How to Measure the Value of Virtual Health Care

How to Measure the Value of Virtual Health Care


                 How to Measure the
                 Value of Virtual
                 Health Care
                 by Meg Barron, Vimal Mishra, Stacy Lloyd, and Jared Augenstein

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How to Measure the Value of Virtual Health Care
HBR / Digital Article / How to Measure the Value of Virtual Health Care

                 How to Measure the Value of
                 Virtual Health Care
                 by Meg Barron, Vimal Mishra, Stacy Lloyd, and Jared Augenstein
                 Published on / June 24, 2021 / Reprint H06FNF

                 Steven Puetzer/Getty Images

                 The Covid-19 pandemic has spurred a dramatic increase in virtual
                 health care in the United States. The rise has been driven by the need for
                 social distancing and enabled by a wide range of policy flexibilities
                 implemented by federal and state legislators, regulators, and payers.
                 However, many of these allowances are temporary. As the pandemic ebbs,
                 policymakers and payers are deciding whether and how much to pay for
                 virtual care services in the future, leaving clinicians uncertain about
                 whether they will be able to afford to continue their virtual care programs.
                 But parties are often making these decisions based on outdated or limited

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How to Measure the Value of Virtual Health Care
HBR / Digital Article / How to Measure the Value of Virtual Health Care

                 measures of success that do not holistically reflect the realities of how
                 value is being generated.

                 To address this need, the American Medical Association (AMA) and Manatt
                 Health, a legal and consulting firm, have developed a framework for
                 assessing the value of digitally enabled care. It accounts for the various
                 ways in which virtual care programs may increase the overall “return on
                 health” by generating benefits for patients, clinicians, payers, and society
                 going forward. The framework can be used by care providers to develop
                 and evaluate new digitally-enabled-care models, by payers to inform
                 coverage and payment decisions, and by policymakers to establish
                 regulations that guide the future of virtual care.

                 Before the Covid-19 pandemic, virtual care adoption was slow going and
                 represented less than 1% of overall health care volume. In most cases,
                 virtual care existed outside of the traditional health care delivery system
                 and was often uncoordinated with in-person care. A patient would develop
                 a fever over the weekend and would see a virtual urgent care provider
                 who, in most cases, was not his or her primary care provider. Some
                 innovative health systems or tech-enabled health care delivery companies
                 such as One Medical and Cityblock Health had implemented integrated
                 virtual care tools, but for the most part, the virtual care ecosystem existed
                 in parallel to and disconnected from the in-person health care ecosystem.

                 Accelerated by the pandemic, we are entering an era, where in-person and
                 virtually enabled care will be seamlessly integrated and the mode of care
                 delivery will be based on clinical appropriateness (i.e., when telehealth
                 should and should not be used) and factors such as convenience and cost.
                 When given the option of telehealth during the pandemic, patients largely
                 saw their existing physicians for their needs versus a new provider.
                 Digitally-enabled-care models will be developed across the full range of
                 disease acuity and across all clinical conditions. The integration of new
                 digital health solutions such as video visits, remote monitoring,
                 asynchronous telehealth, continuous and passive sensors, and AI into

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How to Measure the Value of Virtual Health Care
HBR / Digital Article / How to Measure the Value of Virtual Health Care

                 digitally-enabled-care models offers the potential to provide access to
                 high-quality care and positive patient and physician experiences at a lower

                 While there has been much progress, the existing body of evidence for
                 telehealth is narrowly focused on short-term measures of the financial
                 value of virtual health. There is much opportunity to now gather details on
                 broader benefits such as improvements in access to care, clinical
                 outcomes, the impact on the patient and clinician experience, the potential
                 for operational efficiencies, and the impact on health equity. These benefits
                 will also vary based on a wide range of factors that affect value and
                 outcomes such as payment models, virtual care modalities (e.g., audio/
                 visual visits, asynchronous), or the clinical use case. That’s why we
                 developed a comprehensive framework to help stakeholders measure the
                 various ways in which virtual care programs can generate value based on
                 their specific imperatives.

                 Measuring the Value of Virtual Care

                 To do so, we examined the existing literature on telehealth’s impact and
                 interviewed national experts on virtual care delivery, financing,
                 technology, and research. We also consulted with current and former
                 leaders of Ochsner Health System, Virginia Commonwealth University
                 Health, Cityblock Health, the Healthcare Financial Management
                 Association, Harvard Medical School, the Medical Group Management
                 Association, private practices, and others.

                 The framework describes several environmental variables that impact
                 distinct value streams, which collectively seek to capture the overall value
                 derived from a specific digitally-enabled model. The environmental
                 variables include practice type, payment arrangement, patient population,
                 clinical use case, and virtual care modality. The framework is flexible
                 because it acknowledges that different provider organizations will have
                 different clinical or business rationales for pursuing different models based
                 on their environmental and strategic context. For example, a small rural

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                 primary care practice with a largely Medicare population paid on a fee-for-
                 service basis will experience the value of digitally-enabled care very
                 differently from a large vertically-integrated regional health system.

                 Next, the framework includes six value streams: clinical outcomes, quality,
                 and safety; access to care; patient and family experience; clinician
                 experience; financial and operational impact; and health equity. The
                 impact of a digitally-enabled-care model should be measured on all these
                 value streams — a Balanced Scorecard approach, if you will, to measuring
                 and realizing the full potential of virtual care.

                 Some leading health systems are starting to measure value more
                 holistically. One is VCU Health a Virginia health care system, which
                 increased virtual visits from less than 1% of outpatient psychiatry visits to
                 more than 90% last year in response to the pandemic. It has begun to
                 evaluate the impact of its new virtual model on the various value streams
                 in the framework and has identified some novel findings. For instance, the
                 visit no-show rate (an element of financial and operational impact)
                 dropped from 11% pre-pandemic to 6% during the pandemic, and VCU
                 Health is now considering how it can use virtual care to reduce the
                 number of wasted time slots to improve its operational performance and
                 improve access (another value stream). VCU Health is also measuring the
                 impact of virtual care on health equity given concerns that older people
                 may not be as digitally savvy as younger people; it found that there were
                 no differences in access to care by age group when delivery shifted from
                 nearly all in-person visits to nearly all virtual visits. This report provides
                 additional case studies from organizations such as Ochsner Health and
                 Massachusetts General Health and resources, such as upcoming sessions
                 and virtual discussions for the industry to share their own experiences.

                 Virtual care is here to stay, but many stakeholders across the industry are
                 in the process of determining how best to invest in their programs and
                 measure their success. This value framework can help.

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                 The authors wish to thank Jacqueline Marks and Michelle Savuto from
                 Manatt Health and numerous AMA colleagues for their valuable
                 contributions to this article.

                                  Meg Barron is vice president of digital health strategy at the American
                                  Medical Association.

                                  Vimal Mishra, MD, is director of digital health at the American
                                  Medical Association (AMA) and a medical director and associate
                                  professor of medicine at Virginia Commonwealth University (VCU).

                                  Stacy Lloyd is director of digital health & operations at the American
                                  Medical Association.

                                  Jared Augenstein is a director with Manatt Health, an interdisciplinary
                                  policy and business advisory group of Manatt.

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        2021-07-28 QPSC A2 Article More Hospitals Impose
              Vaccine Mandates for Employees NYT

7/22/2021                                     More Hospitals Impose Vaccine Mandates for Employees - The New York Times


More Hospitals Are Requiring Workers to Get Covid Vaccines
With some health care workers still refusing to be immunized, medical centers around the country are requiring shots as cases climb once

         By Reed Abelson

July 21, 2021

More and more hospitals and major health systems are requiring employees to get the Covid-19 vaccine, citing rising caseloads fueled by
the Delta variant and stubbornly low vaccination rates in their communities and even within their work force.

Many hospitals say their efforts to immunize their employees have stalled, in much the same way the nation’s overall vaccination rates are
stuck under 60 percent, behind many European countries and Canada. While more than 96 percent of doctors say they are fully
vaccinated, according to the American Medical Association, health care workers, particularly in rural areas, have proven more resistant
even though thousands of workers have died from the virus and countless more became sick.

One recent estimate indicated that one in four hospital workers were not vaccinated by the end of May, with some facilities reporting that
fewer than half of their employees had gotten the shots.

Some hospitals, ranging from academic medical centers like NewYork-Presbyterian and Yale New Haven to large chains like Trinity
Health, are going ahead with a mandate because they recognize that the only way to stop the virus is to vaccinate as many people as
possible, as quickly as possible. A large Arizona-based chain, Banner Health, announced Tuesday that it would impose a mandate, and
New York City said it would require all health care workers at city-run hospitals or clinics to be vaccinated or undergo weekly testing.

Watching cases rise prompted Trinity Health, a Catholic system with hospitals in 22 states, to become one of the first major groups to
decide earlier this month that it would mandate inoculations. “We were convinced that the vaccine can save lives,” said Dr. Daniel Roth,
Trinity’s chief clinical officer. “These are preventable deaths.”

At UF Health Jacksonville, in Florida, the number of Covid patients being treated has surged to levels not seen since January, and only
half of its health care workers are vaccinated, said Chad Neilsen, the director of infection prevention. Seventy-five employees are out sick
with the virus, the vast majority of whom are unvaccinated, while more are waiting for test results. “We are absolutely struggling for
staffing right now,” he said.

“It’s like déjà vu,” said Mr. Neilsen, who described growing frustration with colleagues refusing to get the shots. “We have a reason to
believe this could be over if people got vaccinated.”

Despite dozens of virtual town halls, question-and-answer sessions and educational videos, many employees are wary. “We still
stagnated,” Mr. Neilsen said.                                        1/4
7/22/2021                                       More Hospitals Impose Vaccine Mandates for Employees - The New York Times
                                      Dr. Leon Haley Jr., chief executive of UF Health Jacksonville, getting the shot in
                                      December. Bob Self/The Florida Times-Union, via Associated Press

Some employees want more data, while others say the process has been too rushed. Many of the same conspiracy theories and
misinformation — that the vaccines will make women infertile or contain microchips — hold sway among staff members. “Our health care
workers are a reflection of the general population,” he said.

Hospital leaders and others plan to meet with state officials in the coming weeks about the possibility of imposing a mandate, he said.

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   places you care about each day.

Unvaccinated workers also continue to care for even the sickest patients, raising concerns that they will spread the infection, especially
now that the highly contagious Delta variant comprises more than 80 percent of the nation’s cases.

“Nowhere is this more important than in hospitals, where health care personnel — who have been heroic during this pandemic — are
caring for patients with a wide variety of health challenges under the assumption that the health care professionals treating them are not
at risk of acquiring or transmitting Covid-19,” Dr. David J. Skorton, the chief executive of the Association of American Medical Colleges,
which represents teaching hospitals, said in a statement last Friday calling for a mandate.

On Wednesday, two more groups, including the American Hospital Association, joined the growing clamor for vaccine mandates. “We have
lost too many of our caregivers to Covid-19,” said Dr. Bruce Siegel, the chief executive of America’s Essential Hospitals, which represents
hospitals in underserved communities. “Vaccination can reduce the risk we lose more.”

With formal approval of the vaccines by the Food and Drug Administration potentially months away, hospitals find themselves at the
center of the national debate over whether to impose mandates. While the vaccines are being offered under emergency use authorization,
supporters argue there is ample evidence that the ones available in the United States are both safe and effective.

In states like Missouri, which has reported a sharp increase in cases, there is newfound urgency. “We felt we could not wait,” said Dr.
Shephali Wulff, the director of infectious diseases for SSM Health, a Catholic hospital system whose headquarters are in St. Louis. SSM,
where about two-thirds of employees are now vaccinated, is requiring everyone to get their first dose by Sept. 1.

SSM’s decision was also motivated by concern that Covid infections could spike this fall when there could also be a surge in other
respiratory infections. “We need a healthy work force going into the flu season,” Dr. Wulff said. “We do not have the time to wait for

                                      Doses of the Pfizer-BioNTech vaccine at the University of Iowa Hospital in
                                      December. Kathryn Gamble for The New York Times

But some systems are already worried about staffing shortages caused by departures during the pandemic, with many employees quitting
because of the stress and burnout experienced by caring for Covid patients. Hospitals are hesitant to risk losing more workers if they force
the issue.

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7/22/2021                                         More Hospitals Impose Vaccine Mandates for Employees - The New York Times

     Latest Updates ›
     Updated July 22, 2021

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“They are afraid it could be a tipping point,” said Ann Marie Pettis, the president of the Association for Professionals in Infection Control
and Epidemiology, one of the professional organizations that is urging hospitals to require the vaccine.

At Mosaic Life Care, a small Missouri hospital group, executives are reluctant to adopt a mandate if other hospitals do not. “We have the
potential to lose some caregivers to other systems,” said Joey Austin, a spokeswoman for Mosaic, which has vaccinated about 62 percent
of its staff.

Many hospitals already require their employees to get a flu shot, a mandate that has been in place for over a decade. While that was also
met by resistance from employees skeptical of the vaccines’ safety, it is now largely accepted. Individuals can seek a medical or religious
exemption, typically representing a small sliver of the work force, which hospitals say would also apply to the Covid vaccines.

Mandates “establish a social norm and say it’s an institutional priority,” said Saad B. Omer, the director of the Yale Institute for Global
Health, who emphasized that hospitals need to strongly encourage workers to voluntarily get the vaccines to be successful.

Unions like the National Nurses United and 1199 S.E.I.U. say they want members to be vaccinated but oppose making it a condition of
employment. At the first hospital to impose a mandate, Houston Methodist, a group of employees sued to challenge the requirement but
the lawsuit was recently dismissed. About 150 employees ultimately resigned or were fired for refusing to meet the deadline for
vaccination out of a total work force of some 26,000 people.

                                        Workers protested vaccine mandates outside the Houston Methodist Baytown Hospital in
                                        Baytown, Texas, in June. Yi-Chin Lee/Houston Chronicle, via Associated Press

Hospitals say they are working hard to dispel much of the pervasive misinformation around the vaccines, even among physicians and

“I have to remind them that reputable scientists do not publish their findings on YouTube,” Dr. Wulff said. In addition to presenting hard
data about the vaccine, she and her colleagues at SSM are also sharing their personal experiences, like getting vaccinated while trying to
get pregnant. “What I’m finding is people are moved by stories and anecdotes,” she said.

“Generally it’s a lot of listening and homing in on what is driving their fear,” Dr. Wulff said.

Some high-profile systems like Intermountain Healthcare and the Cleveland Clinic are waiting. The clinic, which has a sprawling network
of 18 hospitals in the United States, said existing policies, like masking and closely tracking infections, protect patients and workers.

“We know if we ensure these safety precautions are in place we know we can continue to keep our patients and caregivers safe,” said K.
Kelly Hancock, the Cleveland Clinic’s chief caregiver officer.                                             3/4
7/22/2021                                                          More Hospitals Impose Vaccine Mandates for Employees - The New York Times

About three-quarters of employees are now vaccinated, and efforts are continuing “full force,” she said.

At Intermountain Healthcare, based in Utah, “a good majority” of employees are vaccinated, said Dr. Kristin Dascomb, medical director
for infection prevention and control and employee health.

If more safety data is compelling and the F.D.A. approves the vaccines, Intermountain may require immunization along with other
hospitals in the state. “We are starting the conversation now in Utah,” she said.

The lack of full F.D.A. approval has also influenced other hospitals. Mass General Brigham, which has vaccinated more than 85 percent of
its work force, said it would adopt the requirement as soon as the vaccines were approved.

                                                      A nurse at the University of Iowa became emotional after receiving her first dose of the
                                                      vaccine in December. Kathryn Gamble for The New York Times

Some hospitals argue a mandate is not necessary. “In my opinion, there isn’t one right answer,” said Suresh Gunasekaran, the chief
executive of the University of Iowa Hospitals & Clinics. About 90 percent of its workers are now vaccinated, he said, adding that he was
confident that virtually everyone would be immunized by the end of the year.

The system has been “successful in chipping away” at vaccine hesitancy, Mr. Gunasekaran said, in part because Iowa was involved in the
clinical trials for the Pfizer-BioNTech vaccine.

Northwell Health, the large New York hospital group, does not require workers to be immunized against the flu but about 90 percent of its
work force is vaccinated against it, said Maxine Carrington, Northwell’s chief human resources officer. It is taking a similar approach to

“We want people to be believers,” Ms. Carrington said, so they are better able to persuade the community at large to get vaccinated. She
described the system as “pounding the pavement on education, education, education.” About 76 percent of its work force is currently
vaccinated against Covid. Northwell will revisit the idea of a mandate after F.D.A. approves the vaccines, she said.

Yale New Haven Health is now requiring employees to get vaccinated, as have the other hospitals in Connecticut.

“From the very beginning, we messaged that it isn’t mandatory — yet. We emphasized the yet,” said Dr. Thomas Balcezak, the chief
clinical officer for Yale.

“Health care has to lead,” he said.

Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The
Times since 1995. @ReedAbelson
A version of this article appears in print on , Section A, Page 12 of the New York edition with the headline: More Hospitals Are Requiring Workers to Get Covid Vaccines                                                                         4/4
Separator Page

      2021-07-28 QPSC A3 Article New York to Require Vaccination or Weekly
                      Testing for City Health Workers NYT


New York to Require Vaccination or Weekly Testing for City Health
The new city policy takes aim at improving vaccination rates at public hospitals. Around 60 percent of workers in
the city’s public hospital system are vaccinated.

         By Joseph Goldstein

July 20, 2021

For months, Mayor Bill de Blasio has been reluctant to make coronavirus vaccinations mandatory for anyone, hoping
that encouragement, convenience and persuasion would be enough.

But with two million adult New Yorkers still unvaccinated — including a high percentage of employees in the public
hospital system — and the Delta variant threatening the city with a third wave of cases, City Hall is trying out a new
tactic: requiring workers in city-run hospitals and health clinics to get vaccinated or else get tested on a weekly basis,
the mayor’s spokesman said Tuesday.

The new policy, which will be announced by Mr. de Blasio on Wednesday and goes into effect at the beginning of
August, goes nowhere near as far as San Francisco’s announcement last month that it would eventually require all
municipal employees to get vaccinated. Still, it is Mr. de Blasio’s first move to require any city employee to show proof
of vaccination or a recent negative coronavirus test as a condition of showing up to work, city officials said. It will
apply to more than 10 percent of the well over 300,000 people who work for city government.

It remains unclear whether City Hall intends to expand this approach to other city employees — police officers,
teachers, clerical workers — or will limit this to those who work in hospitals and clinics.

“It’s all about the safety of a health care setting,” Bill Neidhardt, the mayor’s press secretary, said of the policy.

Hospital workers were the first group to get access to Covid-19 vaccines, when the city’s vaccination campaign kicked
off in December amid New York’s second wave. Seven months later, the vaccination rate among workers in New York
City’s public hospital system is slightly below the citywide average for adults, to the dismay of public health experts
and government officials.

City Hall’s policy — which is more of a mandatory testing policy than a mandatory vaccination policy — seems crafted
to avoid litigation or a fight with labor unions. Some of the largest labor unions representing city health care workers
have publicly stated their opposition to mandatory vaccination requirements.

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The city’s new policy will apply to the entire 42,244-person work force of the public hospital system, Health and
Hospitals. The system has 11 hospitals, which include Bellevue and Elmhurst, as well as nursing homes and clinics.
The policy will also cover some employees of the city’s Health Department.

There are still two million adult New Yorkers who have yet to receive a dose of any coronavirus vaccine.

As the initial crush of adults eager to get vaccinated began to subside in late April, the city tried knocking on people’s
doors and offering shots in settings ranging from subway stations to museums, among other tactics. And yet that has
not done much to jump-start the flagging vaccination campaign. Each day, fewer than 10,000 New York City residents
on average are opting to get their first shot.

Getting more adults vaccinated is a pressing concern as the Delta variant has already sent case counts spiking to
nearly 600 a day in the last week, more than double the daily average in late June.

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And while nearly 54 percent of city residents of all ages are fully vaccinated — some five percentage points more than
the national average — there are some neighborhoods with far less protection. The vaccination rates across the Bronx
and Brooklyn are below the national average. Black neighborhoods and Orthodox Jewish neighborhoods in particular
tend to have lower vaccination rates, with as few as 35 percent of residents fully vaccinated in some ZIP codes.

Hospital workers tend to be vaccinated at slightly higher rates than the general population. Across New York City, 70
percent of hospital workers are fully vaccinated, according to state data, compared with an adult citywide vaccination
rate of nearly 65 percent.

But within the city’s public hospital system, Health and Hospitals, the vaccination rate is markedly lower. Almost 60
percent of the system’s work force is vaccinated, a Health and Hospitals spokesman, Christopher Miller, said.

One reason for the low rate, city officials have said, is intertwined with the demographics of the public hospital
system’s work force. About 44 percent of city hospital workers are Black.

Black New Yorkers, who make up about a quarter of the city’s population, have gotten vaccinated at lower rates than
other groups. In interviews, many Black New Yorkers have voiced doubts about the safety of the vaccines and
expressed concern that a full understanding of the side effects had yet to emerge. Others also cited the long history of
doctors treating Black patients differently from white patients and past medical experimentation on Black people.

The city’s largest private hospital system, NewYork-Presbyterian, announced last month that it would require
employees to be vaccinated against Covid-19, becoming an outlier among the city’s large hospital systems.

But it has yet to enforce that policy, allowing employees until Aug. 1 to apply for exemptions and until Sept. 1 to get the
first shot. More than 70 percent of employees are vaccinated, according to Alexandra Langan, a spokeswoman for

Other major hospital systems in New York City have yet to make coronavirus vaccinations mandatory.

NYU Langone Health, a large New York City hospital group, said that 81 percent of its staff was currently vaccinated
against Covid-19. Vaccinations would become mandatory for employees without valid exemptions after the vaccines
receive full approval from the Food and Drug Administration, an NYU Langone spokeswoman, Lisa Greiner, said.
Currently, the vaccines are being administered in the U.S. under an emergency use authorization.

District Council 37, the union that represents city workers, has been part of conversations with Mr. de Blasio’s
administration about vaccinating health workers, although the union did not learn about the mayor’s new policy until
Tuesday, according to two people familiar with the matter.

“The union strongly encourages vaccinations among membership and we’ve done a lot to help our members get
vaccinated,” a union spokeswoman, Freddi Goldstein, said. Still, she said, “the union does not believe it’s the place of
the employer to mandate it.”
Ms. Goldstein added that the union was supportive of more testing. “Of course with all things, we’ll need to see how it’s
being implemented,” she added.

One epidemiologist said the new city policy was better than nothing, but he wondered why testing was only occurring
once a week, and why the policy was not expanded beyond health care settings to include other city employees.

“One test a week is better than no test, but more frequent testing is always better when you have a lot of community
transmission and we may have that situation among unvaccinated people in the fall,” said Denis Nash, a professor of
epidemiology at CUNY School of Public Health.
Emma G. Fitzsimmons contributed reporting.

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