Before COVID-19, Bryce Elliott had never experienced a telemedicine visit. Since early March, he’s had three: all via video. One from the cab of his pickup truck outside work, where he followed up with his cardiologist. Another to review medications with his rheumatologist. A third, to go over bloodwork. It felt a bit awkward at first, he admits, but each time he was more at ease. At the last appointment, he not only went over his lab results, but also had a lovely conversation with his doctor about their respective Memorial Day weekends. “We were all smiles,” recalls the 62-year-old, who lives in Gainesville, Georgia. After this taste of telemedicine, he intends to continue using it once the outbreak subsides. “Absolutely, for the convenience,” he says.
The novel coronavirus pandemic has been a particle accelerator for virtual care. Out of necessity, video visits have gone from a nice-to-have option to a mainstay of medicine, aided by rapid changes to regulations and policies that previously restrained their broader use. In less fearful times, NYU Langone Health logged 25 or so virtual urgent care visits per day. By early March, the volume soared, notes Paul Testa, an emergency medicine physician and chief medical information officer for the health system. And once video visits were expanded to non-urgent outpatient care — think: visits with everyone from primary care physicians to specialists like oncologists, diabetes experts and cardiologists — those also skyrocketed, rising to over 5,500 a day, on average.
Now that many more doctors and patients have experienced telemedicine, it will be tough to revert to a pre-pandemic normal. “It became a necessity, and (patients are) not going back,” says David Houghton, medical director of telehealth and digital medical programs at Ochsner Health in Louisiana. While virtual appointments can’t substitute for all in-person visits when the emergency is over, telemedicine finally, and likely irrevocably, will have a major role to play in medical care.
According to a 2019 survey from telemedicine company Amwell, only 8% of more than 2,000 respondents had actually experienced a video visit with a doctor. There are a lot of reasons for that. Before COVID-19, Medicare rules mostly limited the use of telemedicine to patients living in very specifically defined rural or non-metropolitan areas, explains Mei Wa Kwong, executive director of the nonprofit Center for Connected Health Policy. If eligible, patients had to travel to local clinics to participate in the videoconference, versus connecting from the convenience of their own homes. For non-Medicare patients, even if their regular physicians offered the option, or their insurer paid for visits through a platform such as Amwell or Teladoc, many people weren’t aware of it, she says. Physicians generally weren’t permitted to treat a patient without having a license to practice in the patient’s home state, even virtually. And when health care systems did offer telemedicine, it wasn’t usually reimbursed by insurers at the same rate as in-person visits, Houghton says. “There was inertia on the part of both providers and patients,” he explains.
Then, of course, came the pandemic. Amwell President and CEO Roy Schoenberg describes three waves of telemedicine adoption. First, that “huge influx” of urgent care visits starting in early February, when people began to worry about the virus. “The last place you wanted to be was in the waiting room with 50 other people,” he says. Then came an even bigger influx of new users, as hospitals and medical offices canceled any visits that weren’t emergencies or COVID-related. “That forced health systems to literally take all of the nonemergency health care that they usually do in person and (put) it on telehealth,” he says.
A third wave came when single proprietors or small group practices that were locked down signed on to telehealth for the first time to maintain their patient relationships and keep their businesses alive. Enforcement of privacy and security requirements under the Health Insurance Portability and Accountability Act was relaxed, permitting providers to use consumer video platforms such as FaceTime or Skype. Telemedicine was also more widely deployed within many hospitals to care for more seriously ill patients while reducing contact and conserving precious personal protective equipment like masks.
The easing of HIPAA standards wasn’t the only change that permitted clinicians to rapidly meet the demand for online care. Medicare temporarily permitted all beneficiaries to use telemedicine — and agreed to reimburse those visits at the same rate as in-person appointments. Restrictions were also temporarily relaxed so that doctors could use telemedicine to treat patients across state lines. Many state Medicaid programs and private insurers also made telemedicine more accessible. “It’s staggering,” says Bimal Desai, assistant vice president and chief health informatics officer at Children’s Hospital of Philadelphia. “Every possible barrier — reimbursement, payer parity, state licensure, even internal policies — all of it had to change.”
CHOP had already established a video visit platform, but when COVID-19 hit, it had to ramp up by investing in more infrastructure, quickly training all providers and building out digital scheduling and documentation tools. Some providers who were new to video visits wanted guidelines on the mechanics and etiquette of conducting them — things like how to dress (no pajamas), how to ensure good lighting in the room and how to do a remote physical exam. Before COVID, there were about 20 video visits a week; that peaked at more than 8,000 per week by mid-May.
In late May, Blue Cross Blue Shield of Massachusetts said it was processing 38,000 telemedicine claims per day, up from about 200 in February, nearly half of which were for mental health services, including psychotherapy. Medicare has also relaxed restrictions for psychologists offering therapy by video and has allowed typical services such as individual and family therapy sessions to be delivered by audio only; it has also expanded the list of services it will reimburse for, including group therapy and psychological testing, says Stephen Gillaspy, senior director of health care financing at the American Psychological Association. Private insurance coverage is inconsistent, he says.
Maryland psychologist Mary Alvord says she’s been offering therapy via video since about 2011, though she used it in only about 10% to 15% of her visits pre-pandemic, mostly for people who couldn’t make an office visit on time or who were out of town. Since COVID-19 canceled all in-person visits, she’s helped convert most patients to videoconferencing. She requires an emergency contact number for all online visits. “If someone tells me in person that they’re suicidal, we can make sure someone takes them to the ER,” she says. “If they’re somewhere else, they can just close the laptop.” She also advises patients to protect their privacy by using earbuds.
So what happens when the pandemic is in the rearview mirror? There will certainly still be an important gap that telemedicine can fill, says Amwell’s Schoenberg. For example, people with chronic conditions who have a hard time getting to the doctor due to physical limitations and transportation issues, say, could benefit from doing some follow-up visits via video. The alternative may be not checking in at all. “If there’s a grueling amount of effort involved with seeing a physician, they will see the physician less,” he says. But continued use will depend to a large extent on whether changes instituted during the pandemic continue. Some of the regulations and rules eased during the crisis will return, and rightly so, says Ochsner’s Houghton. He thinks platforms will again need to comply with HIPAA’s standards, for example. But equitable reimbursement, in particular, is “fundamental to telehealth being available to patients,” says NYU Langone’s Testa. Permanent changes will require Congressional legislation, in some cases, as well as action by state governments and licensing boards and private insurers.
The Trump administration seems to be signaling that some of the changes may be here to stay. In late April, Seema Verma, administrator for the Centers for Medicare and Medicaid Services, told The Wall Street Journal that “I think it’s fair to say that the advent of telehealth has been just completely accelerated, that it’s taken this crisis to push us to a new frontier, but there’s absolutely no going back.”
Pushing ahead with telemedicine may also require increasing connectivity. During the pandemic, physicians say most patients have had no problems connecting via phones or other mobile devices. Some providers have offered free WI-FI hotspots and free or low-cost broadband. But broadband access is lower in the most rural areas, where access to primary care physicians is the least adequate, according to a 2019 report published in the Annals of Internal Medicine.
Finding a Balance
Crucially, telemedicine isn’t for every patient. Some people, especially those with serious illnesses, just prefer in-person encounters, says Eric Topol, a cardiologist and executive vice president at Scripps Research in San Diego. It’s not right for every type of care, particularly visits that require a physical exam. “Unless the patient has a skin rash or some kind of sensor, like a blood pressure cuff, you’re mostly just talking,” he says. That is likely to change, though, he adds; doctors will increasingly get more objective data through smart phones and other devices that can record heart rate and body temperature and potentially even diagnose illness through the sound of a cough, using artificial intelligence, for example.
There are many ways for providers and patients to interact, including reminders by email or text messages, telephone calls, video visits, in-person appointments and hospitalization, CHOP’s Desai says. The key is figuring out which style offers the highest value for a given patient with a given health need, he says. “Every other industry has already realized there’s a balance between physical and digital services,” Schoenberg notes.
That’s the thinking behind the TeleOB program at UW Medicine in Seattle, launched six months before the first U.S. coronavirus case was detected in the state. Participating patients — who must fit the criteria for a low-risk pregnancy — are loaned equipment to monitor their blood pressure and their baby’s heartbeat at home. They have the option of replacing between three and six of the standard 14 doctor’s visits (and an early postpartum visit) with telemedicine appointments. It’s intended to enhance rather than replace traditional prenatal care, making it more flexible and accessible, says Sue Moreni, an OB-GYN at UW Medicine. Routine visits that don’t include lab tests, vaccinations or imaging can be made more convenient. “Many visits are there to provide patient education and address concerns,” she says. “We can do that effectively and safely through videoconference.” During the pandemic, the number of participants has tripled. “COVID just accelerated this process,” she says.
Jennie Funk, 34, enrolled in TeleOB well before the virus hit Seattle. “I have a fairly demanding job where I’m in a lot of meetings and traveling quite a bit,” she says. She thought the frequent doctor visits later in her pregnancy were going to be hard to squeeze in. “It was great to not have to adjust my work schedule prematurely,” she says. She scheduled her telehealth visits for Monday mornings, and took time the night before to measure her blood pressure, use the handheld sonogram device to check the baby’s heartbeat and reflect on any questions she had for Moreni, her doctor. Her baby girl was born in February, and by the time her first postnatal visit rolled around, the pandemic was in full swing — so she did that remotely, too. Funk has recommended the program to friends. “If you’re medically appropriate,” she says, “I can’t say enough good things about it.”
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Telemedicine Explodes to the Forefront Amid COVID-19 originally appeared on usnews.com