be receiving,” Elliott urged. “Otherwise, they run the risk of redundancy and healthcare fragmentation.”
Consumers seem to prefer a mixture of bricks and clicks. According to a McKinsey & Co. report issued in May, 76% of consumers are now interested in using virtual care, as compared to 11% prior to COVID-19. Along those lines, 33% would leave their current physician for a provider who offered telehealth access, per an April survey by Sage Partners.
Teladoc’s own data, shared during a September investor presentation, show that nearly two-thirds want a virtual-care doctor to partner with their existing in-person doctor. Levy echoed the need to integrate services and to find a balance between virtual and in-person care.
“We’re working on how to really make these worlds come together in a meaningful way, in a cohesive patient experience, and in a way in which medical information is interoperable so that we will not have virtual care be a siloed part of one’s overall healthcare journey but an integrated solution with the rest of the individual’s care,” he said.
“The ideal mix of in-person and virtual care will evolve,” added Dr. Francoise Simon, a senior faculty member in Icahn’s department of population health science and policy and professor emeritus at Columbia University Business School, who moderated the lecture. “That may be very specific to different therapeutic areas.”
More research needs to be done on this front. Levy referred to recommendations issued this month by the NCQA Taskforce on Telehealth Policy, whose windup was that telemedicine is a bona fide modality of care – the “natural evolution of healthcare into the digital age” – and not just another type of care or benefit. As such, it demands the same standards and quality measures as in-person care.
“The story is more complicated than just simply thinking of telemedicine as convenient care,” explained Levy. “It really is care that is being rendered in a safer environment for the individual.”
Moreover, the NCQA taskforce has argued that systematic reviews confirm that telehealth improves health outcomes, utilization and cost of care for many chronic diseases. For nonurgent complaints in primary care settings, diagnostic accuracy and the likelihood of diagnostic error appear to be roughly comparable in telediagnosis versus face-to-face encounters.
Policymakers, said the taskforce, need to fund research on best practices and update the existing patient safety event reporting structures to incorporate telemedicine as an integral piece.
For Teladoc, a company which is projecting an 85% revenue increase to $1.3 billion in combined turnover this year, the emerging hybrid model of care is but one of several open questions. It also remains to be seen whether Teladoc will be as successful providing chronic care as it was offering acute care during the pandemic, especially given that some private health plans have launched their own bespoke chronic disease management services.
Teladoc sells subscriptions to employers and health plans that enable their employees or members to access short MD interactions on its platform (patients also pay access fees). Livongo, too, makes its AI-driven “nudges” and health coaches available to employees as a benefit.
“But to date, Livongo has never been prescribed by a provider,” Levy pointed out. “So it’s going to be pretty interesting what that patient experience looks like in terms of our own virtual primary care program.”
As Rock Health also noted, Teladoc’s promise of “whole-person care” seems unfulfilled while missing elements like at-home lab tests and medication delivery. These are areas in which Rock Heath expects the company to round out its services through M&A.
Yet another question is whether telemedicine firms can sustain their growth. Virtual care visits were expected to soar to more than one billion this year, per a Forrester forecast in April, with Teladoc itself expecting 10 million. Rival telemedicine firm American Well, which had a $742 million IPO last week, said it facilitated more than 2.9 million virtual visits in the first half of 2020 alone. MDLive, another competitor in the space, plans to go public next year.
But demand is softening. “We were doing over 20,000 visits a day a few months ago, but as the healthcare system has reopened, we’ve seen a little bit of a tapering off,” Levy acknowledged. “We are still far above where we were last year. We also fully expect, with the coming flu season, that we are going to be seeing record volumes of individuals seeking our services.”
Of all the unknowns surrounding the newly formed “Teladongo,” though, the aforementioned balance seems like the most intriguing. For years, physicians and others have pondered a future in which a large portion of patient care might eventually be delivered remotely. That vision seems to be close at hand, given the pandemic-driven surge in demand as well as physician career trends.
“In the future, we will see more and more clinicians that choose to be ‘virtualists,’ just like a subset of primary care providers prefer hospital-based medicine to outpatient care,” Elliott predicted.
Meanwhile, Teladoc is certainly doing its part to foster the virtual-care era – whatever that may look like – by setting up its own robust quality and safety metrics, partnering with academic centers on research, and training physicians in remote patient engagement. Teladoc relies on physicians who are independent contractors, and an important part of its onboarding and mentoring of clinicians, Levy said, focuses on honing their ability to connect with individuals virtually.
“It’s a little bit more complicated than ‘Here’s your camcorder. Here’s your microphone. Have fun,’” he noted. “It really is clinical practice guidelines and important training that individuals know how to leverage the technology to deliver a high-quality member experience that makes people truly feel cared for in the virtual setting.”