Though the pandemic greatly accelerated the use of telehealth, use of pure-play virtual care has waned as COVID-19 cases drop off across the U.S. But telehealth is increasingly being woven into hospitals' digital roadmaps, and some are even upping their investments in the modality despite moderating visits, experts said at the annual HIMSS healthcare conference.

That's giving hope to proponents of hybrid care models, who point to the value of meeting patients where they are to lower costs and improve outcomes.

Use of telehealth was relatively low before the pandemic, accounting for fewer than 1% of outpatient visits, by one metric. However, at its peak between March and August of 2020, telehealth made up 13% of outpatient visits, before dropping to roughly 8% in the same time period the next year.

Despite undulating consumer usage, "that genie's out of the bottle. We have got to keep going with telehealth," Donna Roach, chief information officer at University of Utah Health, said.

Video conferencing giant Zoom, which saw its telehealth business boom during the pandemic, conducted a survey with Qualtrics finding that 61% of people who used virtual care during COVID-19 said they would prefer both digital and in-person access to health services in the future. 

"The hyperdigitalization of healthcare in general and the virtualization of healthcare has been quite significant," Ron Emerson, global healthcare lead at Zoom, told Healthcare Dive onsite at HIMSS. "We're seeing sort of the post COVID — well I won't say post COVID, but we're seeing as we move through the different stages of COVID that telehealth and virtual care continues to be a delivery model that's kind of consistent."

Hybrid care models — where appropriate

Physical care delivery is never going to go away completely. Some healthcare services necessitate in-person delivery, such as surgeries. Physical touchpoints will remain even for segments like primary care, which telehealth proponents pointed to as one area where almost the entire experience could be digitized with tools like wearables, health coaching and artificial intelligence.

The simple fact is, some patients want virtual care, and some don't, Rani Khetarpal, head of value-based care partnerships at CVS Health, said.

So, "how do we treat that individual patient? What is the modality to reach that patient?" and how can a care team use digital and physical avenues to meet their health needs and personal preferences, Khetarpal asked.

Where these hybrid models can most move the needle on improving care while reducing costs is the inpatient space, experts said.

Research has shown that hospitalization is one of the most expensive types of healthcare utilization, and inpatient costs have risen consistently year over year.

"There is always going to be a critical role for some patients to be seen physically by their physician," Chris McCann, CEO of care-at-home tech platform Current Health, told Healthcare Dive. "There's a tremendous value to putting hands on patients. But it's totally logical to say there is a percentage of care being delivered today that doesn't need to be delivered in an inpatient facility."

In a perfect world, providers would be able to let a specific patient's needs determine the modality through which they receive care, experts said. Hybrid models, like hospital at home, would be prevalent, use technology to coordinate care, and require inclusion and exclusion criteria to make sure patients are receiving the type of care that best fits their situation.

"Under the premise that there's a correlation between access and quality, let the level of interaction needed based on the situation dictate what sort of care should happen," Zoom's Ron Emerson said. "The first thing is now that clinicians and patients are used to the technology and we are in more of a consumer-driven world, I think it's becoming a de facto thing that we have to meet consumers where they are."

This also jibes with the shift to value-based care. If providers have a certain amount of funds to take care of a specific population, instead of being paid on a per-visit basis, they can use whichever delivery methods are most effective based on that populations' clinical presentation.

That makes programs that operate in capitated or other value-based models low-hanging fruit for hybrid models in the near-term, including accountable care organizations, payer-provider organizations, self-insured employers and Medicare Advantage plans, Emerson said.

But even in a fee-for-service ecosystem, hybrid models should be a cost saver by winnowing down the number of in-person consultations, and preventing worse (and more expensive) outcomes down the line by increasing access to care. This could especially move the needle among the small percentage of high-need patients that consume the majority of healthcare, experts said.

Some are concerned that greater telehealth availability could actually add more cost into the system if virtual visits are used in addition to physical services, instead of as a replacement for them. Early studies are mixed, as telehealth has been shown to pare down cost in some and add to it in others.

But some evidence, even pre-COVID-19, points to the efficacy of virtual care in diverting patients from costlier care settings.

Data from Philadelphia-based Jefferson Health in 2019 showed using telehealth platforms to prevent patients from unnecessary ER visits saved providers some $1,500 per patient encounter. And hybrid models, like hospital-at-home platforms — integrated models where telehealth plays a huge role — can save 30% or more per admission, while resulting in fewer complications than inpatient care, according to one pilot.

More futuristic models

A significant portion of healthcare services could be digitized in the future. But some in the industry are looking beyond simply offering virtual care permanently.

A claims-based analysis from McKinsey in 2020 found some 20% of emergency room visits and 24% of office visits and outpatient volume could be done virtually, while another 9% of office visits could be done near-virtually. Up to 35% of home health services could be virtualized, while another 2% of all outpatient volume could be shifted to the home using tech-enabled medication administration.

But as technology becomes more interwoven into the fabric of care delivery — stabilizing at 38 times pre-COVID-19 levels, per McKinsey — and becomes more commodified and comprehensive, simply offering video calls is "no longer a unique thing," McCann said.

Penn State Health is currently trying to stand up its own virtual care company as a separate for-profit arm, Cletis Earle, chief information officer of Penn State Health, said.

The timing is interesting, given telehealth services have waned, but digitally delivered care is becoming integral to prepare the system not only for the next pandemic, but the next business imperative, Earle said.

"We continue to say look — we need to push back and say, 'Okay, is this the right thing to do?' And the answer is, absolutely," Earle said. "The telehealth piece is one piece, one component, of many other things ... it's a combination, a collection of efforts, that standing up a telehealth business is not just the thing that's going to make you successful."

Hybrid models could eventually result in more futuristic applications, like augmented reality, Alysa Taylor, corporate vice president of Microsoft, said.

Taylor gave the example of a physician in Uganda using a hololens, or mixed reality smartglasses, to bring in specialists from across the world to consult on cases.

"Care of the future is adding these new modalities" — including remote work, said BJ Moore, chief information officer at nonprofit giant Providence.

Like in other industries, a majority of healthcare workers coming out of the pandemic have said they'd prefer some sort of hybrid work model where possible. According to Deloitte, most healthcare employers either planned to or had started implementing new work methods at the end of 2020, though it's rarely an option for burned-out frontline staff.

But that increased virtualization of the workforce is a silver lining of the pandemic, by reinvigorating the family and helping combat isolation, Bill Fera, a family practice clinician by training and principal at Deloitte Consulting, said.

"There was this renewed sense of community where we were," Fera said.

Aging population accelerates interest

As the population ages, demand is expected to increase for these connected care models. Seniors, though not digital natives, took to telehealth during the pandemic better than many market watchers expected.

More than two in every five Medicare members — some 28 million beneficiaries — used telehealth during the first year of the pandemic, according to government data. Prior to COVID-19, fewer than 1%, or roughly 341,000 beneficiaries, had used virtual care.

According to a report from the HHS Office of the Inspector General this month, telehealth was "critical" for serving Medicare beneficiaries during the pandemic, a fact that demonstrates the "long-term potential of telehealth to increase access to health care for beneficiaries."

This older population is a big opportunity for hybrid models, experts said at HIMSS, as healthcare organizations can leverage telehealth and technology to keep them out of more expensive care settings like hospitals and nursing homes and help them age gracefully in place.

That opportunity is growing as the American population skews older, with the number of Americans aged 65 or older projected to more than double by 2060 to a fourth of the total population.

"What the pandemic showed us is, telehealth isn't all that bad," Joe Drygas, VP of healthcare of AT&T Business said. "What does it mean for our loved ones and the ones that are aging?"

A majority of Americans over the age of 65 say they'd prefer to die at home, but in 2009 only 24% of them actually did. However, the percentage of Medicare fee-for-service and Medicare Advantage beneficiaries that are dying at home or in community settings appears to be growing, likely in response to the current inadequacy of end-of-life care as, for many older people, spending their final days in a hospital can mean aggressive and expensive treatment that doesn't always elongate their lives.

New startups and models that zero in on tech-enabled solutions in home health, chronic illnesses and end-of-life care to address this inadequacy have been emerging and raking in funding.

Aging-at-home technology is an area of interest for healthcare venture capitalists like Yaniv Sadka, an investor at Israel-based aMoon Fund.

"As the boomer generation grows older and older, more people want to be cared for in the home," Sadka said on a panel about how VCs are viewing the future of health IT.

But even as hybrid care models become more accepted, barriers to adoption remain. One of the largest is cultural, as some providers are leery about the growing use of digital health.

"Culturally, if your organization isn't open to it, your community isn't open to it, you can do small little improvements but it won't get you very far," Roach said. "Culture is the biggest barrier."

Financial concerns are also a roadblock, as standing up new care models with the goal of reducing inpatient visits in a majority fee-for-service environment threatens provider revenues. Additionally, the future of reimbursement for virtual care is still being written, as is how much digitally delivered care the government allows after the pandemic.

Now, more than two years into COVID-19,  many states have legislative mandates that they have to reimburse for telehealth, though a handful do not. Virtual care vendors' biggest concern is that sweeping telehealth flexibilities that caused use of the modality to soar during the pandemic might be rolled back when the public health emergency expires, Zoom's Emerson said.

Currently, there are a slew of bills on Capitol Hill that would extend this access in various shapes and forms. One bipartisan proposal that's received significant support from the industry is the CONNECT for Health Act, which would permanently remove all geographic restrictions on telehealth services, and allow patients to receive telehealth service in the home and other sites.

It's also imperative also that, as healthcare delivery becomes increasingly more virtual, no populations — regardless of race, age, socioeconomic status, sex or location — are left behind, as some worry the growing use of telehealth will exacerbate America's digital divide.

Many older adults, especially low-income seniors and those in rural areas, face acute difficulties accessing telemedical services. A study conducted in 2020 found more than 41% of Medicare beneficiaries lacked access to a computer with high-speed internet access at home, while almost 41% didn't have a smartphone with a wireless data plan.

More than a fourth of beneficiaries didn't have either option, making conducting a real-time video visit with a doctor at home almost impossible.

Since the beginning of the pandemic, the federal government has benchmarked millions in grants to ameliorate the digital divide and expand rural access to telehealth. But the private sector can also do more, experts said at HIMSS.

One solution is ensuring the communities you serve have access to any broadband or devices required for their care delivery, Current Health's McCann said. In some of its patient populations, more than half don't have internet or a smartphone. Among other measures, Current Health works with telecommunications companies to try to improve cellular connectivity to rural areas.

"It's a hard challenge," but it's not an option to exclude those patients," McCann said.