The regulation allowing full reimbursement for telehealth visits in the setting of the pandemic was a wise and compassionate decision. As more doctors participated, many thousands — likely millions — of sick and susceptible elderly were able to access needed care without exposing themselves to COVID-19. It was a double-edged sword, however, and we are now seeing the downside of continuing such a policy beyond pandemic concerns. The problem: Everybody likes it.
Patients are able to get vital information and advice without leaving their homes, or needing to get rides, or even getting dressed! Some doctors have embraced receiving the equivalent reimbursement while sitting at home in their pajamas and seeing more patients in less time. Sounds like a win-win situation. But it is a bubble and it will burst. Patients will be the first to complain about the inadequate treatment.
“How can you monitor and treat my blood pressure, when you never take it? Is the $13.95 cuff and meter I bought really calibrated properly? And do I have it on the right arm in the right place?”
“How can you treat me for cough or palpitations or headache or joint pain without an exam? I might as well get advice from my neighbor who has a niece who is a nurse and already advises me on many medical matters?”
“How can Medicare justify the same reimbursement when the doctor has no overhead involved in the visit except computer time?” (No nurse, no rent, no medical equipment.)
The patients will (should) have many similar questions for which there are no adequate answers. But the real impetus for change should come from the conscientious doctor realizing that the patient is getting cheated. This impetus may be a long time coming, however, as many doctors have embraced the practice of Telehealth, finding it an easy way to work less and get paid more.
To truly discern the components of the doctor-patient office visit — the essentials as well as the nuances — we need to find someone who has had experience with many thousands of office visits, maybe more than 100,000. That would be me. As a family doctor for many decades, the early years were spent delivering babies, setting fractures, the occasional appendectomy, lots of trauma, and ICU care … exciting times, indeed. More recently, as we entered the Hospitalist Era, my time over the last 30 years has been spent in patient care in the office — namely office visits … tens of thousands of them.
I was taught to use every resource, every one of my senses and all my observation skills on the patient sitting in front of me in the office. As a family doctor, there was nothing I could discover that could not be tested, treated, and cured — or referred. I find telehealth visits to be a pale reflection of what should be a valuable interaction — rewarding for both patient and physician.
First of all, the technology is only ”OK” at best with dropped dialogue, dark lighting, and inexplicable gaps, but so much else is missing:
- The “feel” of a rash, not just how it looks
- The smell of urine from an old man’s pants (a clue to continence issues)
- The tremor of the patient’s hands — not visible on the screen
- The curled, uncut hair on the back of a man’s neck (poor hygiene)
- Watching the patient get out of a chair to come to the exam table
- The gait and effort to get up on the exam table
- The sweet smell of “acetone breath”
- Liquid spill stains on the blouse front
- Vertigo when lying supine on the exam table
- Circulation of extremities is found only by feeling the pulse
- The warmth of a swollen joint, not just the swelling
- How can you “feel a lump” in telehealth mode?
- What are the telehealth signs of organomegaly or a mass in the abdomen?
The list is virtually endless.
As family doctors, we are trained to “listen with the third ear” and to be ready to hear, “Oh, by the way”… as we place our hand on the doorknob to exit the exam room. (Often, that is when the patient broaches the real reason he/she came to the office.) Additionally, we “handle” 3 to 5 distinct concerns at each office visit, even if the reason for the visit is listed as heart failure or hypertension.
Recently, a 58-year old man with hyperlipidemia and hypertension, on 4 to 5 medications, was due for his tri-annual visit (two checkups and one physical). He lives 35 miles away, and had his bloodwork done at a lab in his area, and he asked for a telehealth visit. I allowed it, we talked briefly, and I mailed him his lab results. The time elapsed was approximately five minutes, yet I was paid the same as for an office visit. I didn’t really certify his current BP — I couldn’t — nor look at the moles on his back nor check for retinopathy, as I usually do. He was happy, but I felt I cheated him. It is not how I usually feel after an office visit.
Gerald P. Corcoran is a family physician.
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