Covid Was a Tipping Point for Telehealth. If Some Have Their Way, Virtual Visits Are Here to Stay.

By Noam N. Levey, Senior Correspondent. Originally published at Kaiser Health News.

As the covid crisis wanes and life approaches normal across the U.S., health industry leaders and many patient advocates are pushing Congress and the Biden administration to preserve the pandemic-fueled expansion of telehealth that has transformed how millions of Americans see the doctor.

The broad effort reaches across the nation’s diverse health care system, bringing together consumer groups with health insurers, state Medicaid officials, physician organizations and telehealth vendors.

And it represents an emerging consensus that many services that once required an office visit can be provided easily and safely — and often more effectively — through a video chat, a phone call or even an email.

“We’ve seen that telehealth is an extraordinary tool,” said David Holmberg, chief executive of Pittsburgh-based Highmark, a multistate insurer that also operates a major medical system. “It’s convenient for the patient, and it’s convenient for the doctor. … Now we need to make it sustainable and enduring.”

Last fall, a coalition of leading patient groups — including the American Heart Association, the Arthritis Foundation, Susan G. Komen and the advocacy arm of the American Cancer Society — hailed the expansion of telehealth, noting the technology “can and should be used to increase patient access to care.”

But the widespread embrace of telemedicine — arguably the most significant health care shift wrought by the pandemic — is not without skeptics. Even supporters acknowledge the need for safeguards to prevent fraud, preserve quality and ensure that the digital health revolution doesn’t leave behind low-income patients and communities of color with less access to technology — or leave some with only virtual options in place of real physicians.

Some worry that telehealth, like previous medical innovations, may become another billing tool that simply drives up costs, a fear exacerbated by the hundreds of millions of dollars flowing into the burgeoning digital health industry.

Companies offering remote urgent care, virtual primary care and new wearable technologies to monitor patient health are exploding, with the annual global telehealth market expected to top $300 billion by 2026, up nearly fivefold from 2019, according to research company PitchBook.

“I don’t think there’s any debate that there is a value in better access, but if this is just a one-off service that adds another billing option without fitting into patients’ regular care, I don’t know if it will do much for patients’ health,” said Tom Banning, head of the Texas Academy of Family Physicians.

Perhaps the most contentious issue facing politicians, insurers and hospitals is how much a telehealth visit is worth in a system that is already breaking the bank.

While Medicare and other insurers fueled the explosion of telehealth over the past year by paying the same rates as for in-person visits, many are expected to push for lower prices when the federally designated public health crisis ends. At the same time, physicians and hospitals are looking to maintain income.

“Payers are unlikely to give providers carte blanche,” said Dr. Hoangmai Pham, a former senior medical official at health insurance giant Anthem. But Pham noted insurers could reward physicians and hospitals that take greater responsibility for their patients’ overall health with higher rates for telehealth. “There’s an opportunity here,” she said.

For now, tens of millions of Americans have gotten used to meeting their doctor on a laptop or smartphone, and pressure is building on the federal and state governments to loosen rules to preserve virtual visits after the health crisis ends.

“I don’t want to go back,” said Suzy Brantley, a 67-year-old Texan who works at an accounting firm outside Dallas.

Brantley has been going to the same medical practice for more than 15 years. “I love them there,” she said. But when the practice closed its doors last spring, requiring virtual visits, Brantley found she enjoyed the more convenient way to do routine business like refill a prescription.

“You don’t have to leave work to go to the doctor,” she said. “I can just step into the break room for a few minutes and use my phone. … I love it.”

She’s far from alone. In a nationwide poll last year, 8 in 10 Americans who had used telehealth said they “liked it” or “loved it.” Nearly the same share said they were likely to continue using it after the pandemic, according to the survey by the Harris Poll.

Just a year ago, telehealth — or telemedicine, as it’s also called — was largely a curiosity. Patient and physician wariness and strict rules about how doctors could bill had squelched widespread use.

Fearing fraud and overuse, the federal government tightly restricted the kind of video and audio visits that could be billed to Medicare, limiting use mainly to rural areas and to visits in which a doctor was in an office or hospital, rather than working remotely.

“There was a fear that if there was the slightest opening in the Medicare payment system, people would find a way to abuse it,” said Sean Cavanaugh, who oversaw Medicare during the Obama administration.

That changed suddenly in spring 2020 as pandemic lockdowns shuttered physician offices. Almost overnight, doctors were forced to pivot to virtual care to maintain contact with patients and keep money flowing.

The Trump administration moved quickly to facilitate the shift. The Medicare agency dramatically expanded the kind of services that could be provided virtually. Officials added 140 telehealth services to the list of what Medicare would pay for during the pandemic, including emergency visits, eye exams, speech and hearing therapy, and nursing home care.

Critically, Medicare raised fees for virtual visits to match those for in-office exams, a move followed by state Medicaid programs and many commercial insurers.

The surge was explosive. While fewer than 1% of primary care visits in Medicare occurred virtually in January 2020, by April nearly half did, according to data compiled by the Medicare Payment Advisory Commission.

At UnitedHealth Group, the nation’s largest health insurer, the number of covered telehealth visits increased nearly thirtyfold, rising from 1.2 million visits in 2019 to 34 million last year. Other insurers reported as much as an eightyfold increase.

“Very quickly, it became clear that we could deliver very good care to our patients via televisit,” said Dr. Manish Naik, chief medical information officer at Austin Regional Clinic in central Texas.

The medical group not only helped its primary care physicians pivot to telehealth, but it also built a virtual urgent care system that allows patients to connect by video with on-call doctors 24 hours a day, a model used by large medical systems such as Kaiser Permanente.

Other systems are moving beyond televisits to expand use of remote monitoring tools in people’s homes that track vital signs of patients with chronic illnesses such as diabetes.

Perhaps nowhere has telehealth proved more transformational than in mental health services and treatment for patients addicted to drugs.

“Telehealth has been a godsend,” said Ellen Bemis, chief executive of AMHC, a network of behavioral health clinics in rural northern Maine. Bemis said the clinics are already seeing patients adhere better to their medications as they remain in better contact virtually.

“I hope we never go back,” she said.

In Alaska, health officials feel the same way. “What we’ve seen through covid was amazing,” said state Medicaid director Albert Wall, noting a major decline in patients missing appointments.

Whether these changes endure depends largely on Congress and the Biden administration, which hasn’t indicated whether it will make permanent the looser telehealth rules rolled out last year. The rules will sunset when the public health emergency ends, likely at the end of this year.

The uncertainty is fueling an urgent effort by physicians, hospitals, patient advocates and others to persuade government officials not to reimpose the strict limitations.

Democrats and Republicans in Congress have introduced bills to cement the changes. In statehouses, advocates for expanding telehealth have introduced more than 650 bills, according to the Alliance for Connected Care, a telehealth lobbying coalition.

“We’ve seen the potential of telehealth,” said Dr. Christopher Crow, chief executive of Texas-based Catalyst Health Network, which helps primary care physicians manage their practices. “Now, we have to make sure we realize it before everyone starts shifting back to the exam rooms.”

Major physician groups are pushing to maintain equal reimbursement for telehealth and in-person visits.

Dr. Susan Bailey, president of the American Medical Association, said Medicare should continue to allow patients to receive virtual care in their homes and in all areas of the country, not just rural areas.

The association is also pushing for Medicare to keep reimbursing doctors for consulting with patients by phone, a move Bailey said would ensure that patients without broadband internet service aren’t left behind.

The push for more billable services has raised concerns about fraud, especially as physicians and hospitals develop more efficient systems to see patients remotely. “Overuse is absolutely a concern,” said Dr. Von Nguyen, chief medical officer at Blue Cross Blue Shield of North Carolina. “Once these systems are in place, I suspect, the risk will be greater.”

Nevertheless, many insurers and state Medicaid programs, two groups that typically look more skeptically at services that can drive up costs, are backing telehealth expansion.

And despite initial fraud concerns, nearly a dozen Medicaid and insurance industry officials interviewed for this article noted that thus far they’ve seen little evidence of widespread misuse.

“There is fraud in traditional medical care, too,” said Dr. Donna O’Shea, a senior executive at UnitedHealth Group.

Several insurance officials said telehealth could ultimately save money by routing some medical care from high-cost doctors’ offices and hospitals to lower-priced virtual visits, particularly for urgent care.

And some insurance companies — including Harvard Pilgrim Health Care in New England and Priority Health in Michigan — are marketing health plans with lower premiums that steer patients to virtual care.

“We see this being a long-term change,” said Dr. Michael Sherman, Harvard Pilgrim’s chief medical officer.

Sherman said the health plan is even exploring whether to help low-income patients get internet access to expand telehealth further. “We have proven to ourselves that this works,” he said.

KHN correspondent Rachana Pradhan and digital producer Hannah Norman contributed to this report.

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21 comments

  1. Cocomaan

    Fraud is mentioned multiple times in this piece, but I’m failing to see what exactly the worry is.

    This seems like the kind of hand wringing about fraud that you see in other industries, where a lot of thought is given to something that doesn’t happen all that much.

    I mean, insurance companies, banks, etc have no problem verifying identity over the phone. So what’s the e problem?

    Reply
      1. Philo Beddoh

        Thanks for that! NYC’s experience, was “essential” was the new Black (brown and/or refugee?) Terrified of the triage tent testing required for sick-leave, once infected. Many were infected, shuffling for hours packed, in icy rain; only to be sent home, not knowing commercial Chinese fliers! It seemed (as many doctors skedaddled to upstate “vacation cottages” while nurses, techs, EMTs, Uber & MTA… everybody working 1098 gigs all seemed to get D.614G simultaneously) Televisits were soothing for work-from-home Creative Class™ yuppies, terrified by thousands of idling ambulances, calling “stroke,” “arrest,” “pneumonia” deaths on the empty streets, as poor victims were preferring to die together, in cold, dark apartments, all realized they couldn’t get any oxygen & infected first responders, stopped using sirens; realizing there WERE no ICU beds, vents or temp clinicians & cursory intubation was killing >80% of those on gurneys in hallways, waiting rooms, windy tents, Ubers, MTA subways? We’d waited until day 22 and our doctor was up the Catskills, telling us to hang in there. Imaging & diagnosis weren’t available and no protocols proven effective. That, as victims, we knew about as much as anybody (from Asian, Italian & NYC clinician, nurse & epidemiologists’ tweets and viral cellphone video).

        Reply
      2. cocomaan

        Thanks for doing the research. I see that this could be a problem, and I find private equity to be as predatory as the next person, but we’re talking about 80 something bad actors out of an industry with, what, millions of patients served and how many millions of actual telemedicine consultations a year?

        I get that there’s fraud, but it seems to be well in hand.

        It reminds me of worries over student loan debt default. When you dig into the numbers, the people who are doing the defaulting are in the vast, vast minority.

        Reply
        1. tegnost

          It reminds me of worries over student loan debt default. When you dig into the numbers, the people who are doing the defaulting are in the vast, vast minority.

          Hmmm, let’s “dig into those numbers”…

          Fed researchers defined severely derogatory debt as any kind of delinquent loan combined with a repossession, foreclosure, or charge off. The proportion of debt falling into that category in U.S. households has stayed fairly consistent for the past four years. But defaulted student loans now make up 35 percent of that debt.
          from
          https://www.insidehighered.com/news/2019/08/16/report-finds-student-loans-make-growing-share-severely-delinquent-debt
          Student loans are a colossal rip off, but they rip of the right people…

          Reply
  2. ChiGal in Carolina

    I was always skeptical of doing psychotherapy online, but was pleasantly surprised when forced to make the switch, though it has its frustrations. Doesn’t work for everyone and there are some downsides but for some it’s actually better than in person. And I will be able to continue seeing my N Carolina patients when I go back home, at least for as long as the PHE is in place.

    Since people are not interchangeable widgets like the bean-counters seem to think, having the option to continue with the therapist they know is beneficial for patients, and most of mine are opting to stay with me.

    Reply
    1. megrim

      I haven’t missed a single appointment in the 14 months since I’ve started seeing my therapist via the internet. Pandemic aside, it’s been great to not have to travel by public transportation one hour each way, especially when I’m feeling under the weather or whatever. I would prefer to keep doing therapy this way, and hope that I can.

      Reply
  3. Field Marshall McLuhan

    Since remote visits are much cheaper than in-person, the bad incentives around telehealth would seem to actually be worse in places with public health care systems, where the drive to cut costs is the biggest source of financial pressure.

    When I went to get a prescription a couple of years ago – before The Virus – I found myself unexpectedly talking to a doctor through a screen rather than in person. I live in a city of over a million people, so remoteness was not a concern. However, I also don’t live in a…high-priority neighbourhood. It seemed to me then like a pretty obvious bid to reduce the quality of services for the lower orders. Reading the positive experiences of others as quoted in the story has made me a bit less leery of the idea, if the tech is used properly and with respect for the patient. But I see far too many scenarios where it becomes just another vector for crapification.

    Reply
  4. Nikkikat

    field Marshall is correct, “i see far too many scenarios where it becomes just another vector for crapification.”. That is exactly what will happen. Since all medical, hospitals and Medical groups are owned by Wall Street investors. This is about COST cutting. That is their Only incentive. These vultures could care less about your health.

    Reply
    1. Code Name D

      Agreed. In fact, I keep seeing the old saw of “access” to healthcare – not actual health care. If I have a broken arm and need it set – then what is the point? You still have vast healthcare deserts out there and I fear that the wide use of telamedicen will only alow those deserts to grow more, while improving “access” to “script-book” or “drive-through” medicine which is far more lucrative.

      Reply
    2. Laura in So Cal

      So my elderly parents have Medicare Advantage with Kaiser which they have had for 14 years (they are both 79). All of a sudden they are pushing tele-visits instead of in person interactions. This really doesn’t work for my parents as they have to go to Kaiser for labs anyway, my mother has dementia and is hard of hearing to boot (up close with direct eye contact works best with her) AND my father has advanced macular degeneration and has difficulty with the computer interface. He can’t do “You are not robot” etc. He is actually a computer wiz , but it takes him time to find stuff on computer screens and the websites time out on him.

      He is now having to call multiple times and be super insistent etc. to get in person visits.

      Reply
  5. hoonose

    My first experience with telemed dates back to 1978 on the Cree Indian Reservation in Saskatchewan. I was fishing up there, and as a doc in training the locals invited me in to see a child being examined via satellite video by a dermatologist in Ottawa.

    Right now we live in rural AZ, and telemed has been great for us as my wife’s transplant doc is 200 miles away. We haven’t had to travel there since Oct. of 2019.

    Reply
  6. Mildred Montana

    What are the unseen costs—externalities if you like—of telemedicine? Profits, greater number of patients “seen”, lower expenses, etc., these are all easily counted and are.

    What are not are the morbidities and deaths attributable to bad medical care (tele-medicine?). Joe had diabetes and lost a foot because he wasn’t physically examined by a doctor? Well, he had diabetes anyway; it was bound to happen. Jane didn’t have her skin properly examined and died? Well, she had malignant melanoma, she was gonna die anyway.

    The costs of negligent medical care (tele-medicine?) are ignored while the profits are toted up.

    ———–

    And while I’m at it, end the stranglehold doctors have on re-filling prescriptions. This racket is just a cash cow for them. Many prescription refills can and should be handled by a pharmacist, especially if the patient has been using the drug regularly. And some prescribed medications are so innocuous (eg. skin creams) that a refill shouldn’t be required at all. They should be over-the-counter.

    If this were to happen, what a win for doctors! Less time wasted refilling prescriptions and more of their valuable time devoted to actually examining patients! /sarc

    Reply
  7. Arizona Slim

    As your ambassador from the world of hearing loss, I think that telemedicine is a darn good idea. Instead of struggling to hear a doctor in his/her office, I can just pop my headphones on and have a conversation that both of us can understand.

    Reply
    1. Mildred Montana

      Mr. Ambassador:

      I can empathize with you. I took care of my elderly mother for five years. She had severe hearing loss. She loved her headphones for television and she loved her landline phone. She hated the portable phone and cellphones.

      And she really appreciated people who faced her directly, enunciated clearly, and moved their lips in a noticeable way. She often said to me that the hearing-impaired (like the visually-impaired) should carry some sort of obvious marker so that others would make these slight efforts in order to make themselves heard.

      Reply
  8. Jason

    Telehealth is in keeping with the natural order of allopathic medicine, much as the unregulated nightmare of financialized capitalism is in keeping with the natural order of the monstrous economic system they’ve foisted on us.

    Reply
  9. Carolinian

    Perhaps this idea should be taken to its logical conclusion and poorer Americans allowed to tele-visit with doctors in, oh say, Cuba for a vastly reduced bill.

    Says it all that the thrust of the above article is all about money and compensation.

    Reply
  10. Jack Parsons

    My experience has been with Kaiser. Some of the amazing conveniences list above are standard anyway with Kaiser.

    Kaiser has an assistant set up every video call 10-15 minutes before the doctor is available. In other words, the nurse becomes the Zoom Secretary for the doctor. I suspect that this is causing grief inside the management chain.

    Reply
  11. Cuibono

    “Several insurance officials said telehealth could ultimately save money by routing some medical care from high-cost doctors’ offices and hospitals to lower-priced virtual visits, particularly for urgent care.”

    The money quote. Literally. Expect Indian call centers to someday monopolize this trade

    Reply
  12. Sue in SoCal

    I’ve been griping for quite a while about the creeping privatization of Medicare, period. I’m with Nikkitat. It’s all about the big boy CEOs making sure the goose of misery they trapped doesn’t stop laying those golden eggs. Imho, I believe “Medicare for all” will be something like Medicare Advantage with telemedicine and robotics. No, they do not give a rat’s ass about you or your health. They do not give a rat’s about your treatment or pain. Family doctors don’t even treat where I live. They direct you to specialists. And if this government gave a rat’s ass, it would train our own doctors here with debt forgiveness instead of clamoring for more foreign doctors. So there’s that.

    As I waited over over six hours for a simple surgery, I tried to stay calm. It was “line em up and let em wait.” I lay there thinking “all of these doctors are independent contractors, and we’re paying an enormous amount of money for this.” I could go on, but I don’t want to bore you.

    Reply

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