Will Telemedicine Be Singing the “Post Pandemic Blues”? Here Is Why We Hope It Won’t

For decades, patient advocates and the American Medical Association put in prolonged effort, albeit unsuccessfully, to change outdated telemedicine policies. Then in March 2020, our world was turned upside down. Suddenly, access to care was one of the biggest priorities at hand, and previously ignored proposals relative to telemedicine could no longer be swept under the Congressional carpet. Medicare policy historically only allowed telemedicine coverage for rural patients and required that a patient drive to a satellite office of some sort to have their virtual visit. Now providers had some strong tailwinds in the push to get rid of the cumbersome satellite office requirement and expand the service offering to beneficiaries outside of designated rural areas.  Advocates for change became much more vocal in 2020, and it was clear that this old and ineffective rule was no longer sufficient.

The pandemic caused things to speed up in Congress relative to access-to-care issues and handling of critical patient care during a societal shutdown. Staying separated to stop the spread was just a small part of the bigger problem – healthcare providers had to triage their availability toward the sickest patients and the most urgent cases.

How COVID impacted patients and telehealth

A global survey of 202 healthcare providers from 47 countries showed that patients with diabetes were impacted the most during COVID, due to access and changes in routine care practices. Patients with chronic obstructive pulmonary disease, hypertension, heart disease, asthma, cancer, and depression were also greatly impacted. The RxBenefits book of business claims set from 2020 to early 2021 showed a spike in 90-day prescription fills for maintenance meds, and a sharp decline in acute meds — such as antibiotics, steroids for allergic reactions, topical acne products, and other one-time fills for quick-to-fix issues. Cancer diagnoses at advanced stages increased. Visits for second opinions fell in 2020, and the extreme drop in routine visits and preventative care also fell. Breast and colon cancer patients presented at higher stages, when comparing the number of cases staged at level 1 (contained tumors) to the number of cases staged at level 4 (significant metastasis or spread to other parts of the body). This makes it harder to treat patients successfully and would be expected to increase mortality rates. The result at Moores Cancer Center in La Jolla, California: “Across all cancer types, stage I presentations fell from 31.9% in 2019 to 29% in 2020, while stage IV presentations rose from 26% to 26.4%.” Telehealth screening of bothersome symptoms would likely have promoted earlier detection of the above cancers.

The CARES Act saved the day. There’s a great fact sheet here that is full of information about what was accomplished in light of the public health emergency effective March 1, 2020. The high points include expansion of insurance coverage for virtual visits for Medicare, including the elimination of the onsite or satellite office requirement. Providers were permitted to use any secure, non-public-facing available video app like Facetime or Skype, or even just a telephone call, to help patients. They are reimbursed at the normal office visit rate and for as much time as the virtual visit takes to make a medical decision (MDM). With a simple annual consent, Medicare patients began to sign up to receive telehealth services from anywhere in the U.S. – not just in rural areas.  It’s important to note that these new telehealth allowances applied to any diagnosis, not just COVID-related symptoms.

Before the pandemic, less than 1% of Medicare spending was used for telehealth. Spend rose to 16% during the height of COVID and is now settling in at around 5%. For commercial patients, telehealth visits make up around 15% of appointments these days but ranged from less than 1% to 37% respectively before and during the pandemic. These cost numbers and inferred utilization uptick suggest that something is working, and worth maintaining.

Every 90 days, the president decides if we are still in the midst of a public health emergency. Until that PHE period expires, which right now will be mid-July unless renewed, the parameters of the CARE Act remain in place. Once it expires, the emergency telehealth laws go back to the old Medicare setup.

The benefits of telehealth as we know it

• Patient access to care has improved with telehealth – More people are working remotely, so it is natural to have a remote medical visit when appropriate. With gas prices rising, driving less is the trend for anyone who is able. Elderly and disabled people have a much easier time attending a virtual visit and can access care quickly. If we simply consider the potential avoidance of an ER visit for a frightened elder, it makes total sense to maintain this avenue of care.
• Infection control – Keeping infectious people at home and out of the public space is good for public health and infection control. COVID-19 is spiking in certain areas still, but it’s not the only pathogen.
• Efficiency in the healthcare system is improved – Time management is key for provider offices. In corporate America, our efficiency has improved dramatically as a side effect of the pandemic. I can virtually be in eight states in one day using video conferencing. That is a much better sales visit ratio than having to spend a ton of money and get on a bunch of planes. Certainly, face-to-face meetings are amazing and effective when wanting to truly connect as humans, but in many situations, catching up virtually works for all parties. For simple medical visits and ongoing mental health counseling, video can be the most efficient means to a successful end.

The drawbacks of telehealth

• Fraud and abuse – These are already problems in healthcare, and the concern exists that remote treatment billing can’t be validated.
• Misdiagnosis and sub-optimal care – It continues to be very important to triage what should or should not be handled virtually. There are limits to what can happen during a virtual visit. Not being able to physically touch and examine a patient with a physician’s full scope of senses or run labs in real-time may impact the ability to diagnose and treat a patient.  Some virtual sessions can be improved with digital devices and home test kits.  As the body of patient and provider experience in this space continues to grow, developing rules of engagement for telehealth will be part of continuous improvement processes everywhere.
• Diminished sense of human connection as a result of COVID – Loneliness is now an official medical diagnosis (Z60.2 in the ICD-10 code set). Telehealth and virtual connections can be perceived as a cause, but in my opinion seeing another human, even if only over video, is better than a simple phone call.
• Seniors at greater risk of scams – Sharing personal medical information electronically can leave the door open for scammers to try and take advantage of elderly patients. Educating their Gen X children and caregivers will be a great next step in ensuring that elders know what a real offer of telehealth looks like versus a potential scam. The AARP published an article about telehealth for members that reminds folks about the benefits of and the growing interest in this type of visit. As we can tell from the Medicare spend numbers, people are using the technology if they have access to a computer or smartphone.

Keeping telehealth on the shelf

Two bills would extend CARE Act telehealth rules through December – called a statutory extension. Even if the PHE period is not renewed, providers and patients would still be able to operate under the non-antiquated, yet temporary rules.

According to AdvancedMd, “Keep what works! Then do more of it.” Healthcare is a dynamic environment where we can learn from our mistakes and course-correct our processes On a long road trip, wouldn’t you rather the GPS offer you a quickly accessible alternate route rather than continuing along the wrong road for another 100 miles? If we can see that something is broken and fixable, let’s adjust our policies and do what’s right for patients.

Telehealth took off with these temporary rules in place, and as the old saying goes, necessity is the mother of invention. Telehealth as an “invention” is not new, but the extreme demand for a practical, clinically effective, and safe solution puts it at the right place at the right time. Most of us can list at least a few positive things that came out of this horrible global pandemic, and the rise of telemedicine is one of them for me. For our elderly, disabled, and homebound patients, as well as those with chronic diseases who don’t want to be exposed to germs, telemedicine has been a great option. Access to mental health services has dramatically increased using virtual visits, as discussed in our last iteration of this blog. Let’s take what we have learned about this technology, good and bad, and work hard to secure its place on the shelf of effective and affordable healthcare communication options.

References:

• 7 Ways to do more of what Works and Less of What Doesn’t (duh!). AdvancedMD. (n.d.). Retrieved May 24, 2022, from https://www.advancedmd.com/learn/7-ways-works-less-doesnt-duh/
• Ama’s advocacy efforts lead to extension of telehealth coverage | Moving Medicine. (2022). American Medical Association. Retrieved May 24, 2022, from https://www.ama-assn.org/practice-management/digital/protecting-future-telehealth-through-advocacy-jason-marino.
• Chudasama, Y. V., Gillies, C. L., Zaccardi, F., Coles, B., Davies, M. J., Seidu, S., & Khunti, K. (2020). Impact of COVID-19 on routine care for chronic diseases: A global survey of views from healthcare professionals. Diabetes & metabolic syndrome, 14(5), 965–967. https://doi.org/10.1016/j.dsx.2020.06.042
• King, R. (2022, May 11). Ama, AHA among groups pressing HHS to keep covid-19 emergency past July expiration date. Fierce Healthcare. Retrieved May 24, 2022, from https://www.fiercehealthcare.com/providers/ama-aha-among-groups-pressing-hhs-keep-covid-19-emergency-past-july-expiration-date
• O’Reilly K. B. (2022, March 15). Telehealth flexibilities assured for the bulk of 2022. American Medical Association. Retrieved May 24, 2022, from https://www.ama-assn.org/practice-management/digital/telehealth-flexibilities-assured-bulk-2022
• Otto, M. A. (2022, February 15). Increase in late-stage cancer diagnoses after pandemic. Medscape. Retrieved May 24, 2022, from https://www.medscape.com/viewarticle/968495#:~:text=A%20drop%2Doff%20in%20cancer,letter%20in%20JAMA%20Network%20Open
• RxBenefits Book of Business Analysis, 2022