How To Scale A Telehealth Strategy: Pilots, Providers, and Payment

June 17, 2020 - Updated 6/18/2020: The new Blue Shield of California initiative is for Blue Shield of California members. A previous version of this article said the initiative served Blue Cross Blue Shield members.

Payers looking to scale up their telehealth strategies face numerous hurdles, shared Peter Long, senior vice president of Blue Shield of California (BSC). And he should know.

Long is at the head of a sprawling initiative called Health Reimagined that seeks to bring personalized, integrated, digitally-supported care to Blue Shield of California members—and in some cases non-members—in California.

The program started 20 pilot programs in four counties: Butte, Los Angeles, Monterey, and Sacramento. The initiative aims to provide holistic health, personal care, and “high-tech, high-touch” solutions to patients. BSC is scaling up the initiative to encompass the entire state.

Before embarking on such a broad scale move, it was critical to know the problem that this expansion aims to solve, to ensure that the dramatic movement of resources and intensive teamwork is worthwhile.

READ MORE: COVID-19 Spotlights 3 Payer Telehealth Expansion Challenges

BSC is not new to the digital healthcare space. Through tools that fuse in-person and virtual wellness programs, apps that streamline services for self-insured customers, and products that give providers access to formulary pricing, Long noted that the payer has developed a robust digital framework.

So why would BSC need to scale up its digital and telehealth strategy?

“We've had individual successes and we've done things that have gone well, but the magnitude of the challenges requires a more systematic approach,” Long told HealthPayerIntelligence. “How do you take all of that good innovation, put it together, and then—very importantly—put it together with alternative payment models so that you not only support a different delivery of healthcare, you support a different way of paying for it as well that's aligned?”

The challenge of scaling up BSC’s telehealth strategy

For BSC, the biggest challenge lay in scaling up so many projects at once. This process was difficult for two primary reasons.

First, BSC was trying to not just create solutions that were customized to fit community needs, but rather the goal was to create solutions that would generally work no matter where they were implemented.

READ MORE: Beyond COVID-19: Telehealth, Partnerships, Member Engagement

Each region had its own telehealth and technology needs. In Butte, the payer’s new virtual care strategy incorporated virtual visits and eTranscription services. In Monterey, the program’s initiatives were less about technology and more about bringing in-person care to patients via a mobile clinic or establishing new primary care and sports medicine clinics. Sacramento needed real-time claim payments technology, while Los Angeles needed eConsultation capabilities.

But while a key characteristic of the Health Reimagined initiative is personal care, the overarching goal was to bring these solutions to the entire state.

“We, from the outset, are building solutions that are scalable. So this is not just meant to be what works in Sacramento or Los Angeles or Monterey. We want this to become the center of practice, not just for Blue Shield, but for the industry,” Long explained.

To fuel that scalability, the payer began any partnerships for the program with a mindset of scalability. The payer brought this perspective into partnership conversations, ensuring that partners are aligned in considering whether their solutions can extend not only to other regions of the state but also to other lines of business.

After starting each solution with such an aerial perspective, the payer then sent in teams to customize the tool to fit the specific needs of that area.

READ MORE: Telehealth Key to Payer COVID-19 Prevention, Diagnosis, Testing

“There's a huge amount of work around packaging that innovation,” Long said. “We don't do enough of that in healthcare. It isn't just rinse-reuse of Teladoc in Paradise. It’s how does the actual workflow change so that this isn't just a virtual visit, but it's actually a virtual health program.”

The second factor that made scaling up so many projects simultaneously such a challenge was figuring how to test and reiterate these virtual care and telehealth strategies in the real world.

“It's finding the process, then finding those partners who are willing to go in and test these hypotheses. We in healthcare actually don't do a tremendous job of iterating, trying something and some parts of it worked and we need to adjust this particular aspect,” Long said.

BSC has been testing its scaling strategy in the four counties for nearly a year. Long said that the payer learned something new every month and adapted to these lessons.

In order to scale up a telehealth strategy, payers must be willing to pilot their new programs, accept that the first trial will not be perfect, and learn from those test runs.

Scaling up a telehealth strategy requires a new payer-provider-patient relationship

When a payer scales up its telehealth strategy the way that BSC is approaching its strategy, the relationship between health plan, provider, and patient shifts slightly, Long noted.

The new relationship relies on the familiar pillar of shared decision-making. However, BSC is considering removing prior authorizations as a part of that process, which would mark a significant change in shared decision-making implementation.

This new model allows the healthcare provider to decide what is the best modality to connect with the patient—whether by phone or by video call or another telehealth or technological platform.

“The health plan would step back and say, ‘we accept that decision that the patient and provider have made,’” Long explained. “It just changes the entire balance of power. So the health plan is not dictating the type of care that gets implemented. It's the patient and the provider.”

Another way in which the relationship changes is in how payers address social determinants of health. BSC found that payers could use technology and telehealth more effectively to not only conduct patient engagement but to coordinate between payer, provider, and social service provider.

In order to approach these conversations well, payers need to ensure that they are surrounding providers and patients with the appropriate data. This helps formulate effective strategy around social determinants of health as well as regular care and telehealth solutions.

“We think an important contribution of Health Reimagined is to have a technology platform that makes it uniform. The data flows between the healthcare provider and the social service provider. And ultimately, the money will be able to move between those entities to provide the best possible services for a member and their family,” Long said.

Scaling up a telehealth strategy requires flexibility, funding, data

For a strategy like BSC’s to function more broadly, payers would need significant flexibility, funding, and more integrated EHR systems.

Payers would have to be able to offer providers the flexibility to choose between a few technology options to use whatever works best for their patients. They also need to allow patients have the appropriate specialty providers available in-network.

Additionally, payers may need to adjust payment models to support providers spending more time with patients. Providers need to feel that they can spend as much time as they need in each visit.

Furthermore, unlike fee-for-service models, payment models that support these scaled-up telehealth strategies should not incentivize providers to ask patients to come for an in-person visit when an in-person visit is unnecessary or even puts the patient at risk.

Lastly, EHR systems that incorporate social determinants of health and social services are also key to scaling up effectively.

“Having systems that have the same set of information, the same set of incentives, whatever mode of communication or mode of interaction we're using, are going to be more sustainable,” Long emphasized.

Ultimately, Long stressed that it is the magnitude of this effort, the comprehensiveness, and the ability to package these solutions with aligned, alternative payment models that set this initiative apart.

“There are a lot of great startups and a lot of great organizations, but what makes Health Reimagined have real potential to change healthcare is the ability to put all of the solutions together in one place and package them with financing models,” Long concluded.