Table 3:

Direct financial advantages

Quote	Setting to which the Quote Applies
	Inpatient and/or ED	Outpatient
Help hospitals retain patients/avoid transfers
I think, as we look more into the opportunity to provide telehealth services in the hospital, the opportunity to actually keep more patients here locally [will be a financial benefit for the hospital].	x
As a rural hospital, [eICU has] helped us to retain patients… because we don’t have 7/24 intensivist coverage in the ICU. With the eICU, we are able to retain the patients and prevent from transferring them.	x
As we expand our stroke program [to inpatient from the ED], we can keep them, because now we can monitor the patient upstairs, and so the neurologist can keep an eye on them with the hospitalist. From a Medicare standpoint for us, our inpatient payment from Medicare is roughly… $8,000 a visit, and so it’s a chunk of change for us.	x
And it [tele-ED] also allows us to keep some of the patients in-house, whereas we may have had to send them out to another hospital…If we can keep these patients in the ED and treat them and then keep them in the hospital as an inpatient… that helps us immensely financially.	x
I mean, we are reliant on it [telehealth] at this point, to allow us to have a robust inpatient program… [because] part of the issue with the decline of rural health is that the inpatient service is being relocated out, because it’s difficult for a small hospital in a rural geography to employ physicians that are comfortable with such a vast range of diseases and illness…So then you start to move all of that inpatient volume out… even if you are building a large outpatient service, ultimately patients are going to go where their physicians are. So, if you don’t have any specialties in your area, then you just become kind of an urgent care. So, I feel like adding the telemedicine, and that specialty service to our hospital is actually why we’re growing. And it’s kind of contradictory to the thought process with rural hospitals right now, but I think we’re proof that that needs to change. We’ve tripled in size in four years from a gross revenue perspective related to these [telehealth] programs. And I really feel like the telemedicine is what has allowed us to build it, especially from the inpatient side.	x
I don’t think any of us expected the virtual ICU to have the impact [on volume] on the inpatient side that it had for us. So I think that watching the financials change from that volume, I just didn’t anticipate that we’d ever go from two or three [patients] per day to full [occupancy]. And we were shooting for double digits. We were shooting for 10 to 12. And so, yeah, but I had to actually do it to be convinced.	x
Drive ancillary services
[Tele]Behavioral health does makes some profit but primary care, not as much. It does help get labs and other services demanded. Our primary care type services, that’s a little bit more challenging. But we get through referrals back to the hospital for labs, and imaging and additional, say, surgeries, and that’s what primary care clinics really drive. Primary care clinics on their own, if you just look only at that, really are not money makers, it’s about... it’s an entry point for your patients to support the rest of the hospital.		x
Of course initially, [the direct financial benefit of telehealth] would be the grant funding to help us provide that service, but then we’re looking at [whether] they [patients] receive other services. So if they have the one visit, that visit may result in…other ancillary services. And we want to be their provider of choice. In this community, we’re the only hospital, obviously, being a critical access hospital… But also it’s just by out that patient relationship with their providers. So they’ve come in, they’ve had a service and then they need some type of follow up care or they’re referred to another specialty. Well, we want them to stay within our system. So rather than them receiving that same visits from another provider, we’re keeping it within.		x
The one thing telehealth could do is if folks [patients] stay in the [hospital] community, there should be some downstream revenue from that. For example, with tele cardiology, you’ll have echos [echocardiograms], you’ll have other labs, that kind of thing.		x
We’re not going to rely on the telemedicine to bring in a lot of revenue. It’s a great community service. There are some ancillary benefits…some of the providers or labs or some different items that they can do here, which is great.		x
Reduce the risk of permanently losing patients to competitors
These are patients that are in our community, and they do have a primary care physician, but not an intensivist... and it is reality that sometimes when you transfer those patients out of your community, you don’t just lose them for that visit, you potentially can lose them permanently. Because now all of a sudden, they’re establishing a relationship with a different hospital provider and potentially [other] new physician relationships. And so that becomes a very challenging situation for us, because we’re not growing [with respect to] demographics. So, each patient we lose, there’s not somebody that’s ready to fill that spot in there.	x
If [we] don’t provide telehealth for specialty and you refer out, you may never get them back		x
And I think as the program grows more and more, there will be more ancillary revenue created by telemedicine, but it’s a lot of those specialty services that, hey, it’s amazing that they can access it here and hey, maybe those people will actually come here more often that…and will utilize the services and not leave		x
Reduce labor and provider recruiting costs
Yeah. It’s positive, because again, I don’t think we’ll be able to recruit and retain psychiatry here. So, I think it’s a very viable method for us.	x
This program [tele-hospitalist] has big financial benefit because it is cheaper than in-person staff. And honestly, with our model, we get into some wonky things where we did lose some reimbursement along the way, but it made up for itself with again, not having someone here [in-person]... It also helps with finding people; doctors are hard to find these days.	x
The other area that where this whole idea of telehealth really made an impact… [was in] the ability for us to [recruit and] maintain a good physician workforce… We began to see that physicians…coming out of training [were] less and less inclined to do everything…[So, now] at 6:00 P.M. the [telehealth internal medicine physicians], via the E-Hospitalist [program], take it over the night. So again, these [telehealth services] are things that I’m not being paid to do. It’s a fairly significant expense. I’m being paid for the inpatient care, but I don’t get extra because I brought on eDocs, right? It just doesn’t work that way. So it was another expense brought on to the hospital [to start this program]. But it really helped us with our physician recruiting.	x
Help sustain practices during the pandemic
The only thing I will say is the telehealth visits during COVID while we were shut down did help sustain our practices, our physician practices, but that would be about the only financial impact.		x
Telehealth is a positive because it allowed us to keep up volume- I think it’s a positive, ultimately. It gives us another way to see patients that we didn’t really have reliably before.		x

Note: ED = emergency department; eICU = electronic intensive care unit