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The Outlook for Telehealth and Virtual Care at the Cleveland Clinic

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In this episode of TD Cowen’s FutureHealth Podcast Series, Dr. Peter Rasmussen, Chief Clinical Officer of the Cleveland Clinic/AmWell Digital Health Joint Venture joins Charles Rhyee, Healthcare Technology Analyst. They discuss the origin of telehealth at Cleveland Clinic, the drivers for adoption, and continued growth during the COVID-19 pandemic. They also speak about how the nonenforcement of state licensure agreements amid COVID-19 has affected telehealth & the biggest obstacles to digital health adoption. Press play to listen to the podcast.


Speaker 1:                       Welcome to Cowen Insights, a space that brings leading thinkers together to share insights and ideas shaping the world around us. Join us as we converse with the top minds who are influencing our global sectors.

Charles Rhyee:                Hello. My name is Charles Rhyee, Cowen’s healthcare technology analyst, and welcome to the Cowen Future Health Podcast. Today’s podcast is part of a new monthly series that continues Cowen’s efforts to bring together thought leaders, innovators, and investors to discuss how the convergence of healthcare, technology, and consumerism is changing the way that we look at health, healthcare, and the healthcare system. And joining me today is Dr. Peter Rasmussen. Peter currently serves as the chief clinical officer for the joint venture between the Cleveland Clinic and telehealth vendor American Well. Peter is also a professor of neurosurgery at the Cerebrovascular Center, the Department of Neurosurgery at the Cleveland Clinic in Cleveland, Ohio. He’s also the former medical director of digital health at the Cleveland Clinic where he oversaw the clinic’s overall digital health strategy and implementation of their digital medical platforms. This includes the clinic’s flagship virtual care service Express Care Online as well as site to site services and vertical chronic disease management capabilities. So, Peter, thanks for joining us today.

Dr. Peter Rasmu…:         My pleasure, Charles. Thanks for having me.

Charles Rhyee:                2020 was a very challenging year for everybody. Hopefully 2021 will get better soon. And telehealth has really kind of shown as a bright spot during all of this. But, clearly telehealth has been around for much longer than that. The clinic itself was an early adopter of telehealth going back, call it eight to 10 years. Maybe starting from there, talk about how yourself and the Cleveland Clinic looked at telehealth and to start what kind of drove adoption of telehealth at the beginning here.

Dr. Peter Rasmu…:         Telehealth at the Cleveland Clinic goes back probably 25 or 30 years, predates me even to starting the Cleveland Clinic in 1998. I believe they were instrumental working with NASA in terms of cardiac telemetry data being sent from Spacelab down to Earth. So they’ve really been working in digital health for quite some time. Cleveland Clinic has been doing a site to site primary care visits on a very limited basis for the past 25 years. It really kind of got going in the modern era about 15 to 18 years ago when we started the Telestroke program to bring access to Cleveland Clinic experts in rural hospitals and underserved EDs in Ohio, in Western Pennsylvania. And that program has grown fairly dramatically over the years now servicing between 3000 and 3500 patients every year and really brings great access to the highest level of care when patients are in an emergency situation facing life and death problems.

                                         Toby Cosgrove recognized a stronger need for telehealth and digital health as a future strategy of Cleveland Clinic growth. And for those of you who don’t know Toby, he was the most recent CEO who stepped down about three years ago. Tom Mihaljevic is our current CEO. Toby recognized that digital health was the future that just as retail moved from local stores to online venues like Amazon, that the Cleveland Clinic needed to move in that direction as well. And he energized the digital health strategy. That was one of the reasons was to modernize the care and meet patient expectations for online access. It was also to help prepare the organization for lower cost alternatives to delivery of care as we begin to move more at risk models and servicing our ACL population, and we needed to create efficiencies also to lower the cost of delivering care regardless of how things were moving forward.

                                         And so he got things moving, created a digital health team within the organization. I was fortunate enough to serve as medical director of that for six years prior to moving to the joint venture about one year ago. We moved in multiple directions at that time. Probably the area that got the biggest traction was we created our own branded online urgent care solution, which was called Express Care Online that continues to this day. At any given moment, it can service up to 20 different states, approximately 20 different states. Most of the work of course is concentrated in Ohio, Pennsylvania, Kentucky, Indiana, and Michigan, where brand recognition is most readily available.

                                         We chose to partner at that time with what was known as American Well, now Amwell, as our technology vendor to facilitate virtual visits. And for those of you who know how that platform functions, it not only does on-demand urgent care type functionality, but also allows for scheduled virtual visits. So we began to move to develop virtual visit care six years ago in the specialty space and the primary care space in addition to this demand urgent care. It did help meet that need of the organization to provide broader access to Cleveland Clinic experts from around the nation and Canada as a global health care system. The desire is always to allow patients around the world to have better access to Cleveland Clinic physicians.

Charles Rhyee:                Peter, you talked that Toby, when you guys were kind of embarking on expanding sort of virtual care lower cost, you kind of noted lower costs trying to be ready for new payment models. Was that the primary business case for adopting sort of what we now look at as telehealth?

Dr. Peter Rasmu…:         I think that was predominantly the primary business case, but I think it was equally important for us to move in the direction of what we were thinking patients wanted. And as I mentioned, just as so many other things are done online now, airline tickets, shopping for virtually everything, buying cars, things that when I was a child, we never imagined that you would be, or when I was a young man, never imagined that would be doing online, people are doing readily online. And certainly as medicine has moved more toward grounded in hard data by laboratory and imaging data in terms of rendering diagnoses and treatment recommendations that is greatly facilitated by online care and has diminished the requirement of a physical exam and many of the medical interactions. So I think a lot of it was driven to meet what patient’s expectations are. If I can buy a car online or do other things online, why can’t I get the most aspects of my health care online?

Charles Rhyee:                And one of the big challenges, it seems reimbursement has been sort of the biggest challenge, and so you’re talking about this business case and obviously a view where you thought that patient demand would be. Has the lack of reimbursement let’s say prior to last year been the primary reason why we have not seen greater adoption of telehealth until now?

Dr. Peter Rasmu…:         I think there were a lot of reasons why providers and health system leaders were reticent to move more directly into digital health at a large scale. I think questions around reimbursement certainly are one. Depending upon how integrated the healthcare system is, obviously the vast majority of revenue can come from other areas like laboratory services, imaging services, procedures, and points of healthcare contact that require actual hands-on. And in my mind, the business case for digital health is that by essentially offering free or low cost initial contact points for patients, you will greatly increase your downstream revenue when those patients come for laboratory imaging and procedure care. Obviously some administrators and healthcare leaders don’t see things that way that every interaction should be captured by some kind of reimbursement. Budgets are built on an annual basis based on the number of patient interactions that are going to occur. And frequently there is reticence to deviate from known reimbursement models of in-person care with fear of not being able to meet a budget.

                                         So it does take a little bit of a leap of faith that you’re going to ultimately do as well financially by widening your funnel to patients or improving access to patients. But sometimes there’s some leadership concerns that’s actually going to be the case. Toby never really felt the lack of reimbursement was a significant barrier to digital health. Didn’t make it a precondition to widening digital health services. He felt that this was the way patients in healthcare, consumers were moving in the future and that we needed to be prepared for what patients wanted. So when there was a larger wholesale shift to digital care by either from a patient’s desire or what none of us could foresee, which would be COVID, he wanted to make sure the organization was prepared for that. And fortunately, we did have a strong foundation of digital health when COVID did strike.

                                         Other times, barriers to adoption can occur at the clinical leadership level. That there’s just a sense that healthcare is practiced in person, this is how it’s been done for decades and decades, and that digital care is inferior, and this isn’t what most patients want. Obviously, I think what we’re recognizing as we emerge out of this COVID pandemic that patients are readily adopters to digital healthcare. And for the most part, this is the preferred way that patients want to interact with their healthcare providers when possible.

Charles Rhyee:                I want to talk about actually obviously COVID. Last year, obviously it’s been a very difficult period as it still is obviously. And the telehealth did kind of come out as a “winner” in all this, because people realized the benefits of virtual care. You talked about earlier, right, in this current, while we’re in this public health emergency. A lot of the rules have been relaxed and reimbursement has been very generous. As things stand, maybe talk about at the clinic itself in terms of how utilization has changed of telehealth, the views of providers, maybe how they have incorporated telehealth into the practices, maybe from peak to current, where things stand maybe, and how durable do you think that is?

Dr. Peter Rasmu…:         Yeah, I think like every other health system that went through COVID saw an immediate, overnight dramatic, 10 to 20 fold increase the number of virtual visits. Really within a two week period of time, we went to about 95% of all the outpatient activity being virtual, which was the mixture of video and telephone calls. It stayed pretty high for the first month. And then it began to taper down. And I think currently at present last numbers I saw the start of January of 2021, about 30% of ambulatory visits were now telephone and/or video, which is a pretty significant decrement from about 95% where we were at the start of COVID. And it is up dramatically from where we were pre-COVID where about 1.5% of all ambulatory visits were a video or telephone. So it’s still a huge increase relative to that. But clearly if we could do 95% of the visits by telephone or video at the height of the Ohio concern of COVID, being at one third of the visits now is a pretty significant decline.

Charles Rhyee:                Why has that dropped though?

Dr. Peter Rasmu…:         Yeah. I think it’s not the patients, that’s for sure. The patients have an initial reticence, I think, to some video connection, but once they were sort of forced through it because of COVID, they’ve really become ready adopters to it. Since March of 2020, Charles, in my own practice, I’ve only seen one patient in person, only one patient in person. Otherwise it’s all been video or telephone. And the vast majority of those have actually been video encounters. So patients adopt this readily I think for the most part. At least within our organization, a lot of it has been driven by the clinical leadership.

                                         As I mentioned earlier on, these clinical leaders are held to budgets and their targets, and these budgets have been constructed based on the revenue that’s associated with in-person visits. And that’s the way they’re assuring themselves of being able to meet their budgetary targets is by going back to how the budget was constructed and the revenue model that’s associated with that. I think there’s some concern or lack of desire to experiment with an increased volume of activity using video and the different reimbursement models that exist for this, which is unfortunate because I think in the long run, that’s going to work against our systems like the Cleveland Clinic. We could probably be more progressive, meet patients and their needs and their desires by staying more digital and probably capturing a larger book of business in the long-term.

Charles Rhyee:                Yeah. I think one interesting aspect of the public health emergency is the relaxation. What’s the right way to say it? The non-enforcement of state licensure requirements, I guess that’s the right way to say it. And that’s sort of not being enforced currently. How important has that been to the ability for the Cleveland Clinic to deliver virtual care not only during the pandemic, but how important you think that will be going forward? We’ve heard from other health systems that they think that’s very important, particularly, let’s say, for example, the tri-state area where people live in multiple states very close by each other, right? And they’re lobbying hard to have those made permanent. What are your thoughts there on that?

Dr. Peter Rasmu…:         Yeah, I think clearly state licensure is an artificial bureaucratic barrier for delivery of care. I understand where it came from historically. I don’t think there’s dramatic difference… And I myself hold about 10 different state licenses for a variety of reasons. I don’t think there’s a dramatic difference in the quality of screening that’s being done by Pennsylvania versus Ohio versus Florida. I think they’re all very diligent in assuring that I have the proper credentials and training to deliver healthcare. So I think it’s artificial. I think it should go away. It does inhibit the access of Americans to quality health care delivery. I think there is good healthcare ubiquitously around the United States. However, if you have a complex problem, it would behoove you to find the best expert you possibly can to render an opinion on what it is that you’re dealing with to try to make sure that the care that’s being rendered is the best possible for you.

                                         Healthcare is not formulaic as much as we try to move toward a guideline and care path driven care. At the end of the day, there’s a patient that’s attached to the care and not a population of patients, and each individual needs and should be treated on an individual basis with an individualized care plan. As an example, I know firsthand how high quality the cardiac care is that’s delivered by the Cleveland Clinic and the joint venture. We run our second opinion program. I’m privy to a large number of patients on a daily basis who have been given diagnosis X and treatment plan Y by their local hospital. And they come in front of our cardiologists and cardiac surgeons and they have dramatic differences in the diagnosis and the treatment plan moving forward. And I think a barrier, I have a patient living in Pittsburgh as opposed to Cleveland, to availing themselves of expertise, wherever it may be in this country is doing a disservice to our citizens.

Charles Rhyee:                One of the arguments I’ve heard made about the state licensure requirement is that states want to know who’s practicing in their state and avoid if someone had some type of black mark against them in one state, they don’t just pop up in their state and their state won’t know it. Are there adequate national databases now that states can refer back to that can keep track of these kinds of things and in terms of


being censured or things like that?

Dr. Peter Rasmu…:         I think there are good databases around that. Obviously there’s some failures that we can all point to and cite to on an anecdotal basis. That being said, I think the Interstate Licensure Compact has gone a long way to streamline the administrative identification of individuals who are practicing telemedicine in individual states. I think that’s a great solution if it would be more broadly adopted. Fortunately Ohio is currently not participating in the telemedicine interstates interstate compact. At the same time, the barrier extends to nurses as well. Digital healthcare delivery does depend not only on providers, but also nurses. Fortunately there is a nursing interstate compact as well, and again, everyone would be better served by a broadening out of these types of bureaucratic solutions to this particular issue.

Charles Rhyee:                So obviously, with vaccines being distributed now and vaccination, we’re heading towards a new normal, or not a new normal, we’re kind of heading back hopefully to a normal world. But in the meantime, we’ve seen continued rise in infections in the US. Have we seen with that sort of an uptick in utilization again for telehealth that corresponds to that, or has that stayed fairly stable?

Dr. Peter Rasmu…:         I think in our organization we’ve seen the amount of telehealth on the ambulatory side declined from high overall 90, 95% down to about 30%. Hope it stabilizes there. We don’t decline more than that. Hard to know when vaccines are going to be more broadly available to the general public. We still only have a tiny minority of all of our caregivers inside our health system who have been vaccinated or starting in the vaccination path. I think time will tell. Some of it’s going to depend upon what happens in the Biden administration around the relaxation, as you mentioned, of the rules around licensure, and reimbursement. We already are beginning to see from our own legal team concerns about even an absence of change in the rules, concerns about seeing patients across state lines. So I think it’s inevitable that we’re going to see some restriction on which patients we can see virtually across state lines, whether it comes from federal government, state government, or local administration.

Charles Rhyee:                How much does the pandemic change the view of virtual care and digital health with physicians at the Cleveland Clinic?

Dr. Peter Rasmu…:         Oh, it’s completely revolutionized it. I used to say we had 20% adopters and 80% skeptics. I would say now we have 90% adopters and 10% skeptics. It’s the really the vast minority of physicians who really insist on in-person care. From a frontline provider standpoint, the providers really are strong proponents of digital healthcare.

Charles Rhyee:                And yet you’re saying that you can stabilize that 30% virtual for ambulatory visit. Is that a function then of leadership saying that we want to be cognizant of budget issues, maybe illegal issues, or is that the real limiting factor?

Dr. Peter Rasmu…:         Well, it definitely is. At Cleveland Clinic, it is definitely a function of leadership. Dr. Mihaljevic’s pronouncements has been is if a patient wants to be seen in person, we’ll see them in person. I think that’s great. I understand where that’s coming from. That’s trying to meet the patient where they are, what the patient wants. I think what can frequently happen in translation of that and implementation of that is that frontline office workers interpret that as, oh, we’re no longer doing video visits, we’re doing in-person visits. So instead of being equitable in offering patients a telephone visit or a video visit or an in-person visit, it’s most easy to fall back into the old ways of just offering patients in-person visits. So it’s a good hearted move, but I think unfortunately, and it can be interpreted as a move back to how things used to be done.

Charles Rhyee:                Yeah. At the beginning, you talked about the fact that the way medicine is practiced, or at least a lot of primary care has done, looking at imaging, looking at lab results, et cetera, that you really don’t need as much physical visits anymore. Kind of along with that, you really shared more and more discussions around virtual primary care, virtual primary care models where you can create sort of networks of physicians to treat patient population virtually from day one. How close do you think we are really to seeing that really implemented on a large scale? I know there are pilots here and there. And what do you think helps get us there?

Dr. Peter Rasmu…:         I think we’re definitely seeing a lot of that going on now, right? So we’ve got a virtual primary care coming from Amwell Teladoc, other places like 98point6. There are commercial payers that are moving toward a virtual first strategy as a product. And I think it’s right around the corner, to be honest with you. I don’t know why a young individual who is otherwise healthy in their twenties and thirties would really want to have healthcare delivered any other way than through a virtual first primary care strategy.

                                         There’s very little reason that a young, healthy person needs to be seen in person for the most part. And I think that’s reflected by the fact that 50% of young adults don’t have a primary care provider because they don’t need one. Even if you’re healthy in your forties, in your fifties, and you move into a health maintenance stage where you need to have things done like colonoscopies and mammography and things like that, for the most part, the interactions short of the procedures and the testing can all be done digitally. If I was an internist, if I was a primary caregiver, I was a family practice doc or nurse practitioner, I would be absolutely moving into delivering primary care from a virtual standpoint.

Charles Rhyee:                Maybe switching gears then to the JV then. Maybe talk a little bit about sort of work that you’re doing there right now and sort of the progress you guys have made so far in the last year since the announcement.

Dr. Peter Rasmu…:         The Genesis of the JV came pre-COVID. And there was a strong feeling that the Cleveland clinic, despite all of the hard work of Toby Cosgrove and Dr. Mihaljevic, that we weren’t moving fast enough to offer digital health solutions to our patients, or to come up with newer, innovative programs for delivering healthcare to our patients that are lower cost. We recognized that it was something that we couldn’t really do ourselves, that we needed a technology partner with great channels to payers and alternative payment strategies. And we decided to work and partner with Amwell to create a joint venture.

                                         The charge of the joint venture is to unlock access to the world’s best expertise at a Cleveland Clinic through innovative digital health programs. We started the joint venture by offering second opinion services to patients around the globe for complex health conditions. We’ve seen dramatic growth to date in the request for our services. We’ve made some tremendous impact on patients’ lives around the globe. We deliver a high level of care where we can turn educational second opinion around from anywhere in the globe on an average within two weeks. And these are for some of the most complex care cases, cardiac problems, neurologic diseases, digestive diseases, cancer, et cetera. About a third of the time we changed the diagnosis. We have a differing opinion on what the diagnosis is or it’s refined. And about 70% of the time we have a refinement to the treatment plan or offer an alternative to surgical therapy or a less invasive surgical procedure. All of this is better for patient care and reduces costs to the payers and the employers.

Charles Rhyee:                Is that going to be rolled out this year?

Dr. Peter Rasmu…:         Well, second opinions have been available all the way through 2020. Our goal is to launch an additional digital health product or two within 2021.

Charles Rhyee:                And then just kind of maybe to wrap up here a little bit, you talked a little bit earlier that you see virtual primary care is something that’s around the corner. What do you think are some of the biggest challenges that investors should really think about in terms of the adoption of virtual care and digital health over the next few years? What do you think are the biggest potential obstacles? Because it seems like the trend has been very positive.

Dr. Peter Rasmu…:         It’s not so much that you just have a technical way to see a patient on a video visit from a primary care standpoint. It’s going to be, can you then seamlessly deliver care to that patient through A, prescribing medications when needed, B, referring that patient for laboratory testing when it’s indicated and imaging assessments when it’s done, and can you efficiently bring those results back into the virtual primary care network for action upon those data points? If you are delivering just virtual primary care and you, you think the patient needs instead of liver enzymes for whatever reason, an ultrasound of the liver and the gallbladder, if you don’t have a relationship either administratively and/or electronically with a laboratory services company and an imaging vendor, you’re going to be greatly hampered in what the scope is of primary care that can actually be delivered.

                                         So I would be looking to invest in that virtual primary care network that has the ability to e-prescribe and e-order laboratory and imaging studies and efficiently retrieve the results of those so that you can action on that data and then close the loop with the patient moving forward. Short of that, I don’t think the virtual primary care solutions are going to compete with in-person care in the near future.

Charles Rhyee:                I would think that the real opportunity is the ability for providers to become more proactive in delivering care, because I feel like, at least when you think about the current paradigm, I, as a patient, I don’t feel well, right. Something I feel is wrong. Unless it’s caught on an annual screen, but generally speaking, right, I don’t feel well, I get an appointment, I go see a doctor. A test is run, and then a diagnosis is made, right? And maybe something is wrong. Maybe something’s not. I would think that the opportunity, when you think about remote patient monitoring capable of chronic disease management, things like that where I can be monitored, and then my physician or my caregiver can figure out or can be alerted appropriately that I’m not adequately managing myself. That can intervene earlier before I recognize it myself. To me, that seems like the real opportunity or a big opportunity here. How close are we to something like that? Is that something that we see today yet?

Dr. Peter Rasmu…:         Yeah. I mean, I completely agree with you, Charles, that these things like remote monitoring and hypertension have some inherent value to it, but the real reason to do a program like that is to put in place the technical infrastructure and the workflows to move on to more advanced care and monitoring. So as an example of what you’re talking about here that may be more proactive are solutions coming from companies like GRAIL. So, say once a year you send a blood sample and a urine and a stool sample off for genetic analysis looking for cancer. You may feel perfectly fine, no weight loss, no pain, et cetera, but on an annual basis, you just send off those samples, and for X amount of dollars, they return back a profitability to you that you’ve got a cancer.

                                         That workflow is exactly in my mind like the chronic hypertension workflow. It’s the same thing. You’re ordering the test. You’re receiving the results. And then you’re actioning on those things all through a digital and a virtual platform. So to me, that’s why health system and/or the joint venture should be moving in a direction like virtual hypertension management is because once you can put it in place, these longitudinal programs in the infrastructure, you can begin to do these much more meaningful things like we’re talking about here.

Charles Rhyee:                Yeah.

Dr. Peter Rasmu…:         So I think the stuff is both here and in the future that you’re talking about.

Charles Rhyee:                Okay, well, we’ll wrap it up there. And as always, Peter, great to catch up with you and thanks for your time and thank everyone for joining us on today’s podcast and look forward to having everyone join us on a future podcast. Thank you, everyone.

Dr. Peter Rasmu…:         Thanks, Charles.

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