Key Barriers to Providing Remote Care and Information [Interview][Transcript]

Dr_Alan_Pitt_2016_National_Telemedicine_SurveyGuest: Dr. Alan Pitt
Presenter: Neal Howard
Guest Bio: Dr. Alan Pitt is the Chief Medical Officer at Avizia and attending physician and Professor of Neuroradiology at the Barrow Neurological Institute. Over the past two decades Dr. Pitt has worked at the nexus of computers and medicine. He believes that aligning patients with the right person at the right time, can replace fear and anxiety with reassurance, and prevent unnecessary system costs.

Segment overview: Dr. Alan Pitt, Chief Medical Officer at Avizia and attending physician and professor of neuroradiology at the Barrow Neurological Institute talks about the key barriers to providing remote care and information.

Health Professional Radio – Key Barriers to Providing Remote Care

Neal Howard: Hello and welcome to Health Professional Radio. I’m your host Neal Howard, thank you for joining us today. Our guest in studio is Dr. Alan Pitt, Chief Medical Officer at Avizia and Attending Physician and Professor of Neuroradiology at the Barrow Neurological Institute. He believes that aligning patients with the right person at the right time can replace fear and anxiety with reassurance and prevent unnecessary system cost and he’s with us here to discuss some barriers to the telemedicine industry as they stand today. Hello and welcome to Health Professional Radio Dr. Pitt.

Dr. Alan Pitt: Neal thank you for having me.

N: Now for 20 years now you’ve been as I said working, combining computer technology and health care, medicine. How is that been working and what types of resistance have you come up against? Is it something that you see on a constant level or are attitudes changing?

P: Well that’s a great question Neal. So yes, I have been working kind of in the IT space for the last 20 years along with my clinical practice. It’s very interesting because most change requires three things: People, Process and Technology. Technology tends to be an enabler but it’s really the cultural change that often represents the largest barrier to change. In the telehealth space we’ve seen rapid change in how people are viewing that but still many barriers persist and I’ve like to kind of break it out into kind of four distinct areas to consider. The first is a kind of an administrative approach to this and most hospitals and administrators are understandably are looking for some level of return on investment on whatever they chose to do and many of them struggle with where this telehealth fit in their strategic roadmap. In a lot of conversations that I’ve had throughout the country that strategic roadmap leads to something of an analysis paralysis. Administrators know they need to bring telehealth to their organization but they struggle with what to do first more than anything else. The second is there’s some confusion in the marketplace in terms of what is the opportunity between what I call data and collaboration. So data gets the majority of the conversation in today’s market in terms of health IT, data is managed by our large electronic health records. Our companies like Epic and Sonar, Athena all manage data but collaboration is equally important but really a separate market. So it’s about how does that data get in the right hands at the right time to provide additional value, I kind of like to say that data is like fish that has an expiration date. If you don’t get that data in the right hands at the right time the value of that goes down. Finally, like many other technologies there are dependent technologies that have to be around to make things work and so Wi-Fi and cell coverage both in the hospital and the home are things that are required to support sophisticated telemedicine efforts and many hospitals in this country are old, they have very thick walls, they are not well-suited for the Wi-Fi or the cell coverage so if you think about how do I bring doctors together, I have to overcome those literally concrete walls. Getting telemedicine to the home is also a little bit of a struggle because many folks particularly older folks may not have the kind of cell coverage or Wi-Fi in their home to support telemedicine. The final real barrier is an issue of reimbursement and so from a legacy perspective, telemedicine has really been put in the bucket of how do I get reimbursed for this activity and that’s largely been based on a fee for service kind of activity and that’s really been an evolution. So we’ve seen certain geographies are covered by telemedicine, certain geographies are not, certain specialties are covered by telemedicine, certain specialties are not. It makes it very confusing to actually write a business plan around telemedicine because of these different reimbursement models. I’m very encouraged, I mean if there is a positive out of the Affordable Care Act, one of the largest things is this idea that we’re moving towards a value based care delivery really should fundamentally change how we think about telemedicine because it’s not how much you make but it’s how little you lose if you will moving forward with the ACA and some of the newer business models. In that world telemedicine becomes a tool to reduce loss if you will.

N: Clearing up the confusion lies in like you say a few the key issues how to implement, what to implement, who gets it when, how to support it and how to get paid fast and fairly for it. So basically the success of telemedicine is connecting all of these factors as well as connecting the right people at the right time, it’s a huge task it seems.

P: Yeah, that’s very much the case but I think particularly with the new types of payment model it will become much easier for people to understand why they’re doing telemedicine rather than the current state of confusion Neal with how legislative rules set.

N: Let’s talk about the current payment model as you stated.

P: So the current payment model, although this is changing is something called fee per service and so fundamentally Americans are all capitalists and our health care system is an expression of that but doctors get paid for what they do. So if you go to the doctor, the doctor gets paid for the care delivered. It doesn’t matter if the patient got better or not, doctors are gonna get paid regardless and so that’s been the model for the last half century. We’re moving to a new model which really says that there’s something called shared risk, there’s an expectation that the patient, or if not the patients so a group of patients have to get better at a certain rate to get paid and if the hospital system and their doctors do not deliver on that, then there’s gonna be a penalty. That’s rolled up in something called macro which is a newer form of payment that will require physicians to basically have certain expectations around different disease states. If physicians execute, if they actually perform this kind of value based care delivery and that they can show that then they actually make more than baseline numbers. If they don’t come up to speed and they don’t develop ways to address the continuum of care they may actually get penalized overtime and this is fast approaching, the data for this is going to be collected starting in 2017 just around the corner, a little over 6 months and it will define how physicians get paid in 2019 based as a baseline rate of Medicare and Medicaid.

N: Okay now you say Medicare, Medicaid. Now, you’ve said Macro is that a…?

P: Yeah. So Medicare it’s actually a roll up of both Medicare and Medicaid and so the full understanding of it is that it stands for the Medicare payment reformat that was passed by by-partisan legislation, the full thing is Medicare Access and CHIP, that’s for children, Reauthorization Act of 2015 and it eliminates some of the other… I’m sorry?

N: Well the title itself it’s all encompassing so it’s gonna cover in every aspect of health care as far as reimbursement and cost is concerned, that’s what I was driving at to make sure that it wasn’t something that was going to exclude any aspect of the health care industry going forward.

P: No, I think this is a very broad initiative and we face a broad problem here in America because generally we spend almost double what other developed countries, similar countries to us, spend on health care every year. So it’s somewhere around 18 to 19% of our GDP whereas say in Britain, Canada mostly Europe they would spend 8 to 9% of their GDP for health care but if you look at it, if you look at just survival Americans tend to not do as well as some other countries that spend far less than we do.

N: Okay, this new, this Macra, this incentive based system where physicians are graded sometimes if you’re in a classroom and you’ve got a student who’s a straight A student and all of a sudden, half way through the semester the professor decides to grade on a curve. How that does affects the doctors that are outstanding and beginning 150% of reimbursement as opposed to those who consistently get less than that?

P: Well that’s one of the core principles here. So fundamentally the government’s not giving more money to those who perform well, it’s taking the same money and it’s transferring the money from the underperformers to the over-performers with the goal of moving the curve if you will to the right. So the goal is these are, how we’re going to score you, then we’re gonna evaluate you against your peers, the high performers, the standard deviation curve, the A student they’re gonna make more than the base pay per visit. The low performers, they’re gonna get, they’re gonna basically be supplementing that and it’s gonna be problematic and I think that there’s gonna be a lot of angst. I think most physicians don’t fully understand the ramifications of this new legislation.

N: You say most physicians don’t understand. So there are physicians who are “…yeah, let’s do this” you obviously are not. What are some of the positives that you’re hearing about this system?

P: Neal I don’t know if I can, it’s funny you say that so I don’t know if I’m not gonna, I can tell you this, so I’m in the middle of my career, right? And change always brings anxiety and I would tell you that I, my peers, most of us in the middle of our careers, this is a big change and causes a lot of anxiety. That being said, I’m an American and at first I’m a physician, second I’m a radiologist, third as an American I kind of understand why these changes are coming, why they’re necessary and so I have very mixed feelings about it. I think the biggest amount of anxiety is the government going to be able to execute on this new form of payment in a fair and equitable way and that remains to be seen, right? So the website for the exchange…didn’t go so well. Many physicians are looking at this going, “We certainly hope this goes better than that did because our livelihood is tied up in how people execute on this vision.”

N: Do you think that this will ultimately change the reasons why people go into health care in the first place? Because if someone wants to go in based on the financial gains in addition to helping people, do you think that it will, we’ll see a drastic drop in those that are signing up foe med school?

P: I don’t think so. So I’m a second generation physician, my father’s a doctor but my daughter is also a medical student soon to be physician. I think most of us going to health care with the idea that we’re entering a worthwhile profession that we think we can help people. It’s an interesting profession and we can help people. If you have this kind of whole role of, you can be both priest and scientist, interesting and intimate. I think that the reasons that people go into health care are similar to decades ago. I think the idea this upside of getting fairly large compensation, I think that’s gonna go away. I’m actually more worried about the debt that medical students are taking on more than anything else. Medical school enrollment is way up, they’re certainly as competitive as ever, I don’t think it’s gonna change that. I think the biggest change is coming to the physician in midlife who has to manage expectations. Change and again change is always anxiety provoking.

N: You’ve been listening to Health Professional Radio, I’m your host Neal Howard. In studio talking with Dr. Alan Pitt, Chief Medical Officer at Avizia and also Professor of Neuroradiology at the Barrow Neurological Institute. He believes that aligning patients with the right person at the right time can prevent unnecessary system costs. It’s been great having you here with us today Doctor.

P: Thank you very much.

N: Transcripts and audio of this program are available at and also at and you can subscribe to this podcast on iTunes.