Alexis Gilroy is a lawyer based in Washington D.C. and a partner at Jones Day. She is a nationally recognized expert specializing in healthcare and technology. She has particular expertise in telemedicine and “compact” legislation, the evolving process for physicians to care for patients across state lines. She offers her perspectives on the innovation and the changing legal requirements.
First Alexis, I just wanted to ask: You’re a lawyer; how did you get into healthcare?
At heart I’m an M&A attorney. In early 2000 I found myself doing a number of mergers & acquisitions with some very innovative companies, the likes of Web MD and other teleradiology companies. [Through that] I found my way to the regulatory and grittier healthcare topics by doing the deal work. It still ties to where I sit between the [legal and financial concerns in catalyzing healthcare]. The deal/business lawyer in me appreciates the scalability; what’s the underpinning goal of the business actors here, as to why the regulations matter and how you can think about scaling and evaluating them.
We certainly need that role to catalyze innovation. As a physician I’m always struggling with this balance between healthcare costs and safety. We put a lot of things in place to keep the patient safe, but many of those things also drive up the cost of healthcare. Do you have any thoughts around some of the legislation historically that we put in place around that? Moving forward there’s a lot of evolving technology that could improve care, but we have to do it safely.
It’s the same task at play. Obviously it’s nothing new or specific to digital health. In a perfect environment you’d be able to take a blood sample the moment a baby is born and know every genetic possibility and be able to plan for that and have all sorts of treatment plans on day one. We all know that it’s just not viable. Even if it were technically possible, the cost involved in that wouldn’t make it feasible.
What’s interesting about telehealth is that we have an interesting possibility with technology. Technology will generally bring down costs. I think we’re at the inflection point in the technology cycle with digital health tools. It enables folks to be more efficient; to do things in a more streamlined and thoughtful fashion and in a more educated fashion. Those things directly tie to safety.
There’s been a lot made in the press lately of digital health: Can you do audio? Can you do video? What’s the safe course? I think the better conversation with digital health is, how is digital health advancing the standard of care? What models are out there? What’s the teleneuro model, which is bringing neurologists directly to the point of care with the patient and assisting the ER doc to evaluate that patient? In some places in the United States that was unheard of previously. They couldn’t afford to have neurologists on site, so that is technology advancing the standard of care and bringing down costs. I think what’s really phenomenal about digital health is that you have the ability for the first time to use this technology to put these two things [together] that have often been out of balance. We need to think about it with the right kind of models though. I’m very positive on the topic of digital health.
At both the federal and state level there have been barriers to telehealth. I know you’ve been a leader in the “compact” legislation. Basically as a physician I need a license to practice medicine in every state in the US. Sometimes that doesn’t make a lot of sense. Compact legislation hopes to have compacts or rules between states to allow physicians to practice across state lines, to lower the cost for physicians to care for folks. What are your thoughts on compact legislation? What might things look like in 12 or 24 months?
This area is another bright light as we try to break down historic barriers to advancing telehealth. Like it or not, we live in an environment where certain laws are designated to be monitored by the state and others by the federal government. An important one is regulation, [which] applies to both my profession—law—and yours—medicine. The current proposed compact out there for physicians [involves] 13 or 14 states, if not more, that have passed legislation in little more than a year since the compact draft first came out. No easy feat, [but] it only took 7 to make the compact effective. The compact is now getting itself in order, getting all the folks together, drafting all the rules to enable it to work the way it’s intended to work. What it will essentially allow folks to do is to hold a license in each of the jurisdictions where they elect to use the compact. It should become effective early in 2017.
There’s a great website, licensereportability.org that anyone can follow to see which jurisdictions are adopting the model compact legislation. In short, if you want to get licensed in one of the states that are party to the compact, you would select that state, submit all your materials, your license, etc. and that would be the only time you would have to submit that paperwork. If you want to be licensed in other member states, you just check them off. You will have to pay a fee in the other states as well but once you submit that paperwork [that one time] you will be licensed in all those states in which you elect to receive licenses through the membership compact.
That would be a huge advantage [not to] have to fill out all those forms. It’s truly burdensome for physicians to do that today. The Affordable Care Act has some implications for telemedicine as well in terms of how telemedicine is being looked on by the payers. What does that mean for the future given the [ideological differences] between Republicans and Democrats. How will a focus on telemedicine impact healthcare more broadly?
Whether it’s the Affordable Care Act or the newer models that have been popping out (MACRA), the focus all around is value-based care. They’re changing the way that payers are paying for healthcare. They’re providing more lump-sum payments and allowing the healthcare provider to decide how to meet the objectives, goals, and outcomes for patients with a set amount of dollars. Just like any smart user of funds, they’re likely to look to technology to be able to make their providers very efficient in doling out that limited amount of funds. If they’re efficient and also meet the goals for cost and safety—safety being the incentive for outcomes—they may even be able to hang on to more of those dollars. More folks are thinking about MACRA and the various MIPs and ACOs goals and bundled payment programs [and] different global billing programs, etc. They’re continuing on an ongoing basis to think how they can use telehealth monitoring tools, etc. to get these funds and remain efficient so that more of the funds stay in their pocket.
The goal of the ACA is to manage the healthcare continuum but the first and most visible foray I’ve seen with telehealth is this idea of providing [such services as] online urgent care. I wonder if that’s the right strategy for many of these healthcare systems. Often when you meet a doctor online it’s not the doctor you know. There’s no relationship. What are your thoughts on these online urgent cares and the direction healthcare systems should go moving forward?
The last thing we want is more siloed care, putting the patient in the [position] of having to gather all the information and to coordinate their own care. We need to help them coordinate that care. In my role I work with a variety of healthcare systems using telemedicine across the US and internationally, and I’ve observed more and more the hospitals and healthcare systems—our traditional network, the mother ship if you will—are looking at a network of care with direct-to-consumer online care. In fact we’ve negotiated a number of partnerships now, and that’s a smart play for both organizations and patients. It connects them to the regional healthcare systems and also enables those systems to have another means to serve their patient population and increase their brand, and [provides] other wonderful outcomes for them. As they also move to value-based care this will allow them to get ahead of things with their patient population, to gather that data about urgent care experiences of their patient population rather than that [task] being siloed out to another care provider. This is slow and will be balanced against the ongoing movement of employers to contract with the direct consumer care providers, which has been the primary business model, but the hospitals recognize that it’s pretty hard for them independently from a cost perspective to stand up a multi-jurisdictional platform for direct-to-consumer, and it’s much easier for them to do that by partnering with one of these existing organizations that have the infrastructure in place to achieve that.
I would like to see the hospitals adopt a strategy where online urgent care is a doorway to other services, where there’s a clean handoff of that patient and some follow-up so they get the care they need.
Alexis we’re almost out of time. I know you have a broad experience in the financing of healthcare and have a lot more to say about the innovator. I hope [we can continue the conversation] in the future.