The COVID-19 pandemic has caused unparalleled shifts in the practice of medicine. Telemedicine has quickly become a staple of medical practices across the nation in response to the pandemic. As of October 2020, use of telemedicine claims had increased by more than 3,000 percent compared to one year prior. By the summer of 2020, 4 in 5 specialists were utilizing virtual care and the majority say it is here to stay. And as we find new ways to use this technology, we can reinvent and reinvigorate the physician house call.
In the 1930s, 40 percent of physician-patient interactions occurred in the home, often as a way to overcome hurdles such as lack of transportation, childcare duties or infirmity. Many of these issues still plague patients to this day, and yet the onus has fallen on patients to seek care from physicians in the office.
By the 1980s, less than one percent of visits were home-based, and only recently has there been a push to resurrect the house call model as an alternative health care delivery system.
The pandemic has magnified the importance of a robust and nimble health care system, one capable of addressing the needs of an entire population and not just those who are fortunate enough to have the health and resources to make the trip to a doctor’s office. House calls fell out of fashion once medicine began to evolve into the machine we’re practicing in today — one that would cause even Rube Goldberg to scratch his head — and we have left behind many of our most vulnerable citizens.
The turmoil and chaos of the past year resurrected telemedicine to solve one of the most critical problems facing physicians — how to see patients quickly and safely in their home.
Telemedicine repairs the ways that travel, cost, and health care finance laid house calls to rest. While establishing a trusting physician-patient relationship can be challenging over Zoom, it tips me off to important clues that can help me provide better care than an office visit alone could provide. For example, I can ask a patient to review her medications with me and observe how she organizes her medicine, whether she has to squint to read the prescription bottle, and her ability to move safely around her home. One doctor discovered that her patient wasn’t taking a needed medication because she could look into her medicine cabinet and see that she didn’t have it; it’s a type of introspection that office visits can’t afford.
On an interpersonal level, telemedicine facilitates equally meaningful moments of connection, an intimacy that a physician and patient can experience when we are invited “virtually” into each other’s homes. Health care providers are equally vulnerable — you can see my bookshelf, and I can see your living room. Pets make frequent cameos. Children pop on-screen or wave in the background. My patient doesn’t spend an hour traveling to visit my office; we meet each other in the middle, and this — at least in my experience — ultimately deepens the therapeutic relationship.
I get that I am necessarily competing with my patient’s time in the calculus of seeking care. From parents who have recently taken a second job as impromptu second-grade remote learning supervisor to those picking up extra shifts to make rent, time has become even more scarce for some during this health crisis. Telemedicine has offered these patients an alternative to the half-day affair a doctor’s appointment used to entail, one that ultimately harkens back to the personalized care of the house call by bringing the physician to the patient.
While it is true that telemedicine cannot replace every doctor’s appointment and some issues still require a hands-on examination, there are far more instances than we imagined where we can deliver care safely and effectively through a video or telephone visit. Even post-operative care will benefit from telemedicine. A recent study that compared postoperative visits delivered by telemedicine and those held in office found identical levels of patient satisfaction. The same number of patients who were seen virtually as those seen in the office were referred for follow-up scans to rule out complications. Telemedicine should be viewed as a permanent complement to a comprehensive care package.
And this is more important now than ever. More than one-third of adults missed important cancer screening tests in the past year, and nearly half missed their routine annual exam. We need medical care to be accessible and timely if we are to make up for what was lost during the pandemic.
Despite these obvious advantages to telemedicine, permanent funding and equal payment of telemedicine for primary care remains uncertain — it varies by state and by insurance plans — as much of the support has been tied to emergency measures. While many insurers currently support telephone-only visits, physician reimbursement for this is inconsistent and often inadequate.
There are structural barriers, too, to optimal delivery of care through a screen. Video medicine tends to be used by more affluent patients with high levels of education. As of 2019, only 53 percent of Americans aged 65 and older and 71 percent of those making less than $30,000 per year had a smartphone. If primary care clinics, which are already struggling to survive, cannot receive appropriate reimbursement for telephone-only visits, this will create an incentive to limit their availability to the outsized detriment of the elderly and the poor.
We must solidify our commitment to this critical modality by ensuring coverage for all patients to this important resource – telephone and video. A robust primary care telemedicine framework necessitates pay parity and permanent financial and technological support to bridge the digital divide. Physicians have the opportunity to provide high-value care to patients in their homes and to reinvigorate the benefits once derived from house calls. Medicare and private insurers must make telehealth sustainable by giving it the respect it deserves.
Stephanie Titus is an internal medicine physician.
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