When you think about digital health, many people take for granted that the patients are going to have the devices and connectivity to be able to do things like telehealth visits and remote patient monitoring (RPM). While the number of people who have both is large, there’s still a significant section of patients who don’t have access to one or both of these things. Plus, these are often some of the most vulnerable people who need healthcare the most. Bridging that technology gap that often includes a health equity gap is a real challenge.
This was illustrated well in a VA program which would issue devices to veterans to be able to take part in virtual visits. The goal of the program was to bridge the digital divide that existed for many veterans who didn’t have the right device or connectivity to receive virtual care. Considering the VA is basically a self insured employer when it comes to veteran care, it makes sense that they would want to do as much healthcare as is clinically possible via virtual care and that they’d want to overcome the digital divide to offer the best care to all veterans.
According to a recent OIG report, the program was successful to a degree, but fell well short in a number of important areas. When it comes to issuing the devices to patients, the program was quite successful as they put 41,000 devices in patients hands in the first three quarters of 2021. That’s a large number of devices to distribute to patients.
Unfortunately, it seems like these devices were not always used to connect to the intended video telehealth visits. Only an estimated 20,300 (49%) of patients issued a device actually did a video telehealth visit. That’s a lot of patients with devices that never used them for patient care. What’s even more shocking is that 10,700 of the patients who got devices never even had a video telehealth visit scheduled. That means about 10,000 patients who had a video telehealth visit scheduled decided not to go. I’ll admit that I don’t know the VA’s cancellation rate which may be higher since their care is essentially “free” for veterans, but I’d have to think that a 25% cancellation rate on telehealth appointments is high even for the VA.
Due to poor processes, the program also issued 3,119 patients multiple devices despite guidance that limited devices to one per patient. The program also required retrieval of the devices after 90 days, but OIG found that about 11,000 unused devices were not retrieved. Some of them did eventually use the devices for a video appointment, but as of the report 8,300 still had never had a video visit which amounts to about $6.3 million in cost to the VA and $78,000 in cellular data fees on top of the device cost during the period they reviewed. The VA also had a backlog of 14,800 returned devices that were pending refurbishment and thus not being used by patients.
That’s a pretty scary report. In some regards they may want to rebrand this a free veteran device program as opposed to a telehealth program focused on bridging the digital divide. Plus, examples of dysfunction like this is why many of us worry about a single payer government run health system, but I digress. These aren’t unsolvable problems, but it seems like no one was really being incented to solve them.
While I could hammer on government processes for a long time, there’s a lot we can learn from this program as other healthcare organizations consider offering devices to their patients to address the digital divide.
First, it’s essential to have a clear plan of action for how the patients will use the device. The first appointment should be scheduled as part of device onboarding.
Second, delivering the devices quickly to patients is likely key. Otherwise, the device may arrive after the visit is supposed to happen.
Third, refurbishment programs are harder than they look. It’s hard to imagine most healthcare organizations would be good at executing a program like this. Instead, it would likely be better to rely on companies who do refurbishment all the time to do it.
Fourth, if patients don’t have skin in the game, don’t be surprised if you don’t see the devices return. And you can’t really deny care because they haven’t returned the device.
It’s hard to imagine a future that doesn’t require more devices to remotely monitor and connect patients to their doctor. Value based care will require it and many of the most vulnerable and expensive patients don’t have access to devices and/or bandwidth to do this. So, we’re going to have to figure out a way to bridge this digital divide. However, the VA’s experience is a cautionary tale for what could go wrong without proper oversight, planning, and incentives.
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