Telemedicine: What's Changed and What Needs to be Addressed? Save

Along with our patients, we've spent the last several months adapting to telemedicine. Following is an update on legislative changes and uncertainties, a look at the care gap that may still exist, and examining the trajectory of telemedicine after the initial rapid growth spurred by COVID-19.

Growth

Although the use of telemedicine was already increasing prior to COVID-19, we have seen an exponential increase during the pandemic fueled by the desire to keep patients and providers safe by minimizing in person contact. 

Prior to the pandemic, the number of annual telemedicine visits increased from just over 7,000 in 2004 to almost 108,000 in 2013. In 2013, only 0.26% of all rural Medicare beneficiaries studied received a telemedicine visit.¹ Then, according to the Centers for Medicare and Medicaid Services (CMS), from mid March to mid June 2020, over 9 million Medicare beneficiaries received a telehealth visit.² CMS Administrator Seema Verma noted an astronomic jump in virtual visits from 13,000 prior to the pandemic to 1.7 million per week during April 2020.³ 

An important question: what will the trajectory of telemedicine look like after this rapid growth spurred by COVID19?

Interestingly, Phreesia, a health care technology company that encompasses over 50 million outpatient visits a year, reported that rates of telemedicine visits have already declined since mid April 2020.⁴ This is likely due, in part, to an interest in resuming at least a portion of face to face visits. Telemedicine has historically been seen as an adjunct to intermittent in person visits, and payors are not keen to reimburse ‘extra’ care. The question becomes whether payors will reimburse telemedicine equally to in person care in the long run.⁵ The ongoing use of telemedicine will depend, in large part, on legislation facilitating the use of telemedicine as well as its reimbursement.

Legislation

While telemedicine has exponentially grown, been surprisingly facile and well compensated during the COVID pandemic, its future is at the mercy of permissive legislation.⁶ Numerous pre-COVID legislative and regulatory obstacles at the federal and state levels include:

• Complying with HIPAA regulations, requiring patients to go to a local facility for AV equipment rather than staying at home
• Requiring patients to live in designated rural areas
• Covering only follow up visits
• Obtaining licensing, credentialing, and malpractice coverage for telemedicine (and interstate variability therein)
• Requiring the provider to be licensed in the state in which the patient lives
• Requiring the patient’s written consent in the electronic medical record 
• Receiving historically poor reimbursement by private payors and CMS.⁷  

The outset of the pandemic brought about CMS’ sweeping expansion of Medicare telehealth benefits under the 1135 waiver and the Coronavirus Preparedness and Response Supplemental Appropriations Act.⁸ The waiver allowed for more than eighty additional services to be provided by telemedicine.⁹ Measures gave physicians the ability to interact with patients with both audiovisual visits and audio only with equal reimbursement to in person appointments. Moreover, other restrictions mentioned above were temporarily lifted, including the ability to access telemedicine from home and to do so in both urban and rural areas. The stimulus package released by the Trump Administration early in the pandemic included a $200 million telemedicine investment by the FCC. These dollars were to be invested in services and devices facilitating telehealth and demonstrated the FCC has a stake in telemedicine.¹⁰ Following the CMS lead, some major private payors including UnitedHealthCare, Cigna, and Aetna expanded telehealth coverage as well. Furthermore, the Department of Health and Human Services waived possible HIPAA violations when providing care in good faith to patients via FaceTime, Skype, and other widespread means of audiovisual communication.¹¹ The ACR also advocates for changes in HIPAA policies regarding the use of these platforms to expand patient access.⁷

The relaxed restrictions by CMS and several large private payors alleviate many obstacles to providing telehealth care, but a major question remains if, and to what extent, these loosened regulations will revert back to prior or become permanent. CMS recently released a promising statement that they are working to make telehealth expansions permanent, which is in line with an Executive Order on Improving Rural and Telehealth Access signed by President Trump.¹² The ACR is a proponent of making the current parity of reimbursement of in person and telehealth visits permanent, and they support the ongoing use of telemedicine assuming certain standards are upheld.⁷ One of these key requirements is the need for intermittent in person visits, which may serve to alleviate some gaps in telemedicine care that have been exposed during its rapid expansion with the COVID 19 pandemic.

Care gaps

Ultimately, to incorporate telemedicine as a sustainable part of one’s ongoing practice, we need to make sure we are providing high quality care at par with in-person visits and be mindful of potential gaps in care provided by telemedicine services. The ACR encourages rheumatologists to evaluate the best use of telemedicine versus in person visits, determine how to remotely assess disease activity, and ultimately measure patient outcomes in those who received remote care.⁷ The rapid implementation of telemedicine has made it challenging for providers to anticipate and troubleshoot barriers to care.¹³

A major barrier to telemedicine is access to, and or/proficiency with, the technology necessary to conduct the visit. Some have dubbed this the ‘digital divide’.¹³ For households led by an individual over age 65, over one third do not have a desktop or laptop and over 50% do not have a smartphone.¹⁴ Those most likely to lack digital literacy tend to be older, less educated, and African American or Hispanic.^15,16 

Unfortunately, simply supplying the technology might not be as quick of a fix as hoped. Out of Americans who have access to a computer, 52 million do not know how to use it properly.¹⁷ Similarly, a group of dermatologists noted that some patients who had the necessary technology and were taught how to use it for a virtual visit were still not able to show their lesions well enough for the provider to properly evaluate. Also, they noted imperfections in ongoing functionality of the technology, such as various malfunctions and bandwidth limitations.¹⁸ 

Neurologists at NYU reported on their experience rapidly expanding telemedicine when New York City was severely impacted by COVID-19. They noted that, as aforementioned, socioeconomic determinants of health created a gap in their telemedicine program, where some patients didn’t have access to computing devices, network connections, or even space to perform a full exam in privacy.¹⁹ In patients who did have the necessary technology, some were unable to perform a neurologic exam remotely even with maximal coaching in a timely manner. Not surprisingly, patients with the greatest difficulty had cognitive, visual, or hearing impairments. Also, the rapid expansion of telemedicine made it difficult to adopt new checkout workflows to ensure appropriate follow up and prevent patients from falling through the cracks.¹⁹

These challenges speak to some reasons why the ACR, among others, note the importance of using telemedicine as one aspect of a patient’s care plan to enhance care, not as the sole mechanism of care.⁷ A study looking at providing rheumatologic care in sub-Saharan Africa noted that telerheumatology can be used as a triage tool to identify patients needing in person visits. They noted the patients best suited for telerheumatology visits are those, as aforementioned, who need screening before an in person visit or patients with an established diagnosis and/or stable disease.²⁰ 

This real-world telemedicine experiment stimulated by the COVID-19 pandemic has brought about exciting possibilities in new ways to deliver healthcare, but we must either wait for or drive the legislative changes that will best serve our patients and use innovation to close the healthcare and technology gaps exposed by the COVID-19 pandemic.  

References

1. Mehrotra A, Jena AB, Busch AB, Souza J, Uscher-Pines L, Landon BE. Utilization of Telemedicine Among Rural Medicare Beneficiaries. JAMA. 2016;315(18):2015–2016.
2. “CMS to Assess Telehealth Reimbursement Rates Post-Pandemic.” RevCycleIntelligence, 21 July 2020.
3. Verma, Seema. “Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19.” Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19 | Health Affairs, 15 July 2020.
4. Mehrotra, Ateev. “The Impact of the COVID-19 Pandemic on Outpatient Visits: Practices Are Adapting to the New Normal.” Commonwealth Fund, 25 June 2020.
5. Numerof, Rita. “Telehealth Is Here To Stay – Once Payers And Providers Overcome These Hurdles.” Forbes, Forbes Magazine, 29 July 2020.
6. Keesara, Sirina, et al. “Covid-19 and Health Care’s Digital Revolution.” New England Journal of Medicine, vol. 382, no. 23, 2020, doi:10.1056/nejmp2005835.
7. Committee on Rheumatologic Care. ACR Position Statement. June 2020.
8. “Press Release President Trump Expands Telehealth Benefits for Medicare Beneficiaries During COVID-19 Outbreak.” CMS, 2020.
9. Webster, Paul. “Virtual Health Care in the Era of COVID-19.” The Lancet, vol. 395, no. 10231, 2020, pp. 1180–1181., doi:10.1016/s0140-6736(20)30818-7.
10. Emma, Caitlin, and Jennifer Scholtes. “Here's What's in the $2 Trillion Stimulus Package - and What's Next.” POLITICO, 26 Mar. 2020.
11. HHS Office of the Secretary and Office for Civil Rights (OCR). “HIPAA and COVID-19.” HHS.gov, US Department of Health and Human Services, 22 June 2020.
12. “Press Release Trump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries Beyond the COVID-19 Public Health Emergency and Advances Access to Care in Rural Areas.” CMS, 3 Aug. 2020.
13. Rajasekaran, Karthik. “Access to Telemedicine—Are We Doing All That We Can during the COVID-19 Pandemic?” Otolaryngology–Head and Neck Surgery, vol. 163, no. 1, 2020, pp. 104–106., doi:10.1177/0194599820925049.
14. Ryan, Camille et al. Computer and Internet Usage in the United States: 2015.
15. Mehrotra, David Velasquez Ateev. “Ensuring The Growth Of Telehealth During COVID-19 Does Not Exacerbate Disparities In Care.” Health Affairs, 8 May 2020, www.healthaffairs.org/do/10.1377/hblog20200505.591306/full/.
16. Samantha Artiga, Rachel Garfield. “Communities of Color at Higher Risk for Health and Economic Challenges Due to COVID-19.” KFF, 8 Apr. 2020.
17. Mamedova, Saida et al. A Description of U.S. Adults Who are Not Digitally Literate. Stats in Brief: US Department of Education. May 2018.
18. Gupta, Rohit, et al. “Teledermatology in the Wake of COVID-19: Advantages and Challenges to Continued Care in a Time of Disarray.” Journal of the American Academy of Dermatology, vol. 83, no. 1, 2020, pp. 168–169., doi:10.1016/j.jaad.2020.04.080.
19. Grossman, Scott N., et al. “Rapid Implementation of Virtual Neurology in Response to the COVID-19 Pandemic.” Neurology, vol. 94, no. 24, 2020, pp. 1077–1087., doi:10.1212/wnl.0000000000009677.
20. Akpabio, Akpabio, et al. “Can Telerheumatology Improve Rheumatic and Musculoskeletal Disease Service Delivery in Sub-Saharan Africa?” Annals of the Rheumatic Diseases, 2020, doi:10.1136/annrheumdis-2020-218449.