Telemedicine on ascendency – or the chopping block?
July 1, 2021 | View PDF
As the nation emerges from the coronavirus pandemic, telemedicine has transformed how millions of Americans, particularly seniors, see their doctors. Now the Biden administration and Congress must decide whether video and audio appointments with doctors should continue as a routine part of health care and should get federal reimbursement.
Telemedicine, also called telehealth, has been the most significant health care shift caused by the pandemic. Before coronavirus, lawmakers had tightly restricted the kind of video and audio visits that could be billed to Medicare, drastically limiting how many people could use it, by geographically allowing only people in rural areas and to visits in which a doctor was in an office or hospital, rather than working remotely. The fear was it would enable fraud and doctors might abuse this capability by over-billing patients and insurance companies.
But the pandemic changed that completely. In the year plus that it has become a mainstream way of visiting doctors, a clear consensus has emerged – many services that once required an office visit can be provided easily, safely – and more effectively – through a video chat, a phone call, or even an email. Almost everyone, from consumers to health insurers, state Medicaid officials, doctor’s organizations and of course telehealth vendors, like it – when it works well.
What this change means and how it happened
In 2020, as pandemic lockdowns shuttered physician offices, doctors were suddenly forced to pivot to virtual care to maintain contact with patients and keep money flowing. As things went from bad to worse, the Trump administration moved quickly to facilitate the shift to virtual visits. Medicare dramatically expanded the kinds of services that could be provided online, adding 150 telehealth services to the list of what Medicare would pay for during the pandemic, including emergency visits, eye exams, speech and hearing therapy, and nursing home care.
Congress then passed the Cares Act, which, among other regulatory flexibilities, provided the Centers for Medicare and Medicaid Services (CMS) the authority to waive the geographic origination requirement, leading to a surge in telemedicine usage among Medicare beneficiaries as patients could, for the first time, access virtual services from wherever they were located.
Once Medicare raised fees for virtual visits to equal those for in-office exams, state Medicaid programs and commercial insurers matched Medicare’s rules and telemedicine exploded in usage. While fewer than 1% of primary care visits in Medicare occurred virtually in January 2020, by April nearly half did, according to Medicare’s own numbers and those numbers kept skyrocketing. At UnitedHealth Group, the nation’s largest health insurer, the number of covered telehealth visits increased nearly 30-fold, rising from 1.2 million visits in 2019 to 34 million last year. Other insurers reported as much as 80-fold increases.
The huge usage prompted groups like UnitedHealth and Kaiser Permanente to not only help its doctors pivot to telehealth, but also to build virtual urgent care systems that allows patients to connect by video with on-call doctors 24 hours a day. Medicare and Medicaid went several steps further as well, including making critical care services, physical and occupational therapy and psychological services available as well as home visits for established patients, virtual group therapies online; care planning services and many private insurance companies and state governments followed that pattern.
Additional uses of telemedicine have also taken off including large increases in the use of remote monitoring tools in people’s homes that track vital signs of patients with chronic illnesses such as diabetes. But while companies have jumped in with both barrels to offer remote urgent care, virtual primary care and new wearable technologies to monitor patient health, their reason wasn’t only the pandemic, but profit.
Wearable sensors, longer-life batteries, faster data speeds, cloud-based analytics – often powered by machine learning – are allowing results and notifications instantaneously. There are smart watches and smart patches, digital stethoscopes that share respiratory and heart rhythm readings now, as well as finger pad readers that come with smart phone case attachments.
What’s coming next? Smart clothing is forecasted to reach more than $2 billion next year, special shirts that continuously monitor ECG and heart rate tracking are already on the market. According to PitchBook, a research company, the annual global telehealth market is expected to top $300 billion by 2026, up nearly fivefold from 2019.
Use of telehealth has also been transformational in mental health services and treatments for patients addicted to drugs, particularly in rural areas from Alaska to Maine. Clinics report being able to better help monitored patients adhere to their medications. It has also helped medical personnel overcome clinician shortages, especially for many specialties in rural and other underserved populations.
The federal issues
Unless Congress moves to act, most Medicare beneficiaries will no longer be able to take advantage of these services as soon as the public health emergency is declared over with. That change, back to the old rules, will mean that the only time video and audio chats can be used will be in specific rural areas, and doctors will be required to be receiving the calls from medical facilities like offices or hospitals.
One of the many questions to be determined by lawmakers, even if the geographic restrictions are lifted, is how much a telehealth visit is worth in a system that is already breaking the bank. Politicians, insurers and hospitals will have to decide whether Medicare should continue reimbursing providers at the same payment rate as for in-person coverage. Consumer groups and many government folks are pushing for lower prices when the federally designated public health crisis officially ends. At the same time, however, physicians and hospitals are looking to maintain income.
These days, with Capitol Hill in total gridlock until lawmakers figure out how to agree on some kind of infrastructure bill, something simple – like getting Congress and the federal government to agree that the sun is shining outside – is next to impossible. So even an issue like telemedicine, where nearly everyone agrees the benefits are significant and helpful, faces a difficult battle toward permanency. Doctors warn poorer care,
inequities and even higher medical bills are at risk without carefully written rules.
So far, Biden administration officials have not yet indicated whether it will push to make permanent the looser telehealth rules rolled out last year. Democrats and Republicans in Congress have introduced bills to cement the changes. A bipartisan effort from
Republican Sen. Tim Scott, R-S.C., and Democrat Brian Schatz, D-Hawaii, would remove restrictions limiting Medicare patients from accessing telehealth services outside of rural areas or from their home. Another House bill, from Ways and Means Committee Health Subcommittee Chairman Lloyd Doggett, D-Texas, would temporarily extend the current waivers to allow experts more time to further study the issue.
Other bills by Reps. Mike Thompson, D-Calif.., Reps. Jason Smith, R-Mo., and Josh Gottheimer, D-N.J., would also waive the rural and home restrictions while giving CMS the authority to designate new eligible sites, like a clinic, library or other community establishment. It would also address telephone-only access, which is particularly important to many seniors and those in underserved areas. Meanwhile, in state legislatures, advocates for expanding telehealth have introduced more than 650 bills, according to the Alliance for Connected Care, a telehealth lobbying coalition.
This issue also gets caught up in the politics of the much larger infrastructure fight. Allowing phone and video access requires adequate broadband internet services. The Biden administration has already taken some steps to address the connectivity needs. The Federal Communications Commission has expanded connectivity to people in need of discounted internet services – particularly older Americans who currently receive or qualify for Lifeline benefits through federal programs such as SNAP and households with incomes at or below 135 percent of the federal poverty guidelines. Congress included money for this expansion last year when it passed its coronavirus relief bill.
Depending on what emerges from any infrastructure compromise – if one happens at all – funding for broadband expansion is expected to be included, even if the final legislation is mostly dollars for bridges, roads and airports and not the Biden administration’s expanded definition of infrastructure including home care for seniors and child care support for parents.
But telehealth can't do these
Sometimes, telemedicine cannot replace hands-on care for some conditions. It can’t perform a colonoscopy, draw blood or replace a hip. During the pandemic, patients canceled tests, screenings and physicals, and many postponed elective surgeries. Recently, Kaiser Health News asked a variety of medical personnel for tips on the types of concerns that are best handled in person and when video visits are most useful. Here are three of their recommendations:
1. Chest pains, new shortness of breath, abdominal pain, new or increased swelling in the legs — all those things point to the need for an in-person visit. And, of course, blood tests, vaccinations and imaging scans must be done in person. The best rule is if patients are concerned enough about the situation that you are thinking about going to an urgent care clinic or an emergency room, go see the doctor in person.
If a condition, even something seemingly simple, has not resolved in a reasonable time, that’s also a smart time to go see the doctor in person. In-person visits can also prove more productive because a physician gains visual clues to what might be wrong by watching how a patient walks, sits or speaks.
2. It’s not always necessary to trek into a medical office or clinic. Check-ins for chronic conditions such as diabetes or hypertension that are basically under control, can easily be handled remotely. This is especially true if you have to inconvenience someone else to take time off work to get you and bring you to your doctor. But if you are short of breath just walking or suffering chest pain, those are times to see the doctor.
For those patients who monitor blood sugar or blood pressure at home, reporting those results to the doctor can often be done during a tele-visit or in a simple phone call. Some dermatologic conditions, like rashes, can also be handled by video, as long as the patient is comfortable with the technology. But that’s one to talk about with the doctor to see if you need to get an in-person evaluation or perhaps even a biopsy.
3. Both patients and providers can get the most out of a video visit if they first take a few simple steps. Find a quiet place without distractions. Turn off the TV. Have a family member present if you want a second set of ears, but choose a private setting if you don’t. Video visits from your car are not exactly ideal. Have a list of medications you’re taking and write down the problem or symptoms you wish to discuss, as well as specific questions you have, to make the most out of the time available.
Also contributing to this column: NPR; KHN; Reuters; Roll Call; Popular Science; Politico and JAMA Internal Medicine.