Roy Schoenberg, MD, has worked in healthcare and technology for many years. But it wasn't until one decade ago that he and his brother, Ido Schoenberg, MD, took a step back to observe the relationship between patients and their physicians.
What they noticed drove their 2006 founding of American Well, a Boston-based telehealth services partner. American Well works with health plans, health systems and employers to deliver healthcare to patients struggling with everything from infections to diabetes. Its Amwell telehealth app allows patients to connect to a healthcare provider within minutes.
Now serving as president and CEO of American Well, Dr. Roy Schoenberg spoke with Becker's Hospital Review to discuss everything from telehealth reimbursement, barriers to access and what convenience means in healthcare.
Question: What was the inspiration behind co-founding American Well?
RS: My brother and I founded American Well about 10 years ago, after we concluded the transaction of selling our previous company to Trizetto. The company created health portals for patients, and the portals included health encyclopedias and risk assessments. Even though people got excited about the portals and signed up, there were never any long-term relationships.
The conclusion when we left was: "Why didn't people linger very long?" The simple answer is when most people think about healthcare, it isn't so much about reading an article or doing an assessment. It's about talking to a doctor.
Fundamentally, getting to a healthcare professional is the essence of healthcare for most Americans. We wondered if we could put together technology that allows for us to conveniently get in front of a healthcare professional; technology that upholds quality, rules of engagement, payment structure and benefits from health insurance. We wanted to make the actual process of healthcare delivery available.
Q: Telemedicine and access to it has greatly evolved, even over the past three years. What are some of the biggest changes that have occurred, from your perspective?
RS: Two or three have made a huge difference. First of all, insurers seeing healthcare delivery through technology as something they need to offer through benefits is very important. Hawaii Medical Service Association (an independent licensee of the Blue Cross Blue Shield Association) and Anthem Blue Cross and Blue Shield made the decision to offer telemedicine as a covered benefit, which opened up the notion of paying for telehealth.
The second occurrence was the release of the Federation of State Medical Boards' guidelines for the use of medical practice, which happened about two years ago. The authorities on healthcare delivery came out and publicly stated, 'Telehealth can be used safely to deliver healthcare.' The statement came with great clarity and started an avalanche of endorsements for telehealth left and right. The American Medical Association followed and the American Psychiatric Association always believed in it. Everybody chimed in and said telehealth is part of healthcare delivery.
The third is the transition of the payment structure in healthcare — payers essentially saying to physicians or health systems, 'We are not going to pay you for services, we're going to pay you for value. You are going to be financially accountable for how well your patients do.' If I am a physician and I do surgery, I am financially accountable for what happens to a patient long after they leave my office. Systems realized they needed technological tools to interact with patients differently.
Q: There are still key regulatory barriers to telehealth, including reimbursement and interstate licensure. How does the industry move past such barriers?
RS: The war around the permissibility of telehealth has materially ended. For the most part, the country has voted from a regulatory standpoint that telehealth allows for good relationships and care between physicians and patients.
There are two levels of maturity we haven't reached. The first is the licensure piece. The internet doesn't stop at state lines. The historical model of licensing, where physicians can only see patients in the state where they are, immediately becomes a barrier for telehealth. The fact that physicians can't see patients across state lines becomes a major barrier. At this point, 26 states have already signed up for the Interstate Medical Licensure Compact and other states are looking to sign up. Even though we'd like to have it happen quicker, it's moving forward at it's own pace.
The reimbursement piece also hasn't been resolved on multiple levels. Many insurance companies have embraced commercial reimbursement for telehealth, but Medicare hasn't really made any sound about embracing telehealth. There is tremendous inconsistency in how telehealth is paid for. In those states where law is enacted for telehealth to be covered, the laws are like Swiss cheese in terms of saying how much physicians should be paid and when payment needs to be processed.
If I am a physician with a mixed panel of patients and I am seeing patients through telehealth, there is a question mark as to the likelihood and amount of how much I'll be paid. If I get paid for every patient who walks into my office, but only 85 percent of payment for patients I see through telehealth, why do telehealth? That 15 percent difference is powerful enough to make physicians say, 'Until this is 100 percent, I'm staying away from telehealth.'
Q: How do you respond to those who get stuck on the limitations of telehealth? What have you found to be effective in changing the collective mindset of providers?
RS: To those who question it, I would say something very simple: The way we care for patients includes many different care settings. Sometimes it's appropriate to treat them in the ER or physician office. The same applies to telehealth, which is a care setting. There are things telehealth can help with effectively and other things are inappropriate for that care setting. The way people think about it — as one of the ways healthcare professionals interact with patients — the more comfortable they will be. We have to think about telehealth not as another medicine, but as another channel for care.
Q: In your presentation at the Becker's conference in July, you mentioned there's little overlap between a map of the U.S. that shows where the regulatory infrastructure for telehealth is in place and where it is most commonly utilized. Why do you think that is? Why is there a disconnect between patient need, available infrastructure and patient utilization?
RS: Generally that tells you the driving forces to telehealth are more about need and what it can do versus the opinions of people who govern certain aspects of healthcare delivery. It's one of those rare technologies, especially in healthcare, that represents what the people want. What people want may not be in line with historical rules, but what people want ends up, in most cases, becoming the way of the world.
A good example is Uber. In some states, there has been a ferocious war against Uber, but the reality is value has been so great and it has created so much mobility for people that the value trumped all other considerations.
There is social friction here. The people have voted — and in many cases today, physicians have voted — that they want to be treated through telehealth. The rules are now catching up.
Q: This Wall Street Journal article makes an analogy between Amazon and American Well. Can you further discuss this idea?
RS: Amazon started as a book business. Now you can pretty much buy anything on Amazon. Samsung TVs are primarily bought on Amazon, even though Amazon does not create Samsung TVs.
One of the opportunities of telehealth is, since it operates services through an online channel, the reach of the services is broader than the constraints of the hospital, which they were historically confined to. We made an announcement earlier this summer that anyone who uses American Well is able to acquire or deliver services from or to everyone else who uses American Well. Cleveland Clinic, which uses American Well, can deliver services, for example. Cleveland Clinic's services can be acquired by members who never dreamed they could get that quality of care.
Samsung generates amazing TVs, but the reach of those TVs was limited to Samsung stores before Amazon arrived. Now anybody can buy that TV. We're looking at the exchange not as a product of American Well, but as a place that allows the supply and demand of healthcare to take place.
Q: How would you define the cultural shift that has brought about telehealth acceptance for providers and patients?
RS: It's a combination of factors. The fact that technology has matured helps. We all have on our phone enough bandwidth to carry out telehealth.
The two big pieces of the puzzle have always been physicians and patients. They're the ones who really matter. From the patient standpoint, we are increasingly exposed to the costs of healthcare in many different ways, whether by premiums or high deductibles. We have to start asking questions and being cost-conscious. Bringing healthcare into the pockets of every American and letting them get it in an affordable way, especially when everything else about healthcare costs an arm and a leg, has been a very important factor.
With physicians, it's the understanding that they're no longer going to be paid under the fee-for-service model, but rather by how well their relationship with the patient is orchestrated. That fundamental understanding has made physicians say, 'We've got to start implementing those technologies, or we're not going to survive in this world.'
Q: The WSJ article questions whether patients trade quality for convenience. Do you have thoughts or comments on this? What room is there for convenience in healthcare?
RS: Convenience is important. We tend to trivialize this, as we all have busy lives. Some people think of convenience as something that will save you a two-hour drive to an office. But when you think of an elderly patient who is homebound and needs regular follow-up to take insulin medication for diabetes, the difference between telehealth and no telehealth means that patient will or won't be seen. That translates to a longer period of time without care, readmissions, deteriorations and other bad things.
We need to think of convenience as allowing people to get the healthcare they need versus having to struggle with a lot of other barriers that would prevent that. The difference is the livelihood of many people and how they can gracefully live with medical conditions and their associated expenses. Convenience sounds like a small, cheap word, but it has a dramatic implication as far as healthcare spending in the United States.