The doctor is in on your nearest screen, hopefully.
May 1, 2020
With social distancing, depression, isolation and loneliness hitting the nation’s seniors particularly hard as a result of the coronavirus pandemic, the federal government has made big changes to Medicare to help doctors reach patients easier without visiting offices or hospitals. But while it appears well-intentioned, these policy changes also are going to have to be more carefully thought out over time.
The COVID-19 pandemic has prompted Medicare to open access to telehealth, connecting patients to health care providers through videoconferencing and online in lieu of in-person visits. People have been making appointments online for a long time, and even using internet-connected monitoring devices to check blood pressure, diabetes and other conditions, but this expansion allows Medicare to pay doctors so they can do actual medical appointments.
For those Americans living in rural communities and even small towns, a visit to the doctor can turn into a day-long ordeal. So easy access to doctors has suddenly become more important than ever. The irony is not lost, however, that prior to the pandemic, the biggest criticism of telehealth was that it was too distant, wasn’t intimate enough, or as one doctor suggested, “you couldn’t be a hand on the shoulder” – now it’s precisely that degree of distance that has everyone embracing telehealth as fast as possible.
In addition to reducing the strain on doctors’ time and resources, telehealth eliminates unnecessary hospital and emergency room visits by seniors. It also prevents the spread of illness to an older population that has much higher risk of getting COVID-19 due to underlying chronic health problems like heart issues, diabetes and lung/breathing issues.
Until changes made in March, Medicare had previously limited telehealth to particular circumstances like patients in rural areas. But those patients would typically still need to travel to a medical facility to consult with a doctor at another location. Now, for the coronavirus time frame, Congress waived Medicare rules, enabling more than 40 million seniors access to the program. Another 20 million seniors already have access to telemedicine through their Medicare Advantage plans offered by private insurers.
But the new rules go even further, encouraging states to expand their use of telehealth in their Medicaid programs for low-income people. One of the now-waived Medicare restrictions that will encourage use of telehealth had required medical offices to have an established relationship with a patient in order to bill for telehealth services. Medicare has lifted that during this emergency.
Telehealth pros and cons
All kinds of creative and innovative uses for telemedicine are happening as a result of the changes. Mostly that’s because people are now aware of it as a viable alternative to going to the emergency room for the first time. Still, the idea of talking to a doctor through a computer or a smartphone is undoubtedly intimidating for many – especially tech-phobic seniors. There are new services to learn about, privacy concerns to deal with, and insurance issues to figure out.
Throughout the U.S., urgent care centers are encouraging patients to use their telemedicine options instead of physically showing up. Some hospitals are making use of virtual platforms to screen and triage patients who might have COVID-19, while others are using the technology just to free up personnel and space.
By changing the rules, Medicare eliminated one barrier it had imposed on itself. Until recently, Medicare had only allowed telehealth consultations if patients had both “audio and video capabilities,” thereby eliminating the easiest way for a doctor to communicate with a patient in a simple phone call. Why should people who are visually impaired have to do a video chat? That was nonsensical.
Under the new rules, phone calls are fine, as are the use of Apple’s FaceTime or Microsoft’s Skype, both of which allow phone and video chatting. Zoom, another video platform, has also been given temporary approval, although there have been recent security issues. Some other services that were designed specifically for telehealth consultation and are used by medical folks include VSee, Doxy, thera-LINK and Amazon Chime.
Many people already use a wide array of medical devices to check blood pressure, blood oxygen levels, and some wearables like the Apple Watch can even produce electrocardiograms. But the problem remains that some 35 million Americans don’t use the internet at all, according to a 2019 Pew Research study.
Some 44 percent of Americans who make less than $30,000 a year don’t have access to home broadband, and 29 percent don’t have access to a smartphone, leaving some of the nation’s poorest folks unable to access their doctors. Rural areas, as well as some city communities, are particularly vulnerable to this digital divide. And nearly all libraries – the place where many people go for internet access – have been shut down to comply with social distancing requirements.
To provide some hope, the Federal Communications Commission (FCC) recently loosened its rules governing the popular LifeLine program, which entitles some low-income Americans to discounted telephone and internet services. The FCC has said no one will be kicked out of the benefit until this summer, and it also waived the “gift rules” for certain health and education programs so internet providers can boost internet speeds and give assistance to institutions. In addition, many phone carriers have recently expanded the amount of data available to individual’s mobile data plans in response to the coronavirus.
Health and Human Services has also temporarily relaxed the HIPAA privacy laws to allow doctors to provide telehealth from their personal cell phones. Until recently, doctors couldn’t use their cell phones at all. Also to make things easier for seniors, Medicare recently temporarily agreed to pay doctors to include telehealth mental health counseling and preventative health screenings.
Virtual check-ins, brief text chats and emails between doctors and patients are now also covered, even though they used to be prohibited. For those people who don’t have a primary care physician or need urgent care, there are also new telemedicine platforms like Doctors on Demand ( https://www.doctorondemand.com ), Teladoc ( https://www.teledoc.com ), MDLive ( http://mdlive.com ) and Amwell ( https://amwell.com/cm/how-it-works ), which used to be called American Well.
Security concerns remain a problem and HIPAA privacy rules remain largely in place. Patients need to remain vigilant with their medical records and must be aware that there are risks of sending very sensitive photos to their physicians, especially because if your doctor is on his cell phone, that would be stored outside a typical secured electronic health record.
Who pays for what and to whom?
In one of the recent congressionally-approved coronavirus bills, lawmakers provided $200 million earmarked for the FCC to fund telehealth services and devices for medical providers, doctors, hospitals, medical schools, community health centers, rural health clinics and even long term care and skilled nursing facilities. These places can now apply for up to $1 million to cover the cost of new devices, services and personnel. But patients will need to check to see about co-pays and deductibles. Under traditional Medicare, the Part B deductible of $198 in 2020 and the 20 percent co-insurance will still apply. However, individual providers may elect to reduce or waive the cost-sharing requirements for telehealth visits.
Problems are quickly emerging as telehealth skyrockets in use. One of the largest barriers has always been how doctors get paid. To make this work finally, Medicare recently announced that it agreed to pay the same rates for virtual visits as it does for in-office appointments. The Trump administration also temporarily eased regulations to allow the use of mobile devices for virtual visits which has enabled some doctors in areas hard hit by COVID-19 to work from home and curtail nonessential office visits. Now many patients are waiting long times to get virtual time with their doctors because of high demand.
Insurance remains another huge barrier to telehealth usage. Medicare is federally run, but insurance including most telehealth policies are regulated at the state level. That means that every state and every private health insurance company have different policies. This is further complicated because tens of millions of Americans are not insured, and tens of millions more are on self-insured plans, which have different policies than those who are fully insured.
So without a one-answer-fits-all policy nationwide, patients are going to have trouble figuring out which policy applies to them, further complicating the ability to find the proper care they need. And since states will have to adopt these new rules and regulations, there will be a fragmented adoption of policies. That will be complicated even more for multi-state providers.
If you have private health insurance, you should check to see whether your insurer has made adjustments to their policies for reimbursement for telehealth. For instance, Aetna and Blue Cross Blue Shield are waiving copays for telemedicine for many members until June. But, as always, be prepared to read the fine print. Insurance companies have historically been slow to offer telehealth options.
While Medicare expanded access to psychological testing via telehealth for the first time, it still does not cover typical therapy services by phone. And this comes at a time when obviously some people will experience depression as a result of the coronavirus, social distancing and isolation.
As a potential alternative, Recode, a tech-focused online news outlet, recently suggested that a nonprofit called the Open Path Psychotherapy Collective ( https://openpathcollective.org ), offers low cost counseling at between $30 and $60 a session. HeyDoctor from GoodRX ( http://heydoctor.com ) and PlushCare ( http://plushcare.com ) also offer low-cost telemedicine doctor visits. In addition, there are low-cost text-a-therapist services like Crisis Text Line, which facilitates text-based conversations with volunteer crisis counselors, and others like TalkSpace ( http://talkspace.com ) and BetterHelp ( http://BetterHelp ), though they’re not a replacement for speaking to a therapist in real time.
One thing is already clear while many of the adjustments for telehealth, including the suspension of copays and certain regulations, are temporary. Even with its problems, it may be hard for insurers and the government to pull back once patients become more used to using digital health services. Whenever the pandemic is long gone, the convenience of reaching a doctor online is likely to stay.
Also contributing to this column were PBS, CNN, CNBC, Tech Crunch, ABC, the New York Times, AP, Recode and Statnews.