Fad or future? Telehealth expansion eyed beyond pandemic

WASHINGTON — Tele­health is a bit of Amer­i­can inge­nu­ity that seems to have paid off in the coro­n­avirus pan­dem­ic. Medicare tem­porar­i­ly waived restric­tions pre­dat­ing the smart­phone era and now there’s a push to make telemed­i­cine wide­ly avail­able in the future.

Con­sul­ta­tions via tablets, lap­tops and phones linked patients and doc­tors when soci­ety shut down in ear­ly spring. Tele­health vis­its dropped with the reopen­ing, but they’re still far more com­mon than before.

Per­ma­nent­ly expand­ing access will involve strik­ing a bal­ance between costs and qual­i­ty, deal­ing with pri­va­cy con­cerns and poten­tial fraud, and fig­ur­ing out how tele­health can reach mar­gin­al­ized patients, includ­ing peo­ple with men­tal health problems.

“I don’t think it is ever going to replace in-per­son vis­its, because some­times a doc­tor needs to put hands on a patient,” said Seema Ver­ma, head of the Cen­ters for Medicare and Med­ic­aid and the Trump administration’s lead­ing advo­cate for telehealth.

Caveats aside, “it’s almost a mod­ern-day house call,” she added.

“It’s fair to say that telemed­i­cine was in its infan­cy pri­or to the pan­dem­ic, but it’s come of age this year,” said Mur­ray Aitken of the data firm IQVIA, which tracks the impact.

In the depths of the coro­n­avirus shut­down, tele­health account­ed for more than 40% of pri­ma­ry care vis­its for patients with tra­di­tion­al Medicare, up from a tiny 0.1% sliv­er before the pub­lic health emer­gency. As the government’s flag­ship health care pro­gram, Medicare cov­ers more than 60 mil­lion peo­ple, includ­ing those age 65 and old­er, and younger dis­abled people.

A recent poll of old­er adults by the Uni­ver­si­ty of Michi­gan Insti­tute for Health­care Pol­i­cy & Inno­va­tion found that more than 7 in 10 are inter­est­ed in using tele­health for fol­low-ups with their doc­tor, and near­ly 2 out of 3 feel com­fort­able with video conferences.

But pri­va­cy was an issue, espe­cial­ly for those who hadn’t tried tele­health. The poll found 27% of old­er adults who had not had a telemed­i­cine vis­it were con­cerned about pri­va­cy, com­pared with 17% of those who tried it.

Those who tried tele­health weren’t com­plete­ly sold. About 4 in 5 were con­cerned the doc­tor couldn’t phys­i­cal­ly exam­ine them, and 64% wor­ried the qual­i­ty wasn’t as good.

“After the ini­tial excite­ment, in the after­glow, patients real­ize ‘I can’t get my vac­cine,’ or ‘You can’t see this thing in the back of my throat over the com­put­er,’ ” said Dr. Gary LeRoy of Day­ton, Ohio, a pri­ma­ry care doc­tor and pres­i­dent of the Amer­i­can Acad­e­my of Fam­i­ly Physicians.

For Medicare ben­e­fi­cia­ry Jean Grady of West­ford, Ver­mont, telemed­i­cine was a relief. She need­ed a check­up required by Medicare to con­tin­ue receiv­ing sup­plies for her wear­able insulin pump. Being in a high risk group for COVID-19, Grady wor­ried about poten­tial expo­sure in a doctor’s wait­ing room, and even more about los­ing her dia­betes sup­plies if she missed Medicare’s check­up deadline.

“I would have had to go back to tak­ing insulin by syringe,” she said.

Grady pre­pared for the vir­tu­al vis­it by call­ing her clinician’s tech depart­ment and down­load­ing tele­con­fer­ence soft­ware. She says she would do some future vis­its by video, but not all. For exam­ple, peo­ple with dia­betes need peri­od­ic blood tests, and their feet must be checked for signs of cir­cu­la­to­ry problems.

Still, quite a few fol­low-ups “could be done very effi­cient­ly and be just as use­ful to the physi­cian and myself as going in and see­ing them in per­son,” Grady said.

Many pri­vate insur­ance plans, includ­ing those in Medicare Advan­tage, offer some lev­el of telemed­i­cine coverage.

But tra­di­tion­al Medicare has restrict­ed it to rur­al res­i­dents, who gen­er­al­ly had to trav­el to spe­cial­ly des­ig­nat­ed sites to connect.

Under the coro­n­avirus pub­lic health emer­gency, the admin­is­tra­tion tem­porar­i­ly waived Medicare’s restric­tions so enrollees any­where could use telemed­i­cine. Patients could con­nect from home. Mak­ing such changes per­ma­nent would require leg­is­la­tion from Con­gress, but there’s bipar­ti­san interest.

Sen. Lamar Alexan­der, chair­man of the Sen­ate Health, Edu­ca­tion, Labor and Pen­sions Com­mit­tee, says he’d like to see broad­er access, with­out break­ing the bank.

“Our job should be to ensure that change is done with the goals of bet­ter out­comes and bet­ter patient expe­ri­ences, at a low­er cost,” said Alexan­der, R‑Tenn.

That’s a tall order.

Pay­ment will be a sticky obsta­cle. For now, Medicare is pay­ing clin­i­cians on par for vir­tu­al and in-per­son visits.

“Pol­i­cy­mak­ers seems to be in a rush to pass leg­is­la­tion, but I think it is worth tak­ing a lit­tle more time,” said Juli­ette Cuban­s­ki, a Medicare expert with the non­par­ti­san Kaiser Fam­i­ly Foun­da­tion. “Fraud is one big area that pol­i­cy­mak­ers need to be cog­nizant of.”

Fraud-busters agree.

Tele­health is so new that “we don’t have at this point a real sense of where the huge risks lie,” said Andrew Van­Land­ing­ham, a senior lawyer with the Health and Human Ser­vices inspec­tor general’s office. “We are sort of in an exper­i­men­tal phase.”

Despite the risks, advo­cates see opportunities.

Expand­ed Medicare tele­health could:

–help move the nation clos­er to a long-sought goal of treat­ing men­tal health the same as phys­i­cal con­di­tions. Sen. Ron Wyden, D‑Ore., wants to use telemed­i­cine as a spring­board to improve men­tal health care. IQVIA data shows 60% of psy­chi­atric con­sults took place by tele­health dur­ing the shutdown.

–increase access for peo­ple liv­ing in remote com­mu­ni­ties, in low-income urban areas and even nurs­ing homes. Medicare’s research shows low-income ben­e­fi­cia­ries have had sim­i­lar pat­terns of using tele­health for pri­ma­ry care as pro­gram enrollees overall.

–improve coor­di­na­tion of care for peo­ple with chron­ic health con­di­tions, a goal that requires patient and per­sis­tent mon­i­tor­ing. Chron­ic care accounts for most pro­gram spending.

Uni­ver­si­ty of Michi­gan health pol­i­cy expert Mark Fendrick says Medicare should fig­ure out what ser­vices add val­ue for patients’ health and tax­pay­ers’ wal­lets, and pay just for those.

Tele­health “was an overnight sen­sa­tion,” said Fendrick. “Hope­ful­ly it’s not a one-hit wonder.”

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