Listen to the Podcast: COVID-19 GC Roundtable - Part 5
In the fifth podcast in this series with counsel on the front lines of the coronavirus pandemic, Sarah Swank, Counsel, Nixon Peabody LLP, speaks with Rene Quashie, Vice President of Policy and Regulatory Affairs, Digital Health, Consumer Technology Association (CTA) and Ross Friedberg, Chief Legal and Business Affairs Officer, Doctor on Demand, about how the COVID-19 pandemic has impacted telehealth. The podcast discusses the future of telehealth, including clinician buy in, payer/provider collaboration, privacy standards, and using the pandemic to inform how we should address future public health emergencies. The speakers also talk about how the pandemic may reshape the health care industry, particularly primary care. From AHLA's In-House Counsel Practice Group. Sponsored by PHIflow.
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Sarah: All right. Welcome everybody to AHLAs COVID-19 GC Roundtable podcast. This is our fifth podcast.
And today I have two great speakers with me. Um, I'm Sarah Swank from the law firm of Nixon Peabody in the Washington DC office. And I have Ross and Rene here with me. Ross, why don't you introduce yourself to the audience?
Ross: Yeah, thanks Sarah. Hi everybody. I'm Ross Freedberg Chief Legal and Business Affairs Officer at Doctor on Demand. And we are a national telemedicine platform providing primary care and behavioral health, in all 50 states and I oversee our law policy and human resources division.
Sarah: Great, thanks.
Ross: And Rene?
Rene: Yeah, this is Renee Quashie, I'm the Vice President for Policy and Regulatory Affairs Digital Health at the Consumer Technology Association.
CTA is the largest tech trade association in the United States. We focus on every industry sector imaginable, but healthcare is one of the fastest growing sectors of our membership. Um, and it's also a, an increasingly important part of our CES trade shows. It's held every year in January in Las Vegas.
Sarah: Excellent. So Rene I'm going to start with you since you can kind of answer some of these questions in both personally, professionally, and even outside of healthcare. Um, how much time are you spending on COVID-19 and what is your typical, the typical day look like? And, you know, we're talking about not only this health changes, but our day to day work life changes. What do you, what are you seeing out there just from your personal perspective, but also professionally through your association work?
Rene: Yeah, it's been interesting, I think right when the lockdowns started in early March and for the two months after that, it was all COVID all the time. That's all we dealt with the waivers, making sure our members were informed about what was going on, uh, talking to the white house and various agencies, um, that had jurisdiction over healthcare and particularly health tech issues. But since probably the last, I would say month I have started to focus in some other non COVID related, um, health care issues, which has been refreshing, but COVID still, um, probably represents a little over half of my daily work, I would say.
And in terms of, you know, work, we've been working from home since a lockdown. Um, I've been lucky in that I don't have school aged kids. My kids are college age, so I don't have a lot of the complications my colleagues have. So my sort of transition from office to home has been pretty seamless. I have to say.
Um, and I know that's not everybody's and I know Ross is going to talk a little bit about this because he does have school aged children, but us, for me, it's been, it's been pretty seamless and I'm very lucky for that. And I understand how lucky I am.
Sarah: So then I have to ask you whether your kids cook you dinner because that's something I hear. I have, I have young kids and they don't cook me dinner. So I've heard some, there's some benefits to this having college-aged kid home sometimes for adult children.
Rene: It is. And you know, they're pretty self sufficient. And, uh, we don't really have to look after them in the same way. But what I always say is I've paid my dues.
We went through the teenage years. I paid my dues. So, in some way, I think we deserve this.
Sarah: Excellent. Great. Um, so Ross, why don't you tell us a little bit about what percentage and time, and we can really dig in with, you know, again, what's happening with telehealth in a minute, but what percentage of your time when you're spending on COVID matters and what is your kind of typical day look like?
Ross: Well, well, first I will say that my, my 10 year old daughter has become quite a Baker and chef during this pandemic. So she is cooking a lot of dinners for us. So that's been one really nice benefit to these last few months, but, but like Renee I'd say the first of March was, was really all about COVID all the time we were, we were in, you know, the stage of ramping up as fast as we could to meet the demand for telemedicine. And then there was just a ton of work around that. And, and it's changed. I'd say, I'd say today. Most of my work is still indirectly related to COVID because it's just had such a big impact on our business and the marketplace and what, but not in the same way as it was, you know, a month or two ago. It's more about, we have new ways of contracting with payers working within the Medicare program and Medicaid programs. And that's all changed as a result of, of the pandemic for us. My, my day to day is, um, it's interesting, you know, we're a California company primarily, but we have an office in both here in the DC area, and so typically I'd get a few hours in the morning right. And get stuff done. And then, and then everybody wakes up in California and my days, it was just meetings after meeting, after meeting, um, you know, midday. And then, uh, then, you know, in California they go to bed later. So, um, so there's usually a lot going in the evening as well, but it's worth, we've got, I think one of the advantages of, of our company being a telehealth company is from the early days we set up a really good, uh, system for remote work. The video calls and other systems. And so it's been quite seamless for the company. For me, it's been, it's been challenging at times because I have three little ones running around and they definitely enter the room at times while I'm in meetings and otherwise, but, but so far so good.
Sarah: Yeah, I think one of the things I've found is that people are understanding. Um, and I usually, I, I keep saying it's like the over, under on whether someone's going to come in to my office when I'm on call. It's pretty good, actually. So, um, so that's helpful. Um, but I mean, maybe there's some of this cultural changes we'll, we'll stick to about how, um, just understanding we're whole people. Um, and we talk a lot about right now about physicians and physician burnout and especially the how technology augments that or maybe actually causing some of it. And we're trying to work through those issues. But as far as attorneys, you don't want to think of ourselves as having those issues, but those discussions were starting to happen before the pandemic. And, um, I think there's a way that we can be supportive of each other.
Um, so let's talk a little bit about the physician. Um, and the user experience, you know, with telehealth. Um, we, we know that there was historic changes as we were talking about, especially in March around the waivers and expansion and, and this telehealth surge that happened. Um, the three of us, all are, you know, healthcare attorneys who focus on technology and kind of where that ends up going and, um, but, but here we are, um, with this, what happened in like a matter of, you know, weeks changes that didn't you know, I don't know about you, but we were probably all personally hoping that would happen. Of course, the constraints of being compliant with the law. Of course, some of it that needed to change some of it that was, I think, relevant. I mean, Rene, what do you do? I mean, did we, was that? Did it feel like it, it did, to me where it just it's like, Oh great, this is happening. And that just happened really, really quickly. Um, and how did you manage that?
Rene: Yeah, that's a, that's a great point. And it did feel as if it happened very quickly, but you know, I've been thinking a lot about it. I think part of the reason is because of all the work that had been done in years previous, and I think, um, telehealth was at a tipping point anyway. Um, and so I think the pandemic provided it a certain kind of opportunity, but without all the legwork, all the advocacy, um, all the thought leadership. Um, by various organizations and players, um, over the last, at least decade, I don't think a lot of what happened would have occurred. So I want to make sure that we underscore the point that the, the, the rapid nature of the changes as a reflection of what happened before.
In terms of managing it, it, it was, it was tough. And so at CTA, we have three law firms that help us, uh, manage our healthcare, uh, legal and policy portfolio, even with that tremendous help that we were getting, it was hard to keep up with everything that was happening. Particularly in the first month where there was just one announcement after the other. It wasn't just CMS. It was FDA, it was OIG. It was the Office for Civil Rights. It was DEA. And so that was very tough. Um, but I think over time we got adjusted, we got accustomed. And I think now we've got a much clearer picture of what the regulatory landscape looks like, but I will, I can't deny that in the first few weeks it was a whirlwind and it was hard to keep up.
Sarah: I'm kind of laughing because don't you think it will be a little bit, um, when we used to say, okay, we have a 30 day or so much comment period, or I'm just thinking about one time when. Um, there was proposed regulations that came out over the summer that were like to implement, I'd say were that were, uh, related to clinical research. And like, um, they came out like at a time where like the academic medical centers, faculty were on vacation and feeling like, oh, that's so rushed. I don't know in my career if I'll feel that way again. Maybe, maybe it'll take a while. I don't know. What do you think Rene? I mean, we usually, we have to like, respond to things quickly and we're like, wow, that's rushed. How are we going to do this in 30 days or 45 days or whatever timeframe.
Rene: This is a, this is, uh, what the point number 3,500, that's going to change a post COVID sort of. Uh, things we didn't think were imaginable or doable, all of a sudden are doable. Right? Um, you know, we've been told forever about how hard it is to change the Medicare program and, um, really sort of how telehealth is being dealt with internally from a policy perspective within CMS, pandemic happens and all those reasons go out the window. So, I think it has exposed that sometimes we constrain in an artificial way. Um, and I think what we've learned over the last three months is there's a lot that's possible if we put our minds to it and if there was a will to do it. Um, I think that's the thing that is, um, uh, been most, um, um, sort of noticeable for the pandemic and yeah, you're right. In terms of timing and, you know, 60 days to respond to a comment and that's going to seem very relaxed, whereas before we'd always be, um, rushed or think that we were being rushed to develop and submit comments, but maybe that'll change as well.
Sarah: Yeah, we're thinking faster. That's for sure. Um, so, so Ross, speaking of thinking and moving and acting faster, um, so we saw the first set of federal dollars go towards telehealth. It was like the first pot of money with, of course no program developed at the, at the time. And then we saw, the waivers and the program and all the things that, that we just heard Rene talk about. So you, you know, looking at your business model and what it was pre that moment, and then post that moment with this, I think, you know, we've talked about surges and hospitals, but there was, there was a telehealth surge to, um, what did that feel like and look like to you that sort of moment right before, and then the tsunami that came.
Ross: Yeah, it was, it was a really, um, interesting place to be as a lawyer because what we had in March was, was this odd situation where demand was surging. And we were getting urgent calls from senior officials within the government of, you know, I've been Washington as well as state governments and payers and everyone else begging us to ramp up. Bring on capacity as fast as we can provide access to different populations that previously we weren't able to provide access to.
So we're under this enormous pressure to do that. And we're talking to regulators about that at the same time that it's their regulations that are slowing us down. So, you know, licensure was one there's rules around how you credential physicians, and there's just aspects of that, that takes time. There's there's enrollment issues around getting in with, with different payers and the timelines around that.
I think it was that moment when everybody was scrambling to rapidly increase access to telehealth, that that is a regulatory community realized like you have to quickly ask and wave a lot of this stuff and it all kind of happens within a few weeks. And then, then it was just this mad rush to understand the waivers and they weren't you know, it took a few attempts in various cases for the waivers to be right. Like a state might come out with a license or waiver that, that wasn't really helpful because he still has to go through an application or the original waiver that removed the Medicare coverage with restrictions so have the requirement that you can only see a patient via telehealth if you've seen them once before in person. And that, that made it impossible for companies like Doctor on Demand. So there was some trial and error in there, but we did ultimately end up with, with waivers, uh, federal and state waivers that significantly, um, set up the, uh, the efforts to improve access to care. And I think even today, like a lot of the work I'm doing day to day is it's under these waivers and contracts with different payers, um, that wouldn't have been possible three or four months ago, you know, pre COVID, um, for legal reasons. Right, but, but are now possible or enabling us to serve different Medicaid populations, Medicare as well as, as well as gig economy workers and others, that it kind of falls through the cracks of traditional, um, payer design.
Sarah: So was it hard to ramp up? I've talked to people and worked with people on, on ramping up different programs. Um, especially on the, of for example, you know, the academic medical center or clinical side, but we also on the, on the tech side. Right. Um, uh, what's that. Yeah, there was never doctors that are coming out of retirement. We're trying to find people who trying to graduate, you know, med students early and, you know, was it hard to find people, um, how do you, how do you...
Ross: Um, there was just a tremendous, uh, surge of interest. A lot of physicians coming in, uh, you know, wanting to help out, but the challenge is that healthcare is still locally regulated. And so if you're trying to provide access to care across 50 States, even with all the waivers and everything else, you're still dealing with different roles in different States, different payment rules, different privacy rules, different rules around, you know, telemedicine coverage and access to standard of care and what can and can't be done.
So, so it just, it just takes time because you have, you have 50 States, but given that, I'd say, I'd say the industry acted super, you know very well. Um, and as the, the regulator, regulator community. So I'm impressed with how quickly we got access up. The other challenges is it's just so hard to forecast demand in a time like this. Like in, in March, there was a huge surge in demand. And, but it wasn't like a consistent everyday thing. I mean, there's spikes up and down. You can't explain why. One state is surging and the others, not, you're not sure why. And you have to of course, staff accordingly, right? He needs physician's license in the right state and everything else.
And now we're seeing similar type surge in mental health, but it's hard to really hard to forecast right now, like where demand will be and when which just further makes it difficult to, you know, continue to provide quick access to care.
Sarah: Yeah, so one of the things that I've been thinking about is like artificial intelligence and how it's been able to kind of help during these times or not help, or we were thinking about it. Do we trust it? Are there ethical and bias issues? But then when we look at, um, like, you know, being able to supplement it, for example, in a telehealth or a bot or a screening, you know, it was helpful sometimes some of the looking at surges and looking at moving of supplies, but there's also some, it's like, we're doing things in ways that we don't have data on. So it's like, what do we, how to, how do we look at that? Like even our supply chain in the United States was, um, disrupted, like toilet paper and bacon, things like that, or just getting groceries. Um, you know, it was there like, is there a place for AI or other, you know, analytics, um, Rene, have you been looking at, I mean, you're looking at across industries with, with technology, um, are there some lessons learned around what does data look like? And, you know, we're waiting for the claims to drop in and the telehealth and we're, you know, we're looking at March and now it's June and hopefully we'll have some data, but it's are we going to be able to synthesize all this and, and analyze it?
Rene: Yeah. And I think that's going to take some time. I mean, that's a very good point, but I think one of the things you raised, some other technological developments, and I think that's probably going to be one of the big lessons learns and takeaways from the pandemic and the reaction to the pandemic is just how important technology was in helping us address the pandemic directly, but also a lot of the, sort of the indirect consequences and how it helped, how technology helped us mitigate some of those consequences. Um, and I think the other thing we learned is that really U.S. life, the U.S. economy is more fragile than we thought. Um, you know, you talked about toilet paper, you talked the other supply chain issues. You talked about the potential shortage of meat and all the other things that have sort of come to the fore. I mean, makes us realize. That a lot of the things that we never sort of discussed or cared about or talked about are incredibly important to the overall economy of the country.
Um, so I think one of the things we're going to have to do, and we're going to have to take this seriously, is look at the data, analyze the data, analyze trends, analyze what we can take moving forward in a post pandemic world. And I think that's going to be critically important. Um, and in fact, so important that at CTA, we've got a, what we were calling a public health tech initiative to do just that, um, use COVID as a springboard to really analyze and think about future public health emergencies, um, how we respond to them, the role the private sector can play in helping mitigate the worst consequences from public health emergencies, particularly when it comes to technology. So I think you're going to start to see a lot of organizations start to think very thoughtfully about future public health emergencies. And hopefully some of those lessons by the way, also are reflected in our healthcare delivery system, changes to the healthcare delivery system. I'm very hopeful that virtual care in all its guises will become a much more prominent and permanent feature of the American delivery healthcare delivery system. But we have to wait and see I'm optimistic, but cautiously so.
Sarah: Yeah. So you do what you think that telehealth and some of these innovations will stick Rene? I mean, and I, I mean, I'm sure you're at the right place to be advocating for that. Um, but you know, what do we need to do to, to, to ensure that?
Rene: I think we've done the one thing that was probably the most important, which is, has always been sort of this conundrum and telehealth that when individuals use telehealth, the satisfaction rates are through the roof, through the roof. Everybody likes it. They like the ease with which they can interact with their clinician, I mean the studies are consistently, um, on point on this. Um, but the big issue is how do you get people to try it? And this pandemic provided an opportunity for millions of people to try telehealth who otherwise wouldn't, or would have been cautious to do so, but they were forced to do so because of the circumstances. And I think what you're finding in some of the post telehealth studies is what we saw pre pandemic, which is high, high satisfaction rates. So I think from the consumer side, I think there's going to be demand that telehealth stay, become a much more permanent part of the healthcare delivery system.
And Ross can speak to this, but I think there's more clinician buy-in even from some major health systems for which telehealth was a small component of the services they provide. But I think through the pandemic, they've seen how incredibly efficient it is at keeping them in touch with patients providing top line service. So I think it's going to stick because of demand, particularly on the consumer side.
Sarah: So Ross, why don't we ask you that? What, what I've heard, um, I've heard that there's some satisfaction from providers is that and patients, um, has that been, has that been the experience that you you've had? Is that, is that how you've seen things? And do you have any anecdotes or stories about that?
Ross: Yeah, I mean, so we've, we've been, I think ahead of the game on that one, because we've been working with providers for years and they love working with us. In fact, um, many of the physicians that work for Doctor on Demand and our physicians are full time employed physicians. Um, you know, they're coming from an office practice where they're, they're running from it. And, and what they like about telehealth is not just the modality of it. It's, it's a good telehealth platform is one that also removes a lot of the administrative burdens of practicing medicine, so that, so that the physicians can focus on on seeing patients. And, you know, that's a big, a big part of our, our goal and focus of Doctor on Demand is it's, you know, developing an electronic health record that's easy for physicians and patients and, and putting teams in place, back office teams in place and support teams in place to remove administrative burden.
So when physicians join they love it, right? Because suddenly they don't have to do all the paperwork. And other work that that's what caused them to flee their in office professional jobs. So I'd say though, like the big change is just drawing on Rene's point about will it stick. You know, before the pandemic, you know that the primary market force that was driving the telehealth sector were payer dynamics. Payers uh, we're, we're really holding up telemedicine, the large insurance companies, some of the employers, and it was, it was a niche product. It was a, it was a supplemental benefit. And that's how it was viewed by, I think most of the payer community, but you didn't really have a strong market force and providers or consumers.
I think the change we see now is like two big new market forces that are propelling telehealth to the next level is you have an awakened provider. And, um, you know, and an awakened consumer, I mean, a lot more demand for telehealth as Rene said, it's already, we're already seeing that some consumers. And we're seeing that at Doctor on Demand for providers as well, just in the form of, of the inbounds we're getting from some physicians across the country who want to come and work with us and join our platform. So I think, I think that, you know, assuming we get policies, right, it is it is here to stay. And I think it will be very different going forward and it'll play a different role. I think in the past, telehealth was seen as a supplemental, um, service offering, that that was just a, a nice to have on top of primary care and other core, core health care services.
I think in the future, if we get our policies, right, telehealth will become an essential anchor for primary care. And, um, and it will become a future where most of the care we received from a primary care physician, is a virtual house call it's powered by telehealth. And so telehealth becomes part of the core, the core of healthcare, not, not supplemental. I think that's the change that, that we, we see coming, assuming we can continue to get our policies right.
Sarah: So one of the things we saw before this was that Medicare advantage was opening up the idea of telehealth. And that was like a, I mean, depending on how cynical or optimistic you are, it was at least a toe in the door in like in the government payer space.
Um, and now we've seen, um, we're seeing we're seeing, some private payers obviously opened this up to for at least, um, because we had to keep the patients out of physician offices, um, because of exposure, risk and lack of PPE. Um, we're seeing offices fully opening up across the country. Um, And I'm wondering what private insurance will say about this.
Will they say it was cost efficient? Will, they feel pressure from patients and their enrollees to keep going with it? Uh, I know that certain payers have promised this benefit through, uh, you know, through either executive order through part of the summer, some through the, through the calendar year in certain markets. Um, how do you, Ross, how do you navigate that with, um, with payer contracting? Because it's, it's it's, you know, and I, you and I know we haven't done the payer contracting. It is patchworky, we'll talk about patchwork and other things, but it's not like all the XYZ health plans are doing the same thing across the country. It is really market dependent.
Ross: Yeah, I think, I think it's a great question. Um, you know, a big challenge we've always had with telehealth policies that the definition of telehealth is so broad and, and telehealth can be deployed in ways that are very high value for healthcare. And then other ways that there are no increased costs. And so payers are sensitive, I think, to like how we use telehealth and how we can incorporate telehealth into more of a value based, um, payment model structure.
I think what, what we've seen is that payer interest in telehealth is, is much higher than it's ever been. And the interest is really focused on, you know, how can we bring, telehealth into the core of our, of our service offerings now, and not, not simply as a supplemental benefit. And that's at least a growing that we saw the beginnings of that before the pandemic, but we're seeing, we're seeing it ever more. You know, as, as things go on, you know, in the last few months, especially, uh, so, so for example, at Doctor on Demand we're we're boring new models, where Doctor on Demand providing virtual primary care in collaboration with a payer, for example, on those, those types of arrangements are new. And, and we had a few before, before the pandemic, but there's just tremendous growth in that area. Payers recognized the power of telehealth to provide better access to primary care, um, you know, for everybody.
Sarah: So one of the things that I, you know, I've noticed with the payer models is this idea that, um, of needing a telephonic backup visit and still paying the rates of a physician office visit because that could happen because one, it could be physician user error, platform error, broadband issues. You know, we give a lot of things to go wrong and you don't want to not see that patient cause they were not necessarily able to come into the office. Um, now there's more of a professional judgment, depending on what state and geographical area you are on the risk of having someone come into the office.
What do you feel? What do you guys like Rene or Ross, like what do you think about this idea of telephonic visits, having the same way or as a, or some kind of payment mechanism around it. And what will that stick? Um, why don't you go? I don't know, Ross. Why don't you go first and then Rene, if you want to jump in after that.
Ross: Yeah, that's a great question. I mean, I think the first thing we need to do here is, is continue to invest and prioritize access to broadband because there is a significant difference between a visit where the physician can see the patients and, and do an evaluation or an exam virtually versus a visit where it's just a phone call. And, and that difference is most significant in situations where the physician is seeing or interacting with the patient for the first time. And it may not have a lot of, a lot of objective data from other sources like labs or medical records, or, um, or images. And so, so I think we have to be careful there, but, but there is a real access issue, right?
As we're reading in the papers every day, like there's, there's a lot of America that doesn't have access to broadband and so can't, can't execute a video visit with a physician, but they do have phones and they can have phone calls. And so, so it is important. I think what I'm, what I'm anticipating we're going to see is, is, is a more permissive rule structure around modality. But I think that that payers are likely going to pay differently depending on modality. Um, and I, you know, I I'm, I do see, um, growing concern within some payer circles that, you know, allowing, um, providers to do phone calls at, you know, an office rate is going to just, you know, be, be cost prohibitive. Um, as every phone call suddenly becomes, you know, a billable visit.
Sarah: That's a big change. Um, and it's been one of the things with broadband. If we look at it, it's, if you look at the poverty rate and both the rural settings and the urban deserts that we have in our country, there's you can feel the, inequality, um, in access and, um, and so what are we going to do about that?
Like even places, if you look at, I'm just trying to think of a place like Illinois, where you have Chicago and there's broadband, you get out past it. Maybe there's not as much, but even within Chicago, there are places where there's just not broadband and you wouldn't expect that, but it's true. Um, Rene, what are you, what are you, what are some of your thoughts on broadband and, and how that fits into expansion and access to healthcare?
Rene: Oh, it it's key. Um, not just for healthcare. But for other facets of life too. So one of the things that has come to the fore during this pandemic is schooling. So a lot of schools shut down and have to go to online instruction. And what they found was a couple of things that not everybody has, as Ross said, equitable access to broadband. And a lot of folks didn't have the devices by which, um, they could get the online instruction and, you know, you could have one laptop for five family members, for example. So it was not just in healthcare, it's across the board. Um, broadband is a huge issue. In fact, there's a growing movement to make access to broadband one of the social determinants of health. That's how important it is. So I think in addition to focusing on all the telehealth waivers and all these sort of policy discussions, we've had one of the, I think major issues underlying all this is access to broadband, the ability for people in rural, underserved and other communities to access the same kind of first rate services, that Doctor on Demand and others are providing, but are unable to do so because there's just not the underlying infrastructure to facilitate that kind of connection. I think that's something that as a society, we're going to have to look at very deeply and I know the FCC has been doing so, but we've got some, we've got a long way to go. We've got some work to do.
Sarah: Right, and we're looking at, you know, it's good to bring up education and healthcare and broadband because right right now, we know we're seeing surges popping up in different parts of the country, you know, as we're sitting here on June, June 12th, but we, um, we're looking into the fall and we have schools, uh, that will be starting up potentially in person. And there's also the potential in healthcare that may be in person or not in person, um, depending on what kind of care and what, what, what we look like from a public health perspective in the fall. And then there's also this opportunity, you know, in the winter, during influenza season and COVID next to each other um, and some other issues that may be happening, uh, and depending on the climate, maybe back in doors again, um, maybe back online for school and maybe back with another telehealth surge. And so, you know, some people it's like, some people want to say, well, we're done, but I don't know or I don't think we're done yet. Right, right?
Rene: No, I agree with that. Yeah. I agree with that. We are, we are not close to being done. And in fact, you know, Winston Churchill has a great quote that, "An optimist is one who sees opportunity in every difficulty." And I think this, these difficulties we're going through present tremendous opportunities for us to refashion major parts of our economy, starting with healthcare.
There's no question, our healthcare system, as a system is dysfunctional. It's fragmented. We don't need to get into all the issues because we all know them. But I think this presents some opportunities and I think virtual care, the ability to access care, um, from the home, the ability for clinicians to provide care where patients are, um, the ability to reduce sort of the distance prejudice we have, and that a lot of people who live in remote areas have to actually drive and get to a facility in order to receive services.
There, there are phenomenal opportunity to here to refashion our healthcare system. Particularly, as you look at what's coming down the pike in the next decade or so, you know, by the end of this decade, um, I think one out of every five Americans is going to be 65 and over, um, we have clinician workforce shortage issues from physicians, the nurses, the nurse practitioners, the medical and lab technologists.
We're going to have trouble finding the people to provide the care we're going to have trouble delivering that care. And I think we need to start thinking outside the box about how we are going to actually continue to think our healthcare system palatable in this country. And I think these troubles in the last four months have given us that opportunity to do so.
Now the question is, are we going to seize that opportunity? And, um, that's, that's up for debate.
Sarah: That's why I invited you and Ross to talk, because we need to hear about this. We need to hear about it from a lot of perspective. Um, Ross, I'm sure you want to add to this. Um, because I know we all think about this a lot.
What are you, what are, what do you think about this? This transformation of healthcare?
Ross: Yeah, well, I think, I think what Rene's touching on, I'm just going to get deeper in one area, which is, which is again, primary care. And if you look at where we were before the pandemic, we were, we were in a state of crisis with primary care, with respect to access. And Doctor on Demand's very existence can be explained by the fact that that people weren't weren't finding access to primary care to be acceptable. And so, so they were looking for alternatives as is true with retail clinic models. But now with the pandemic, we're seeing the complete decimation of primary care practices across the country.
And some, and some states like Texas, I think one fifth of all counties have no primary care. And in every, every week, you know, hundreds of primary care practices are going under because no one's going in. You know, due to fears about, about the virus and, and that that's a really big, big problem. And I think if you have a second wave, it's going to become a full on catastrophe because these practices are barely holding on.
But, but as, as Rene pointed out with, with a quote from Winston Churchill, there is, there is an opportunity here, which is the use of technology that we're suddenly realizing the power of, which is telehealth. Think about a new way of doing primary care in the future. I think we have an opportunity right now in this crisis is to think more bold, more boldly about policies that we can, we can reinvigorate our primary care infrastructure using using virtual care has an anchor and, and in a way of scaling primary care, increasing access, leveraging technology so we can do more in the home, which for many conditions that actually results in a better outcome, right? Because you're, you're, you're caring for the patient, the visibility into their home, and you're leveraging the devices and remote monitoring tools.
And so there is a future with respect to primary care that is very bright, that I think is, is, you know, this opportunity, this crisis is creating an opportunity to realize, and we have to seize that moment. I'm concerned that if, if our focus is solely about how do we, how do we lobby for the best, um, you know, revisions to the rules around Medicare reimbursement under the service, um, under part D and we don't, we don't think more broadly about, okay, how do we, how do we reconfigure a healthcare system so that we have a strong primary care foundation so that we provide access to key specialists across the country, uh, when needed and things like that, we're going to miss the opportunity. And what concerns me is it's most of the discussions right now are very tactical. On the, how do we, how do we increase the payment here or there rather than, okay, how do we, how do we more boldly revise and improve our healthcare system, leveraging these new technologies?
Sarah: So Ross, one of the things that I've been thinking about a lot, and I w w thinking about it before, I think about the passage of the affordable track that was trying to fund, like, for example, primary care, knowing that there was a surge back in 2010, and we're now 10 years later, um, and the pandemic, um, you know, is, do we need to change the educational system for physicians and primary care doctors? And is it techno, you know, we've we've we saw, I mean, I remember the first time like that, oh, an iPad is going to be used in a residency program or something, and that was like, you know, wow, that's shocking. Um, that's not shocking anymore, but so are we, do we need to focus on technology, edu, and integrating education and also just this idea, that there may be another pan, I don't know when we'll be out of this pandemic and maybe another pandemic or other crises we're in other crises, we have racial justice crises. We've got homeless crisis. We have, we have a lot of public health crises that are going on in the background that are obviously amplified during the pandemic.
Um, so should we be one of the places should we go, is it the education system for physicians and the pipeline or other health or other health care providers?
Ross: What's different about today. I know this, this might seem a little extreme, I'm about to say is like we've we've had for 2000 years have a certain type of doctor-patient relationship where the doctor has a monopoly on knowledge. Uh, the doctor is the expert and, and has, um, kind of control over the care of the patient. But what we've seen in the last 20 years is a bit of a, like, Information technology has, has changed that equation, right? So people have access to a lot more information. They have access to devices and tools. As you mentioned earlier, Sarah AI is developing, you know, AI tools are, are progressing to a point where certain paths will be able to diagnose certain conditions better than doctors. And, and it's, it's changing the role of the physician in society and in the way that physicians work with patients within the traditional doctor, patient relationship. And, and so I, you know, and I think that that's disruptive, but, but potentially very positive if we can harness the technology correctly.
And I think it does begin with, with medical school training is to like, what is the role of the future the future physician, um, the future primary care physician, the future specialists, right? It's going to change because of these technologies and, and I'm not sure our, our institutions have caught up to that.
Or, you know, gotten ahead of this.
Sarah: So Rene, I go on the flip side of that, which is from the patient perspective, looking at these, um, these corporations, especially in healthcare, but in other industries is idea of like trust. Like you have my data and I, I have to trust you. If you look at what happened, for example, with Facebook and the things that were happening before the pandemic around you have my data and what were you doing with it? And we were seeing that starting to happen and go into healthcare with some arrangements. And I think in healthcare, people were a little surprised. It's like, cause I'm your doctor, I'm your hospital. And I'm here for you. And I'm trying to help you. And this idea of looking at them as consumers and not just as like patients and this idea of trust, just kind of change. And now we've had this pandemic of how do we look at things such as data privacy and cyber security and data, especially with the public health overlay that's happening in the data that we need. How do we look at that?
How do, how do companies look at that and how do we, where, where should we go to advocate? And how do we balance all these different needs that we have right now during this pandemic?
Rene: Yeah. And so I wouldn't just limit it to the pandemic. I think you bring up a very important issue, which is, there are so many different sectors who are becoming increasingly important in healthcare that were not conventionally the case in the past. And Ross touched on this a little bit in his, in his remarks. And so we have technology companies, we have data companies, we have AI companies, we have others who are increasingly important in the healthcare sector. And we also have a social determinants of health movement, um, that is getting and, um, analyzing data that is not traditionally healthcare center data and how important that is and the overall health of the patient. So you've got all these new players that are getting involved. We've got old legacy laws, old legacy systems that don't necessarily apply. And so I think we have to reimagine, um, our regulatory and policy approach, particularly when it comes to the privacy issue.
I think one of the things at CTA that I we're pretty consistent with this is we believe, um, that we need one standard. Um, and we think the federal government ought to have a, a comprehensive privacy law, um, that is flexible, that balances innovation and trust and all the other issues that, um, folks talk about when they talk about privacy. Um, there are too many state laws, some have conflict with each other. There's too many compliance issues when it comes to privacy, particularly in dealing with the states, so we do believe in preemption of state law. And I think that would get us on the way to ensuring consumer trust because they know there's a standard to federal government law. Um, and, uh, folks who are handling certain kinds of data have to adhere to that law. I think that would go a long way. As it is it's sort of a wild west, um, and some, believe it or not, there are a lot of folks at industry who actually value privacy and value trust. So, so for example, for us in the fall, we just, um, renewed, uh, updated, I should say our guiding principles for the privacy of health and wellness information. And we put together a work group that really analyze and look closely at privacy issues and came up with some very sort of top line principles that any organization that's dealing with, personal health information, uh, ought to consider. Um, and these are folks that are not necessarily covered under HIPAA. So one of our principles for example, is be open and transparent about the personal health information you collect and why. You would think that simple, but a lot of organizations don't do that. Just, um, convey to the consumer, what you're collecting and why you're collecting it. It seems simple. Um, be careful about the personal health information you collect. Um, and then we go through a series of recommendations. So industry has taken it upon itself to develop a lot of these principles because there's a vacuum and that vacuum, I think, exacerbates some of the trust issue you're talking about, but we're hopeful that if not in this Congress, the next Congress, that there will be federal, federal privacy law that is balanced. That makes sense. That doesn't stifle innovation.
Sarah: Thanks, Rene. Um, so I think what I'd like to do is to have you both leave the audience with something, um, to make you think about the future home.
Um, Why don't we start with Ross, um, Ross and I have been worked on transactions together. We actually ended up speaking on something together that actually prompted me that I could take a different direction in my career, when I was sitting there on a panel, talking about all the barriers to innovation and decided instead of being a barrier I'd like to, to be somebody who can help navigate it or advocate for it.
Um, so I'd love to hear what you'd like to leave the audience with Ross.
Ross: Yeah, I think, I think I'd like to leave the audience with is just a point Rene made. I want to emphasize, which is, you know, we can look at a technology like virtual, virtual care telemedicine in a very narrow way. It's just like another tool for physicians. Or where we can look at a technology like virtual care as, as somebody that could, that could open up a new way of practicing medicine and, and result in meaningful positive change. And, um, you know, and how we do things like primary care and behavioral health. And I think depending on the lens of what you look at these technologies, you're going to have very different ideas as to the potential and the advice you give the clients is going to be different. The, the policies you advocate for will be different.
And I would just urge everybody to think more broadly about like the power of these technologies. And it's not, it's not simply like in the case of telemedicine, it's not simply, um, you know giving a doctor the ability to do Zoom with a patient or Skype with a patient. There's, there's a lot more to it. There's a lot more power in this, in this modality and we need to harness it.
Sarah: Great. Rene, what would you like to leave the audience with? And, um, what would you want them to know?
Rene: I think we were at an inflection point in many ways, there are tremendous difficulties, um, that have been exposed, um, by COVID-19. But I think they also present tremendous opportunity. Um, and technology is part of that opportunity.
It's not a panacea obviously, but I think it's a significant aspect of how we can reimagine what health care looks like. It can be an important aspect of how we democratize healthcare, how we increase access to healthcare services for all Americans. And so this is an opportunity for us to do that because I think people's eyes have been opened in a way that wasn't the case pre-pandemic.
And so if we don't take advantage of this opportunity, what another six to eight months, I'm afraid we're just going to go back in many ways to pre-pandemic days with slow changes here and there at the margins without actually taking the opportunity to potentially revolutionize the healthcare system for the better.
Sarah: Thanks Rene. I think that's a great way to end this podcast and I, I really appreciate, uh, Rene and Ross, you joining us today. Um, all those on the audience, please check out the AHLA, um, coronavirus hub. There's actually other podcasts there. There's other, uh, AHLA GC Roundtable podcasts that you can listen to.
And I really appreciate everyone joining us today. Thank you.