For thousands of years, medicine was an in-person enterprise. Patients with mysterious symptoms or requiring complex interventions traveled days to obtain an expert opinion. At times, Medicine appears to be nostalgic for these days now past; as society braces for the advent of 5G, many of us in medicine communicate via pager and landline telephones. The potential of telemedicine – the use of technology to remotely deliver patient care – has laid dormant for many years. COVID-19 has urgently summoned telemedicine to the front lines. It is our hope that once the pandemic abates, telemedicine will persist as an accessible way to provide effective medical care. Only by maintaining reimbursement parity will this be the case.
The benefits of telemedicine
The benefits of telemedicine are obvious. Virtual visits eliminate a costly, uncomfortable commute that is a barrier to accessing care. A nauseated patient will no longer have to get dressed, clamber into the car, sit in traffic, park, walk to the office, wait in the waiting room, wait in the doctor’s room, see the doctor, then walk to the parking garage, drive to the pharmacy, then drive home. A health care provider sitting in their home office in Massachusetts can care for a patient lying in bed in California. Virtual visits provide a flexible pool of physicians and specialists, available to care for all populations, without geographic limitations, a boon when responding to crises. Effective medical care doesn’t have to be a long, painful Odyssey-like journey. It can be practical, efficient – like Amazon Prime or Netflix, delivered to the patient’s couch.
The barriers to telemedicine
Several barriers have prevented wide-spread adoption of telemedicine. One obstacle is the perceived losses in the human exchange – the squeezing of the hand to convey empathy, the information provided by the sacred ritual of the physical exam – which is thought to cause substandard care and to erode the patient-doctor relationship. The evidence does not support this. Research shows that telemedicine provides quality care, and in one comprehensive study, 84 percent of patients experienced an improvement in the patient-doctor relationship when telemedicine was made available by their provider. This phenomenon likely related to the patient being reassured that their physician was reachable and responsive if needed, a key feature of attachment formation in human relationships.
Another barrier is health insurance reimbursement. Medicare will only reimburse for care when it is delivered through live-video, by an “eligible provider,” to a patient located in an “eligible facility” located in a “Health Professional Shortage Area” as defined by the Health Resources and Services Administration – this usually limits eligibility to patients in a health care facility in a rural area at the time of the virtual visit. Notably, a telehealth visit with a patient at home, in a rural area, would not be covered since home is not an “eligible facility.” Reimbursement by Medicaid and private payers is highly variable and dependent on an individual state’s policy. Only 20 percent of states require payment parity – equal reimbursement between telehealth and in-person visits – resulting in many insurers paying less for a telehealth visit. The combination of esoteric, restrictive policies, and often lower reimbursement rates has discouraged the adoption of telemedicine.
COVID-19 summons telemedicine
The desperate times around the COVID-19 pandemic have favored the adoption of telemedicine as a desperate measure. Initial adoption has had its challenges. Physicians scrambled to find a HIPAA-compliant telemedicine application before President Trump stated he would loosen HIPAA regulations. A surge in the number of users caused several telemedicine platforms to experience outages. Physicians felt uncomfortable and awkward with this new practice and had few mentors to turn to. Telemedicine is being asked to meet our needs in crisis when in a non-crisis setting, we had not incentivized health care systems to develop its infrastructure or use it.
In response to COVID-19, the Coronavirus Preparedness and Response Supplemental Appropriations Act allotted $500 million to expand Medicare coverage of telehealth services. This includes reimbursement of telehealth services regardless of patient location, including pay for virtual visits with patients seen at home. Many states’ Medicaid and commercial plans have followed suit, expanding reimbursement for telehealth visits. The public health crisis and monetary incentive have spurred health care systems to develop telemedicine workflows and providers to learn webside manner and to practice safe virtual care.
Telemedicine: beyond COVID-19
But this expansion in coverage and reimbursement of telehealth services is temporary. We are concerned that when the COVID-19 pandemic subsides, when the toilet paper is back on the shelves, and when our children return to school, we will regress to medicine as usual – pagers, landline telephones, and many barriers to care. We must not allow this to happen. Payment parity for telehealth services is the best incentive to develop the infrastructure to increase access to quality care for all, and to better respond to health crises. It is our responsibility to advocate for it.
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