Telemedicine - a boon for many in the pandemic - threatened with cutbacks

Medical director of Doctor on Demand Dr. Vibin Roy waves good-bye to a patient at the conclusion of an online primary care visit conducted from his home, Friday, April 23, 2021, in Keller, Texas. Some U.S. employers and insurers want you to make telemedicine your first choice for most doctor visits. Retail giant Amazon and several insurers have started or expanded virtual-first care plans to get people thinking telemedicine routinely, even for annual checkups. (AP Photo/LM Otero)
·8 min read

When Gabi Berner stopped responding to her ulcerative colitis treatment in summer 2020, she was grateful to confer with her doctor over the telephone. Together, they made a plan for a new medication and transitioned her care to a different doctor who could coordinate transfusions.

Telehealth visits, which flourished during the pandemic, made it possible. They were popular with patients like Berner. And experts predicted they would expand in the months to come. Instead, telehealth opportunities are being steadily pared away.

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For Berner, the new clinic was almost an hour away from her apartment in Cambridge, Mass., and she didn't have a car. She was working full time from home as a data scientist and hardly went out to shop for groceries - much less to sit in a clinic waiting room. She could check-in easily with telemedicine visits.

"It's usually just a short conversation between you and the doctor," Berner said. "So unless I'm out of remission, a phone call is preferable."

Patients and doctors like me welcomed the transition to telemedicine during the early phases of the pandemic. By April 2020, telehealth accounted for 32% of office and outpatient visits, and have stabilized at 13% to 17% across all specialties, according to a McKinsey report. The nation's largest health insurer, UnitedHealth Group, covered 1.2 million telehealth visits in 2019 and 34 million in 2020. While not an absolute replacement for in-person visits, many assumed telemedicine was here to stay. When Berner's clinic told her they would offer only in-person visits after June 15 this year, she dropped her appointment.

"I didn't really want to pay money to Uber an hour away for a general checkup," she said. Her new medication was working well, and after living with ulcerative colitis for eight years, she knew what symptoms to look out for. "It would all be for a quick five-minute appointment for my doctor to confirm I'm doing well."

Beyond a pandemic necessity, telehealth held promise for the long term. Its potential to reach individuals in remote communities, nursing homes, and low-income neighborhoods could mitigate barriers to care. The release from certain restrictions enabled patients to hear expert opinions without moving from their dining room tables. In turn, it gave physicians the opportunity to see patients across the country without obtaining licenses in multiple states. Telehealth also allowed providers an informative window into the actual living environments that shaped their patients' well-being.

But as the second summer of the pandemic wanes, state emergency orders that mandate coverage of telehealth visits and waive the requirement for out-of-state medical licenses are expiring.

In their wake, more patients are discovering that telemedicine is no longer an option for them. With a fourth wave of coronavirus cases surging, the safety of in-person visits, especially for immunocompromised patients, remains a concern.

"Even with vaccination, cancer patients don't always mount enough of an immune response," said Pashtoon Kasi, a medical oncologist at the University of Iowa. "So if there's any way we can minimize their exposure to the hospital, minimize their number of visits, we want to."

After Kasi's clinic began offering telemedicine visits, he was thrilled by a huge uptick in out-of-state patients seeking his opinion. Because of it, he said, clinical trial enrollment in his field reached an "all-time high" in 2020 - a record that he believed would be surpassed in 2021. Such trials can offer patients new, innovative treatments that they would otherwise not have a chance to try - often the best option for many patients with advanced disease.

On Aug. 22, however, the state emergency order in Iowa expired. The United States is one of the few countries in the world where physicians must apply to practice medicine separately in each state - an antiquated requirement that was waived by many emergency orders at the start of the pandemic. In several states, those waivers have already terminated.

"A lot of patients don't have the time or the money to fly down from New York or Florida to come see me in Iowa and discuss if they are a good fit for our trials," Kasi said. "And while they're busy taking time off and taking two flights to get here, their cancer isn't taking a vacation for them to figure this all out."

Many people are capitalizing on the loosened rules while they can. A recent patient was evaluated virtually by Kasi's colleagues at five of the leading institutions in the nation within a span of two weeks before meeting him for a final opinion.

Without telemedicine, "this would not even have been physically possible," he said.

Other patients are losing access to telemedicine because of a technological gulf. For in-state patients, some providers continue to reimburse video visits at comparable rates to in-person, but this has become infrequent for telephone visits. Medicare announced it will no longer offer payment parity for video and telephone visits after the federal public health emergency order expires (most recently extended until Oct. 18, 2021, by Xavier Becerra, secretary of Health and Human Services). As of March, only 22 states required insurers to even cover telephone visits.

This can exacerbate a troubling inequity.

"You're basically cutting people off at the knees," said Ji Chang, assistant professor at the NYU School of Global Public Health, recalling how one physician described the effect.

Her work found that the digital divide - that is, the gap between people who have full access to digital technology and those who do not - affects not only patients but also providers. Practices in an area of higher social vulnerability are more likely to use telephone than video systems to provide care.

Early in the pandemic, at least 1 in 4 Americans did not have the digital literacy skills or devices to participate in video visits. At highest risk included the elderly, people on Medicaid and those whose preferred language is not English.

Patients at the intersection of all three are routine for Leah Karliner, primary care physician and professor of medicine at the University of California at San Francisco. Nonetheless, she was heartened to observe many of her patients grow comfortable with telemedicine over time, often with the help of family living together in lockdown. As care delivery patterns keep shifting, she emphasizes being "nimble" with solutions.

"With every change," Karliner cautioned, "there is a potential for creating or worsening health-care disparities."

The deluge of cumbersome, rapidly evolving policies that differ by payer, state and type of service has sowed unease about reimbursements, sometimes deterring practices from offering telemedicine at all.

"It's not even just about reimbursements now," Chang said. "That perception of uncertainty poses a bigger barrier than the actual reimbursement itself."

Megan McKnight, a physician assistant at Johns Hopkins Bayview Medical Center, and her team receive more than 400 referrals a year from across the nation. Her patients' complex gastrointestinal motility disorders regularly baffle multiple specialists before reaching her.

Besides alleviating distance issues, telemedicine helped McKnight build rapport as many of her patients have a history of trauma or anxiety.

"When they're in the comfort of their own homes, they're in their element, so it's easier for them to focus on telling us exactly what they want to tell us," she said. "Patients who are more anxious in person seem to be more calm on video."

Removing this added stressor, McKnight said, probably played a big role in the clinic's improved no-show rate during the pandemic.

She was caught off guard when her team was informed by hospital leadership that after July 1, all visits needed to be strictly in-person. McKnight found herself trapped in a disturbing paradox: unable to treat patients who could not physically travel due to covid-19 concerns, but now also unable to provide virtual care.

"A lot of these patients have become accustomed to telemedicine not just with us, but with their other providers," she said.

The decision to shift back to in-person visits is based on a host of factors, said Kimla Baugh, ambulatory operations manager at Johns Hopkins Hospital. Out-of-state licensing issues aside, states such as Maryland have a dual-billing system for regulated clinic spaces like those at Johns Hopkins Bayview Hospital. This means that there is a provider fee as well as a facility fee for each visit.

"There's definitely been a hit as far as telemedicine goes because that revenue of patients physically coming into the space - you're not going to get much," Baugh said. "That's been a huge issue in Maryland."

McKnight continues to feel the heat of being a middleman explaining the abrupt change to her patients.

"I tell them that this is a new rule that we didn't choose to implement or even necessarily agree with, but unfortunately have no control over."

         

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Trisha Pasricha is a journalist, physician and research fellow in gastroenterology at Massachusetts General Hospital. 

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