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Health and wellness   |   The Telehealth Era Is Just Beginning
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Health and wellness


THE TELEHEALTH ERA IS JUST BEGINNING

by
 * Robert Pearl
   and
 * Brian Wayling

by
 * Robert Pearl
   and
 * Brian Wayling

From the Magazine (May–June 2022) · Long read
Adam Voorhes/Gallery Stock 
Summary.    Contrary to what many people think, virtual health care, also known
as telemedicine or telehealth, is much more than a cheap digital knockoff of
in-person care. When used appropriately, it improves patient health, reduces
costs, and makes care more...more
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IDEA IN BRIEF

THE PROBLEM

The use of telemedicine soared during the height of the pandemic but has since
plunged, owing to regulations, payment regimes, and patients’ and providers’
long-established preferences.

THE MISSED OPPORTUNITY

Virtual care can be much more than an add-on to conventional medicine. It can
play a central role in diagnosis and treatment, raising the quality of care,
increasing access, and lowering costs.

THE SOLUTION

The care delivery model could be revamped to tap telemedicine’s full potential.
Kaiser Permanente and Intermountain Healthcare are among those showing the way.

Contrary to what many people think, virtual health care, also known as
telemedicine or telehealth, is much more than a cheap digital knockoff of
in-person care. When used appropriately, it improves patient health and reduces
costs. It also makes care more equitable and accessible to the 89% of U.S.
adults and 78% of adults globally who own a smartphone, including those in
medically underserved communities.





And yet telemedicine usage in the United States has plunged from its peak in
April 2020, during the first surge of Covid-19 cases, when it accounted for 69%
of doctor-patient visits. Similar patterns have been seen across Europe and Asia
over the past two years, prompting some governments to take actions in support
of telehealth. The European Parliament and the European Council recently
announced the EU4Health program to spur the sharing of digital health records,
e-prescriptions, and telehealth in general. And Saudi Arabia is implementing a
strategy that includes smartphone applications and a network to connect
specialized facilities with primary care centers and hospitals in remote areas.

But in many countries, barriers in the form of regulations, payment regimes, and
patient acceptance remain. Any nation seeking to raise health care quality,
increase access, and lower costs should be expanding, not contracting, the use
of virtual care.

In this article we take an inside look at two of telemedicine’s earliest
adopters and most effective users: Kaiser Permanente, where one of us (Robert)
was CEO; and Intermountain Healthcare, where the other (Brian) is an executive
director of telehealth services. For more than a decade these integrated health
systems have used virtual care platforms to improve preventive medicine, care
coordination, chronic disease management, and affordability for more than 13
million patients.

Having analyzed health outcomes data from the independent National Committee for
Quality Assurance, health plan member satisfaction surveys from J.D. Power, and
internal data from our own organizations, we are confident that full
implementation of five opportunities would improve clinical quality nationwide
by 20%, increase access to care by 20%, and reduce health care spending by 15%
to 20%.


OPPORTUNITY 1: REDUCE EXPENSIVE AND UNNECESSARY TRIPS TO THE ER

“If this is a medical emergency, please hang up and dial 911 or go to the
nearest emergency room.” Many Americans have heard this recorded after-hours
script. Too often it leaves sick callers and worried parents with a difficult
decision: Do I drive to the ER and lose a night of sleep or chance it and wait
until morning to call my doctor’s office?

Those who drive to the ER will endure a two-hour wait, on average, along with
duplicative testing and wildly inflated prices. ER services are 12 times as
expensive as visiting a physician’s office and waste more than $32 billion each
year, according to a 2019 analysis by UnitedHealth Group.

Those patients face heightened medical risks as well. Emergency physicians often
can’t access patients’ electronic health records, owing to a lack of
interoperability between systems, and they don’t offer follow-up care. Both
facts can cause discontinuity in treatment and avoidable errors. Unless one is
experiencing symptoms of a severe medical crisis—crushing chest pain or
half-body weakness, say—the emergency room isn’t the safest place to be,
especially when ERs are crowded with Covid-19 patients. Yet many who go to the
ER after hours require no emergency services. They simply have no other place to
go.

Kaiser Permanente members in Virginia, Maryland, and Washington, DC, have a
better option: They can access a 24/7 video health center that connects them
with a doctor who can quickly assess the problem and offer guidance. If the
doctor determines that the problem is life-threatening, she tells the patient to
go immediately to the ER, sending the relevant medical information ahead to
reduce the risk of complications. But telehealth physicians can solve the
problem some 60% of the time. And when a patient needs follow-up care, they can
schedule an appointment with his personal physician and communicate relevant
details ahead of the visit. This application of virtual care not only addresses
medical problems immediately and around the clock; it also prevents unnecessary
ER visits that can lead to inappropriate hospital admissions and thousands of
dollars in unnecessary expenses per patient.

During the pandemic Utah-based Intermountain Healthcare devised a remote
patient-monitoring Covid program that combines telemedicine and home monitoring
to unclog emergency rooms and free up hospital beds. Following evaluation by a
physician, patients who test positive for (or are suspected of having) Covid-19
and have non–life-threatening symptoms are given a Bluetooth pulse oximeter.
They pair the device with their smartphone and use it to measure their blood
oxygen levels daily for two weeks, sending the data to a centrally located nurse
care team. If the level is low, the center contacts the patient and conducts a
clinical evaluation via phone or video. Patients deemed to remain at low risk
for severe illness continue with home monitoring. Those whose condition is
severe or deteriorating are instructed to go to the ER.

Kaiser Permanente members in some areas have a better option than going to the
ER: They have 24/7 access to telehealth physicians, who can solve the problem
60% of the time.

In its first 14 months the program handled just over 10,000 patients and allowed
Intermountain to avoid more than 1,800 hospital admissions and save almost 4,800
hospital bed-days, freeing up beds for critically ill patients. If all providers
in the United States had been using such a program, hundreds of thousands of
hospitalizations could have been safely avoided, tens of thousands of lives
might have been saved, and significant cost savings would have been realized.

If telemedicine programs like the two we’ve just described were replicated
nationally and eliminated even half of avoidable ER visits, billions of dollars
a year could be saved.


OPPORTUNITY 2: REVERSE AMERICA’S CHRONIC-DISEASE CRISIS

Chronic diseases are the leading cause of death and disability in the United
States, accounting for seven in 10 deaths. Many patients hospitalized with or
killed by Covid-19 had conditions such as obesity, chronic obstructive pulmonary
disease, hypertension, diabetes, cardiovascular disease, and chronic kidney
disease. Even before the pandemic the United States spent $214 billion a year on
medical interventions for preventable complications from events such as heart
attacks and strokes and lost $138 billion in worker productivity.

A leading cause of stroke, and a major contributor to heart disease and kidney
failure, is hypertension, or high blood pressure. This chronic condition is
poorly controlled 50% of the time in the United States. That means half of all
people with hypertension remain at an elevated risk of severe complications.

For members of large multispecialty medical groups such as Kaiser Permanente,
high blood pressure is a much more manageable problem. KP consistently achieves
a control rate above 90%. It’s not that it has better doctors or medications
than other providers do; the biggest difference is frequency of disease
measurement and timeliness of treatment—factors facilitated by virtual care.

The traditional approach to managing chronic disease is intermittent and
episodic. Once a doctor makes a diagnosis, he schedules follow-up office visits
on a routine basis, usually every four to six months. Most Americans are used to
this cadence, but it makes no sense. Some patients with well-controlled chronic
diseases might not need to see their doctor for a year, while others would
benefit from monthly evaluations. But traveling to the doctor’s office once a
month, often for nothing more than a blood-pressure check, is time-consuming,
inconvenient, and for many people expensive.

Virtual visits can be scheduled more frequently, and they’re less time-consuming
for both patients and physicians. Blood pressure can be checked at home with a
device digitally connected to the electronic health record system. The
combination of telemedicine and wearable devices allows for more-frequent
medication adjustments, resulting in faster and better disease control and fewer
complications at a lower total cost.

With the combination of telemedicine and an increased emphasis on primary care
and prevention, Kaiser Permanente members in California and the mid-Atlantic
region are 14% less likely to die from stroke and 43% less likely to die from
heart disease than are people in the United States as a whole.

Superior clinical outcomes don’t just save lives; they save money, too. Each
year 805,000 Americans suffer a heart attack. The estimated cost of care
afterward was $21,500 as of 2012, the most recent year for which nationwide data
is available; it is undoubtedly higher today. If 40% of attacks could be avoided
through telemedicine and consistent screening protocols, nationwide saving would
total at least $6.9 billion annually.


OPPORTUNITY 3: ADDRESS DISPARITIES IN HEALTH CARE

Telemedicine’s ability to address inequities in access has been demonstrated
during the pandemic. The ubiquitous smartphone, capable of video interactions,
can be a lifeline for underserved populations. In rural areas with few mental
health professionals, for example, Intermountain’s ability to offer virtual
visits gives patients prompt access to both emergency and routine care. When the
pandemic forced the closure of in-person clinics and offices, psychologists and
psychiatrists across the United States quickly instituted virtual visits.
Intermountain delivered 85% of its mental- and behavioral-health visits
virtually, including those for drug- and alcohol-related programs. Telemedicine
visits remained popular even after restrictions eased. Intermountain patients
receiving their care virtually reported high satisfaction and were less likely
to cancel appointments than were patients who had scheduled in-person visits.

Kaiser Permanente uses video to address disparities in urban areas. In 2006 it
began rolling out a program across 21 medical centers for pregnant women
battling addiction. Those who were dependent on buses for transportation or who
lacked reliable childcare struggled to attend group counseling programs that met
three times a week; fewer than 30% of participants were consistently able to
attend. But even women without internet access could join virtual sessions with
a smartphone, as long as they had at least a 3G connection. Perfect attendance
rates soared above 80%, dramatically reducing the need for neonatal ICU
admissions postdelivery, which can cost $100,000 or more per child.


OPPORTUNITY 4: MAKE SPECIALTY CARE FASTER AND MORE EFFICIENT

When treating patients who require specialty referrals, primary care doctors
have a common complaint: They have 95% of the expertise needed to accurately
diagnose and treat but no easy way to obtain the other 5%. Sometimes all they
seek is assurance that their diagnosis or plan is appropriate. But without that
missing 5%, their only option is to make a referral for an in-person specialty
consultation, leading to treatment delays and higher costs.

Waiting lists for specialist appointments can be long. For example, even before
the pandemic, patients in the United States often had to wait weeks to see a
dermatologist. At Kaiser Permanente, primary care physicians routinely use
telemedicine to consult dermatologists—while the patient is in the exam room.
Patients leave with a confirmed diagnosis, treatment plan, and prescription.
Some 70% of KP patients who visit their primary care doctor with a
difficult-to-diagnose rash have the problem resolved in less than 10 minutes via
telemedicine.

Across the most common medical and surgical specialties, KP’s remote-specialist
model resolves patients’ problems 40% of the time, with no specialist visits
needed. Patient satisfaction is 10% higher than for in-person consultations.
When a patient does need to visit a specialist for a procedure, the appointment
is scheduled after the virtual consultation; no in-person consult is required.
If 30% to 40% of in-person specialist visits in the United States were replaced
with this type of telehealth consult, patients would miss fewer workdays and
receive faster and more-effective care, and tens of billions of dollars annually
would be saved.


OPPORTUNITY 5: PROVIDE ACCESS TO THE BEST DOCTORS

Patients with obscure or complex medical problems often find themselves living a
two-pronged nightmare. There’s the pain and fear of having a rare disease and
the frustration of trying to find the right specialist. Patients may bounce from
one local physician to the next, wasting weeks or months sitting through useless
appointments and enduring sleepless nights.

Telemedicine offers a far better solution. Virtual technology can connect
patients with the most experienced and knowledgeable doctors regardless of where
they practice. This scenario is already playing out in Kaiser Permanente’s
Northern California region. A nationally renowned expert in kidney cancer is
located in a remote corner of Marin County, nearly 200 miles from some KP
members. Newly diagnosed patients can meet with him virtually. During video
consultations he educates them about their condition, using visual aids on a
shared screen. He walks them through the relevant clinical information, their
radiological scans, and treatment options. He shares videos of the anatomy and
the anticipated surgical procedure. Given the rapport thus established, nearly
all patients choose to have him perform their surgery, despite the distance many
must travel; the day of the operation is often the first time both parties are
in the same room. The doctor’s patient-satisfaction scores are universally
excellent.

Adam Voorhes/Gallery Stock

Intermountain uses telemedicine to connect patients who have complex (and often
very costly) neurological conditions with specialists. Its Neuro Fast Access
Clinical Team virtual platform enables them to receive treatment for migraines,
low back pain, and neck pain from an expert at a low cost, in the process
freeing up valuable clinical time for patients who require in-person treatment,
such as Botox injections for nerve and muscle diseases.

By eliminating the barriers of time and distance, telemedicine can help address
two serious problems for patients with difficult diagnoses and rare diseases.
The first is misdiagnosis. The second is long waits for a proper diagnosis and
effective treatment plan.

Doctors must often attempt an impossible balancing act with respect to quality,
access, and cost. When they increase access to care, costs rise. When they cut
costs, quality suffers. The rise of telemedicine during the pandemic spotlights
a way to provide rapid access to affordable, high-quality care. Increasing both
the frequency and the scope of virtual care nationwide would transform American
health, improving the lives of patients who get sick during nights and weekends,
those with chronic and mental health issues, and anyone who could benefit from
virtual specialty care. It could save tens of thousands of lives and hundreds of
billions of dollars each year.


HOW TO SPUR ADOPTION

Two changes would accelerate the implementation of telehealth and make care more
cost-efficient and effective.


INTEGRATION.

The health care organizations ranked highest on quality in national surveys are
large multispecialty medical groups such as Kaiser Permanente, Intermountain
Healthcare, Mayo Clinic, and Geisinger Health. All are built around teams of
doctors who are linked through modern information technologies and work together
in a coordinated fashion. According to the American Medical Association, more
and more doctors are choosing to become employees rather than work for
themselves. In fact, the share of U.S. doctors in private practice dropped below
50% in 2021. This movement toward employment and integration enables doctors to
share electronic health records, communicate across specialties, and leverage
virtual care to help patients in ways that physicians in solo practice can’t.


CAPITATION.

Most providers in the United States work on a fee-for-service basis: They are
paid for each test, procedure, and treatment they provide. The model
incentivizes them to offer services whether or not patients need them.
Logically, doctors whose income rides on the quantity of services they provide
will resist any model that reduces ER visits, specialty referrals, hospital
admissions, or surgeries.

An alternative to fee-for-service is a prepaid, value-based approach known as
capitation. Widely supported by policy experts, it pays a risk-adjusted fixed
annual amount per patient for all services provided. Although fee-for-service
still accounts for most U.S. health care expenditures, capitation is gaining
steam. For example, 42% of Medicare beneficiaries in 2021 were enrolled in
Medicare Advantage programs, which use capitated reimbursement—up from just 13%
in 2005.

Telemedicine can help address two problems for patients with
difficult-to-diagnose and rare diseases: misdiagnosis and long waits for
effective treatment.

More than 90% of Intermountain members belong to one of the organization’s
SelectHealth capitated insurance plans, while 95% of KP’s 12.5 million members
are in a capitated plan. The combination of an integrated system that uses
telemedicine to provide superior care and a capitated pay structure explains why
physicians in integrated prepaid medical groups embrace telemedicine solutions
more enthusiastically than do community-based doctors.


THE DESTINATION: A TELE-DRIVEN HEALTH SYSTEM

The ideal model for the future of U.S. medicine—one to replace or at least
significantly augment today’s fragmented fee-for-service approach—is tele-driven
health: an integrated, prepaid, tech-enabled system in which teams of primary
care and specialty physicians work together to deliver exceptional care. All the
system’s physicians have the same financial incentives to keep people healthy.
They aim to provide convenient, expanded access via telemedicine. They are
rewarded on the basis of the quality of care delivered to defined patient
populations and the cost savings achieved.

The most logical candidates to drive the creation of such a system are
employers, who currently provide health insurance coverage to 155 million
Americans—nearly half the country’s population. They bear the financial brunt of
health care inefficiencies and have the most to gain from boosting quality and
affordability.

Creating a tele-driven system won’t be easy, but it’s more possible now than
ever before. Physicians are increasingly dissatisfied with the current system
and open to alternatives. Before Covid-19 forced the issue, they were generally
apprehensive about virtual care. But their positive experiences with it over the
past two years have made them more receptive to expanding its use post-pandemic.

Businesses and doctors can take several steps to create tele-driven health
systems.


DEVELOP PARTNERSHIPS.

Businesses will need to band together to achieve economies of scale and identify
the right leadership in the surrounding medical community. Large national
organizations such as the Purchaser Business Group on Health could lead the way.
PBGH represents nationwide goliaths including Walmart, Costco, Microsoft, and
Intel. It has already formed a division focused on reducing the costs of care; a
tele-driven system would align with its current direction. Alternatively, local
businesses could form consortia like the NorthStar Network in Rochester, New
York, which aims to lower health care costs for all area employers.

KP and Intermountain’s experiences suggest that 30,000 to 50,000 enrollees are
needed to support the requisite hiring of primary care and specialty physicians.
Few businesses have that many employees in a given geography or the financial
ability to make the necessary changes themselves. But 15 or 20 companies
together could achieve critical mass.

Businesses might wonder whether creating a new health system merits the time and
energy that would be required. They should consider that rapidly rising medical
costs will significantly affect their bottom lines. Even before Covid-19 struck,
sparking supply chain challenges and exacerbating the shortage of health care
professionals, experts predicted that health care spending would increase by
5.5% annually. Businesses can expect extremely high medical-cost inflation if
nothing is done. The time to act is now.


DESIGNATE LEADERS.

During the first wave of Covid-19, doctors replaced office visits with virtual
ones seemingly overnight. They could do so because using video technology to
deliver patient care is the easy part. The hard part is flipping health care’s
current delivery and reimbursement model on its head. And that can’t happen
without excellent leadership.

If 30% to 40% of in-person specialist visits in the U.S. were replaced by
telehealth consults, tens of billions of dollars annually would be saved.

Having formed a partnership, whether through national or local associations, an
umbrella organization must make two key hires. It needs a skilled financial
leader from the payer side and an effective physician leader from the care
delivery side. Together the two must figure out an appropriate employer
contribution, how quality and access will be measured, and the breadth of
services that will be delivered. They’ll need to negotiate contracts with local
hospitals, deploy IT systems, and purchase reinsurance to protect against the
unexpected costs that a single patient with a massive injury or in need of a
transplant can generate.


DESIGN REIMBURSEMENT AND CARE DELIVERY SYSTEMS.

When creating a new model of health care, the hard work is in the details, and
because a tele-driven system will affect every aspect of care delivery,
developing one entails thousands of decisions. Medical and financial leaders
will need to design, shape, and implement the processes by which care will be
delivered and paid for. The specifics of how best to do this are beyond the
scope of this article, but here are two major considerations.

Reimbursement. A tele-driven system functions best when most if not all
physicians and advanced practice providers (nurse practitioners and physician
assistants) are salaried employees. With the majority of doctors and APPs in the
United States now working for health care organizations (hospitals, medical
groups, or insurance companies) rather than for private practices, this is now
possible. But effective implementation will require a shift in how those
organizations pay practitioners. Instead of rewarding them individually for the
number of patient visits, tests, and procedures they perform, as in
fee-for-service models, organizations should incentivize overall group
performance. Telemedicine offers a big advantage here: Groups don’t need to be
colocated.

Care delivery requisites. A tele-driven system typically needs at least 20
primary care physicians and APPs on staff to facilitate 24/7 virtual coverage.
It also requires a broad range of specialists, with at least one from each
specialty available each day to give primary care doctors that missing 5% of
information they may need to quickly resolve patient problems.

Physician staffing will need to radically change. Some 65% of U.S. clinicians
today are specialists; only 35% provide primary care. A tele-driven system would
reverse that ratio over time. Medical students’ preferences for residency
training would likewise shift.

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When telemedicine is at the heart of care delivery, patients require fewer
specialist visits; as noted, KP’s experience suggests that primary care
physicians can resolve 40% of problems with the help of telehealth-based
specialists. What’s more, collaboration among doctors and the improved overall
health of patients mean fewer medical complications and surgical interventions.
Finally, the availability of experts for rare and complex diseases facilitates
correct diagnosis and treatment at the outset.

Kaiser Permanente and Intermountain Healthcare have adopted many of these
elements, including a significant degree of capitation, sophisticated
technology, and right-sized staffing ratios. But barriers remain for both,
limiting their ability to achieve full-fledged tele-driven systems. KP still
draws heavily on brick-and-mortar facilities, which require large capital
investments. Intermountain depends on doctors, particularly in rural areas, who
are paid on a fee-for-service basis and care for people insured through a
variety of plans. Still, both organizations could move rapidly toward
full-fledged tele-delivered systems if the businesses buying health insurance
demanded it.

Lowering medical costs while maximizing the health of employees is the best way
for American businesses to stay profitable and maintain a loyal workforce. The
pandemic has highlighted the opportunities that exist and the problems that will
worsen if nothing changes. Done well, the transition to a tele-driven health
system could be accomplished in a few years. If left to chance, it could take
decades—if it happens at all.

A version of this article appeared in the May–June 2022 issue of Harvard
Business Review.
Read more on Health and wellness or related topics Health care and treatment and
Healthcare sector
 * RP
   Robert Pearl is a faculty member of the Stanford University schools of
   medicine and business. He was the CEO of the Permanente Medical Group—the
   largest physician organization in the United States—from 1999 to 2017 and is
   the author of Uncaring: How the Culture of Medicine Kills Doctors and
   Patients.
 * BW
   Brian Wayling is an executive director of telehealth services at
   Intermountain Healthcare, a not-for-profit health system based in Salt Lake
   City.

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Your personal data will be processed and information from your device (cookies,
unique identifiers, and other device data) may be stored by, accessed by and
shared with third party vendors, or used specifically by this site or app.

Some vendors may process your personal data on the basis of legitimate interest,
which you can object to by managing your options below. Look for a link at the
bottom of this page or in our privacy policy where you can withdraw consent.

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Data preferences


MANAGE YOUR DATA

You can choose how your personal data is used. Vendors want your permission to
do the following:

TCF vendors

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STORE AND/OR ACCESS INFORMATION ON A DEVICE

Cookies, device identifiers, or other information can be stored or accessed on
your device for the purposes presented to you. View details
Consent


SELECT BASIC ADS

Ads can be shown to you based on the content you’re viewing, the app you’re
using, your approximate location, or your device type. View details
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CREATE A PERSONALISED ADS PROFILE

A profile can be built about you and your interests to show you personalised ads
that are relevant to you. View details
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SELECT PERSONALISED ADS

Personalised ads can be shown to you based on a profile about you. View details
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CREATE A PERSONALISED CONTENT PROFILE

A profile can be built about you and your interests to show you personalised
content that is relevant to you. View details
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SELECT PERSONALISED CONTENT

Personalised content can be shown to you based on a profile about you. View
details
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MEASURE AD PERFORMANCE

The performance and effectiveness of ads that you see or interact with can be
measured. View details
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MEASURE CONTENT PERFORMANCE

The performance and effectiveness of content that you see or interact with can
be measured. View details
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APPLY MARKET RESEARCH TO GENERATE AUDIENCE INSIGHTS

Market research can be used to learn more about the audiences who visit
sites/apps and view ads. View details
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DEVELOP AND IMPROVE PRODUCTS

Your data can be used to improve existing systems and software, and to develop
new products View details
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ENSURE SECURITY, PREVENT FRAUD, AND DEBUG

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Your data can be used to monitor for and prevent fraudulent activity, and ensure
systems and processes work properly and securely. View details


TECHNICALLY DELIVER ADS OR CONTENT

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Your device can receive and send information that allows you to see and interact
with ads and content. View details


MATCH AND COMBINE OFFLINE DATA SOURCES

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Data from offline data sources can be combined with your online activity in
support of one or more purposes View details


LINK DIFFERENT DEVICES

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Different devices can be determined as belonging to you or your household in
support of one or more of purposes. View details


RECEIVE AND USE AUTOMATICALLY-SENT DEVICE CHARACTERISTICS FOR IDENTIFICATION

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Your device might be distinguished from other devices based on information it
automatically sends, such as IP address or browser type. View details


USE PRECISE GEOLOCATION DATA

Your precise geolocation data can be used in support of one or more purposes.
This means your location can be accurate to within several meters. View details
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You can choose your data preferences. This site or app wants your permission to
do the following:

Site or app


STORE AND/OR ACCESS INFORMATION ON A DEVICE

Cookies, device identifiers, or other information can be stored or accessed on
your device for the purposes presented to you. View details
Consent


MEASURE CONTENT PERFORMANCE

The performance and effectiveness of content that you see or interact with can
be measured. View details
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Vendor preferences

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Vendor preferences


CONFIRM OUR VENDORS

Vendors can use your data to provide services. Declining a vendor can stop them
from using the data you shared.

TCF vendors

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EXPONENTIAL INTERACTIVE, INC D/B/A VDX.TV

Cookie duration: 90 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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ROQ.AD INC.

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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INDEX EXCHANGE, INC.

Cookie duration: 395 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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QUANTCAST

Cookie duration: 397 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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BEESWAXIO CORPORATION

Cookie duration: 395 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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SOVRN HOLDINGS INC

Cookie duration: 365 (days).

View details | Privacy policylaunch
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ADIKTEEV

Doesn't use cookies.

View details | Privacy policylaunch
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RTB HOUSE S.A.

Cookie duration: 365 (days). Uses other forms of storage.

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WIDESPACE AB

Cookie duration: 372 (days). Cookie duration resets each session.

View details | Storage details | Privacy policylaunch
Consent


THE TRADE DESK

Cookie duration: 365 (days). Uses other forms of storage.

View details | Privacy policylaunch
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ADMETRICS GMBH

Doesn't use cookies.

View details | Privacy policylaunch
Consent


AMOBEE INC.

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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EPSILON

Cookie duration: 400 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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YAHOO EMEA LIMITED

Cookie duration: 397 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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ADVENTORI SAS

Cookie duration: 90 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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TRIPLELIFT, INC.

Cookie duration: 90 (days). Uses other forms of storage.

View details | Privacy policylaunch
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XANDR, INC.

Cookie duration: 90 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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NEORY GMBH

Cookie duration: 90 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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UNRULY GROUP LLC

Cookie duration: 395 (days).

View details | Privacy policylaunch
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NEURAL.ONE

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Storage details | Privacy policylaunch
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ADITION TECHNOLOGIES GMBH

Cookie duration: 90 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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ACTIVE AGENT (ADITION TECHNOLOGIES GMBH)

Cookie duration: 90 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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TABOOLA EUROPE LIMITED

Cookie duration: 366 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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SMART ADSERVER

Cookie duration: 396 (days). Uses other forms of storage.

View details | Privacy policylaunch
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ADFORM

Cookie duration: 60 (days).

View details | Privacy policylaunch
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MAGNITE, INC.

Cookie duration: 365 (days). Uses other forms of storage.

View details | Privacy policylaunch
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ADARA MEDIA UNLIMITED

Cookie duration: 730 (days).

View details | Privacy policylaunch
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SIFT MEDIA, INC

Doesn't use cookies.

View details | Privacy policylaunch
Consent


RAKUTEN MARKETING LLC

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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AVOCET SYSTEMS LIMITED

Cookie duration: 365 (days).

View details | Privacy policylaunch
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LIFESTREET CORPORATION

Doesn't use cookies.

View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


SIZMEK BY AMAZON

Cookie duration: 396 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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OPENX

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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YIELDLAB AG

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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ROKU ADVERTISING SERVICES

Cookie duration: 396 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Storage details | Privacy policylaunch
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NANO INTERACTIVE GMBH

Cookie duration: 182 (days). Uses other forms of storage.

View details | Privacy policylaunch
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SIMPLIFI HOLDINGS INC

Cookie duration: 366 (days).

View details | Privacy policylaunch
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PUBMATIC, INC.

Cookie duration: 90 (days).

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COMSCORE B.V.

Cookie duration: 720 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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FLASHTALKING, INC.

Cookie duration: 730 (days).

View details | Privacy policylaunch
Consent


MEDIAMATH, INC.

Cookie duration: 393 (days). Uses other forms of storage.

View details | Privacy policylaunch
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SMAATO, INC.

Doesn't use cookies.

View details | Privacy policylaunch
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SEMASIO GMBH

Cookie duration: 366 (days). Cookie duration resets each session.

View details | Storage details | Privacy policylaunch
Consent


CRIMTAN HOLDINGS LIMITED

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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BETGENIUS LTD

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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CRITEO SA

Cookie duration: 390 (days). Uses other forms of storage.

View details | Privacy policylaunch
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ADLOOX SA

Doesn't use cookies.

View details | Privacy policylaunch
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BLIS GLOBAL LIMITED

Cookie duration: 400 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Storage details | Privacy policylaunch
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LOTAME SOLUTIONS, INC

Cookie duration: 274 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
Consent


LIVERAMP

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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GROUPM UK LIMITED

Cookie duration: 395 (days).

View details | Privacy policylaunch
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LOOPME LIMITED

Cookie duration: 365 (days). Uses other forms of storage.

View details | Privacy policylaunch
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DYNATA LLC

Cookie duration: 365 (days).

View details | Privacy policylaunch
Consent


FUSIO BY S4M

Cookie duration: 1 (days).

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TEEMO SA

Cookie duration: 30 (days).

View details | Privacy policylaunch
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DOUBLEVERIFY INC.

Doesn't use cookies.

View details | Privacy policylaunch
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BIDSWITCH GMBH

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Storage details | Privacy policylaunch
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IPONWEB GMBH

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Storage details | Privacy policylaunch
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NEXTROLL, INC.

Cookie duration: 395 (days).

View details | Privacy policylaunch
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TEADS

Cookie duration: 365 (days).

View details | Privacy policylaunch
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STRÖER SSP GMBH (SSP)

Cookie duration: 365 (days). Uses other forms of storage.

View details | Privacy policylaunch
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STRÖER SSP GMBH (DSP)

Cookie duration: 90 (days). Uses other forms of storage.

View details | Privacy policylaunch
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PLATFORM161 B.V.

Cookie duration: 396 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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ADACADO TECHNOLOGIES INC. (DBA ADACADO)

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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MEETRICS GMBH

Cookie duration: 365 (days).

View details | Storage details | Privacy policylaunch
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SMADEX, S.L.U.

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Storage details | Privacy policylaunch
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BOMBORA INC.

Cookie duration: 365 (days). Uses other forms of storage.

View details | Privacy policylaunch
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SPOTX, INC

Cookie duration: 366 (days). Uses other forms of storage.

View details | Privacy policylaunch
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EASYMEDIA GMBH

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Privacy policylaunch
Consent


REMERGE GMBH

Doesn't use cookies.

View details | Privacy policylaunch
Consent


ADVANCED STORE GMBH

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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MAGNITE CTV, INC.

Cookie duration: 366 (days).

View details | Privacy policylaunch
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DELTA PROJECTS AB

Cookie duration: 365 (days).

View details | Privacy policylaunch
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USEMAX ADVERTISEMENT (EMEGO GMBH)

Cookie duration: 365 (days). Cookie duration resets each session.

View details | Storage details | Privacy policylaunch
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EMETRIQ GMBH

Cookie duration: 365 (days). Uses other forms of storage.

View details | Privacy policylaunch
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PUBLICIS MEDIA GMBH

Cookie duration: 90 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
Consent


MCCANN DISCIPLINE LTD

Cookie duration: 25 (days).

View details | Storage details | Privacy policylaunch
Consent


ONETAG LIMITED

Cookie duration: 741 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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CLOUD TECHNOLOGIES S.A.

Cookie duration: 365 (days).

View details | Privacy policylaunch
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SMARTOLOGY LIMITED

Doesn't use cookies.

View details | Privacy policylaunch
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IMPROVE DIGITAL

Cookie duration: 90 (days).

View details | Privacy policylaunch
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ADOBE ADVERTISING CLOUD

Cookie duration: 365 (days).

View details | Privacy policylaunch
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BANNERFLOW AB

Cookie duration: 366 (days).

View details | Storage details | Privacy policylaunch
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TABMO SAS

Doesn't use cookies.

View details | Privacy policylaunch
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INTEGRAL AD SCIENCE, INC.

Doesn't use cookies.

View details | Privacy policylaunch
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WIZALY

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
Consent


WEBORAMA

Cookie duration: 393 (days).

View details | Storage details | Privacy policylaunch
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JIVOX CORPORATION

Cookie duration: 90 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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MOBILE PROFESSIONALS BV / SAGE+ARCHER BV

Doesn't use cookies.

View details | Privacy policylaunch
Consent


ON DEVICE RESEARCH LIMITED

Cookie duration: 30 (days).

View details | Storage details | Privacy policylaunch
Consent


EXACTAG GMBH

Cookie duration: 180 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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CELTRA, INC.

Doesn't use cookies. Uses other forms of storage.

View details | Privacy policylaunch
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MAINADV SRL

Cookie duration: 1 (days). Cookie duration resets each session. Uses other forms
of storage.

View details | Privacy policylaunch
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GEMIUS SA

Cookie duration: 395 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
Consent


THE KANTAR GROUP LIMITED

Cookie duration: 914 (days).

View details | Privacy policylaunch
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IMPACT TECH INC.

Cookie duration: 720 (days).

View details | Privacy policylaunch
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NIELSEN MARKETING CLOUD

Cookie duration: 120 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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SOLOCAL

Cookie duration: 365 (days). Uses other forms of storage.

View details | Privacy policylaunch
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PIXALATE, INC.

Doesn't use cookies.

View details | Privacy policylaunch
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ORACLE DATA CLOUD

Cookie duration: 180 (days).

View details | Privacy policylaunch
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1000MERCIS (NUMBERLY)

Cookie duration: 180 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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AUDIENCEPROJECT APS

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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EFFILIATION / EFFINITY

Cookie duration: 60 (days). Uses other forms of storage.

View details | Privacy policylaunch
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ARRIVALIST CO

Cookie duration: 730 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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SEENTHIS AB

Doesn't use cookies.

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COMMANDERS ACT

Cookie duration: 365 (days). Uses other forms of storage.

View details | Privacy policylaunch
Consent


TRAVEL AUDIENCE GMBH

Cookie duration: 397 (days). Cookie duration resets each session.

View details | Privacy policylaunch
Consent


HUMAN

Doesn't use cookies.

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ADLUDIO LTD.

Doesn't use cookies.

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Consent


NEODATA GROUP SRL

Cookie duration: 366 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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INNOVID INC.

Cookie duration: 92 (days).

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TACTIC™ REAL-TIME MARKETING AS

Cookie duration: Uses session cookies.

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NEUSTAR, INC., A TRANSUNION COMPANY

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

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SUBLIMESKINZ - ADLEDGE

Doesn't use cookies.

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SALESFORCE.COM, INC.

Cookie duration: 180 (days). Uses other forms of storage.

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VERVE GROUP EUROPE GMBH

Doesn't use cookies.

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KOCHAVA INC.

Doesn't use cookies.

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Consent


OTTO (GMBH & CO KG)

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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ADOBE AUDIENCE MANAGER, ADOBE EXPERIENCE PLATFORM

Cookie duration: 180 (days). Cookie duration resets each session.

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LOCALSENSOR B.V.

Doesn't use cookies.

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ONLINE SOLUTION

Cookie duration: 365 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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RELAY42 NETHERLANDS B.V.

Cookie duration: 731 (days).

View details | Privacy policylaunch
Consent


GP ONE GMBH

Cookie duration: Uses session cookies. Uses other forms of storage.

View details | Privacy policylaunch
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LIFTOFF MOBILE, INC.

Doesn't use cookies.

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MINDTAKE RESEARCH GMBH

Cookie duration: 93 (days).

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CINT AB

Cookie duration: 730 (days).

View details | Privacy policylaunch
Consent


GOOGLE ADVERTISING PRODUCTS

Cookie duration: 396 (days). Uses other forms of storage.

View details | Privacy policylaunch
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GFK SE

Cookie duration: 730 (days). Uses other forms of storage.

View details | Privacy policylaunch
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REVJET

Cookie duration: 730 (days).

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Consent


PROTECTED MEDIA LTD

Doesn't use cookies.

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CLINCH LABS LTD

Cookie duration: 730 (days). Cookie duration resets each session.

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ORACLE DATA CLOUD - MOAT

Doesn't use cookies.

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HEARTS AND SCIENCE MÜNCHEN GMBH

Cookie duration: 60 (days). Cookie duration resets each session.

View details | Privacy policylaunch
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AMAZON ADVERTISING

Cookie duration: 396 (days). Cookie duration resets each session. Uses other
forms of storage.

View details | Privacy policylaunch
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MOLOCO, INC.

Cookie duration: Uses session cookies.

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OBJECTIVE PARTNERS BV

Cookie duration: 90 (days). Cookie duration resets each session.

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EBAY INC

Cookie duration: 90 (days).

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General vendors

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GSKINNER

Privacy policylaunch
Consent


AKAMAI

Privacy policylaunch
Consent


FACEBOOK

Privacy policylaunch
Consent


AUNICA

Privacy policylaunch
Consent


BOOKING.COM

Privacy policylaunch
Consent


C3 METRICS

Privacy policylaunch
Consent


IBM

Privacy policylaunch
Consent


ADTRIBA

Privacy policylaunch
Consent


PULSEPOINT

Privacy policylaunch
Consent


DEMANDBASE

Privacy policylaunch
Consent


EVIDON

Privacy policylaunch
Consent


CUBED

Privacy policylaunch
Consent


HURRA.COM

Privacy policylaunch
Consent


OPTOMATON

Privacy policylaunch
Consent


INTELLIAD

Privacy policylaunch
Consent


ANALIGHTS

Privacy policylaunch
Consent


DSTILLERY

Privacy policylaunch
Consent


DMA INSTITUTE

Privacy policylaunch
Consent


ZMS

Privacy policylaunch
Consent


DENTSU AEGIS NETWORK

Privacy policylaunch
Consent


IGNITION ONE

Privacy policylaunch
Consent


OMNICOM MEDIA GROUP

Privacy policylaunch
Consent


DIGISEG

Privacy policylaunch
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RESONATE

Privacy policylaunch
Consent


CENTRO

Privacy policylaunch
Consent


SOJERN

Privacy policylaunch
Consent


HAENSEL AMS

Privacy policylaunch
Consent


BDSK HANDELS GMBH & CO. KG

Privacy policylaunch
Consent


VIDEOLOGY

Privacy policylaunch
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TRADEDOUBLER AB

Privacy policylaunch
Consent


TRUSTARC

Privacy policylaunch
Consent


TRUEFFECT

Privacy policylaunch
Consent


MARKETING SCIENCE CONSULTING GROUP, INC.

Privacy policylaunch
Consent


DENTSU

Privacy policylaunch
Consent


ESSENS

Privacy policylaunch
Consent


TRAVEL DATA COLLECTIVE

Privacy policylaunch
Consent


ADVOLUTION.CONTROL

Privacy policylaunch
Consent


VIMEO

Privacy policylaunch
Consent


ENSIGHTEN

Privacy policylaunch
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ADMAXIM

Privacy policylaunch
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BATCH MEDIA

Privacy policylaunch
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VODAFONE GMBH

Privacy policylaunch
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SCENESTEALER

Privacy policylaunch
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NETQUEST

Privacy policylaunch
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MANAGE.COM

Privacy policylaunch
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CLOUDFLARE

Privacy policylaunch
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SCOOTA

Privacy policylaunch
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HAVAS MEDIA FRANCE - DBI

Privacy policylaunch
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NETFLIX

Privacy policylaunch
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MACROMILL GROUP

Privacy policylaunch
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EBUILDERS

Privacy policylaunch
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APPLOVIN CORP.

Privacy policylaunch
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FRACTIONAL MEDIA

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RACKSPACE

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MSI-ACI

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NAVEGG

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ADMEDO

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MOBITRANS

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ADEX

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SPOTAD

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AARKI

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SFR

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CABLATO

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WAYSTACK

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TRESENSA

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