The COVID-19 coronavirus pandemic has changed the way people interact with each other, with scores flocking to video services to get their social fix. This embrace of remote-video technology has extended to clinical interactions with the healthcare system as well, and this has brought about some changes that may be permanent, from the way healthcare is utilized to the reimbursement policies enacted and enforced by the federal government.
Even providers who previously didn't offer telehealth services are scrambling to implement the technology in some form, both as a way to maintain patient-care standards and as a means of making up for revenue lost through avenues such as elective surgeries, which are being put on hold as the pandemic plays out.
Telehealth is exploding in popularity as a result. While the mode of care delivery has never had an equal footing with in-person clinical encounters in terms of the way it's reimbursed, patient demand may spur regulatory action to change that.
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Dr. Gregg Miller of Swedish Emonds, Seattle, and Chief Medical Officer at Vituity, is among those who are preparing care teams to handle patient encounters remotely. Currently, he's engaged in planning efforts to train and prepare clinical teams for this new reality at roughly 300 health facilities across the U.S..
To prepare staff, Miller and his team have been focused on implementing two levels of education. The first is centered on getting clinicians to step into roles they might not have otherwise assumed, such as telehealth treatment. The second level of education is geared toward healthcare leaders and ensuring they have the right systems in place to implement telehealth in an impactful way.
"They need to make sure they have the infrastructure to capture patient information, register them for a visit and help patients navigate to that platform," said Miller. "There's been really good adoption of clinicians on the outpatient side of telemedicine. Where it's lagging is more on the acute care side. Doctors and providers have realized, 'I'm not seeing any patients, and the only way I can see patients is through telemedicine.'"
In addition to being able to capture more revenue, these efforts at telehealth adoption show promise for protecting the health of both patients and caregivers. Telehealth prevents clinicians from being infected by COVID-positive patients. But since clinicians run the risk of becoming virus carriers themselves due to the frontline nature of their jobs, it also protects patients from potentially contracting the coronavirus as a hospital-acquired infection. That's a very real risk in a complex and chaotic healthcare environment.
Implementation of telehealth has differed from health system to health system, depending on their existing infrastructure and capabilities. In some cases, remote care can barely be called true telehealth: Patients use telephones to interact with clinicians during discharge or while waiting for test results. What once was a face-to-face interaction now takes the form of a doctor calling a patient on their phone while the latter is sitting physically in the hospital, awaiting the next steps of their care journey.
"The more complex version is that providers have set up these tents," said Miller. "In the tent there's an iPad that's always on, with an audio-visual connection to a computer that's in the hospital. They've been registered over the phone, and they do have a face-to-face encounter with a triage nurse. … They get placed into an isolation room in the tent, and speak with the physician inside the emergency department through this audio-visual program."
It's a creative, quasi-improvisational approach to implementing telehealth services in some form. In Miller's experience, there have also been inventive ways of using remote technology to follow up with patients after a visit -- which technically falls under the umbrella of remote patient-monitoring, a distinct practice from core telehealth services but a close cousin regardless.
Using RPM technologies, patients have been discharged with thermometers and devices that attach to their fingers, which relay vital, real-time health information to providers, including heart rate and blood pressure. Patients can download a hospital's preferred technology platform onto their smartphones, and with health information flowing freely, they can then receive regular telehealth calls with their providers.
The exact nature of these telehealth encounters are different depending on a specific hospital's capabilities. The Centers for Medicare and Medicaid Services has waived telehealth-reimbursement restrictions in part to encourage the use of these services. These waivers are temporary, but with telehealth gaining in both popularity and legitimacy, could these changes eventually become baked into the system?
History may point the way to an answer.
A HISTORICAL PERSPECTIVE
It didn't take a global pandemic for telehealth to start gaining traction among patients and providers. Use has been climbing steadily, particularly over the past few years as the technology has become more streamlined and younger generations flock to the care model. But due to federal restrictions, implementing telehealth -- and its cousin, remote patient monitoring -- has sometimes been challenging.
Carrie Nixon of Virginia-based Nixon Law Group has been following the space closely for years.
"What I have seen over the past number of years is some regulatory and legislative barriers that have made adoption of technology like telehealth and remote patient monitoring difficult, and without incentive, for physician practices who are already feeling overburdened with costs and administrative duties in running their practices," said Nixon.
Telehealth, she said, was first recognized as a reimbursable service in 1997. But Congress legislated that it could only be reimbursed in limited circumstances. A patient had to be geographically located in an underserved rural area, and the encounter could not take place inside a person's home. A patient would have to drive to a nearby clinic or medical practice with telehealth capabilities set up inside the office.
Under CMS's current reimbursement scheme, not much has changed. Under CMS's reimbursement scheme, not much changed until the agency gave Medicare Advantage plans more leeway last year. But the technology itself has changed quite a bit. The regulatory framework has lagged behind the actual technological advances in the field.
"I think we would have been in a different position with this crisis if a telemedicine infrastructure had already been in place," said Nixon. "There wouldn't be this scrambling."
Since the 1997 recognition of telehealth as a reimbursable service was made possible through an act of Congress, the conditions under which it could be reimbursed for Medicare beneficiaries – and who could provide telehealth services – were set by statute. That means CMS couldn't make subsequent, permanent changes through the regulatory process. It requires an act of Congress to bring about lasting changes, and it's Congress that would have to take the lead if conditions are to change once the waivers evaporate.
"As we know, Congress has had an awfully difficult time agreeing on anything, particularly relating to healthcare, over the past decade," said Nixon. "There were bills introduced over the years, but they were never able to come to the floor and be passed. CMS's hands were tied from a regulatory perspective. They were not able to make changes."
What CMS could do instead was to differentiate telehealth from remote patient-monitoring, which allowed the agency to create standalone rules for the latter. The first standalone for RPM came in the 2018 physician fee schedule.
CMS differentiated RPM from telehealth by defining telehealth as an encounter that could have taken place in person. RPM, by its very definition, cannot be conducted in person, and so CMS was able to set reimbursement amounts for it. But this created confusion for providers.
"The way they were laid out in the schedule had ambiguity around the details," said Nixon. "CMS did this so they were not being overly prescriptive and inadvertently stifling innovation by putting too many constraints around technology, which wouldn't take into account innovations that hadn't occurred by the time they were putting the rules together."
A POST-COVID-19 WORLD
Now that the coronavirus pandemic has foisted change upon the telehealth landscape, Congress may feel increased pressure to evolve the reimbursement scenario beyond the current restrictions. Rural areas in particular were already feeling the detrimental effects of vanishing hospitals and far-flung sites of care, but COVID-19 has highlighted these difficulties and spurred patients to accelerate their embrace of remote technology.
"We're seeing more and more people coming out of the woodwork to access telemedicine," said Dr. Blake McKinney, a practicing ER doctor who is cofounder and Chief Medical Officer at CirrusMD. "People have had telemedicine benefits buried somewhere in their inbox for many years, and now they're searching for it because people are having these thoughts of, 'I'm absolutely, positively not interested in going into a brick-and-mortar facility.' It's not highly desirable. They're rifling through their drawers, searching their inbox for telemedicine information, and they're finding it, and they're using it."
McKinney's experience highlights a main reason why telehealth has been gaining such traction: It isn't just about seeking safer ways to treat COVID-19, but seeking care for more mundane issues without the threat of contracting the coronavirus while visiting a real-world medical facility.
When taking into account patients who seek routine services while avoiding COVID-19, McKinney estimates that about 45% of his business is somehow coronavirus-related.
And that business is seeking to fill the void left by primary care physicians, many of whom have shut their doors and lack telehealth capabilities themselves. This has created problems for which many patients simply weren't prepared, such as refilling prescriptions for things like anxiety and depression – conditions that can both be made worse by the isolation that comes with coronavirus-inspired social distancing guidelines.
"We do that all the time," said McKinney. "We prescribe anxiety medications, initiate antidepressant therapy. That's all under the realm of the GP, so we're dealing with a lot of that."
Personally, McKinney saw about 275 cases during the month of March that ranged from confirmed positive coronavirus cases to cases in which patients were exposed to the virus and are now at home and having difficulty breathing. He has encouraged his staff to manage these patients according to the practical realities of the testing scenario in the U.S., with an eye toward preventing mildly symptomatic people from spreading the coronavirus all over town while searching for reliable testing.
"It's about safety," he said. "The scariest thing I do in a hospital is send somebody home. I'm letting them go out of the safety of my ER, and I'm hoping everything goes well for that person. I know if they have questions they won't be able to get back in touch with me."
That, combined with an uncertain reimbursement picture post-pandemic, is spurring many in the industry to call for permanent changes to the way telehealth is handled in the U.S.
"A lot of hospitals are feeling a lot of financial pressure," said Miller. "Elective surgeries have been cancelled. My hospital has actually stopped delivering babies. That's a source of revenue that's no longer coming into the hospital. So financially they're really feeling it.
"From the federal government there was the (initial) $30 million bailout that got paid out, but it was not enough," he said. "For the hospitals who were the hardest hit, it was not enough. Staffs are being laid off. They're stuck between a rock and a hard place. Staff is getting infected, there'll be another surge of patients, and we'll be right back to where we were in the middle of March."
As long as CMS's telehealth reimbursement waivers are in place, hospitals can lean on the technology to replace some of their lost income and open up new revenue streams. But the coronavirus's reign will end one day, and when that day comes, many hospitals – and patients – will want remote care to remain a staple of U.S. healthcare.
"We'll likely need a legislative change for these changes to be permanent," said Nixon. "There will be more of an impetus now. Once patients have had telehealth, it's likely they won't want to go back."