Virtual care may be here to stay

Telehealth use surged from 8% of Americans in December to 29% in May as primary care and mental health physicians and specialists turned to remote care out of necessity during the COVID-19 pandemic, according to a UnitedHealth Group report.

Telehealth evangelists long have touted using high-speed internet connections and a range of devices to link providers and patients for remote care. But regulatory hurdles and medicine’s conservative culture limited virtual checkups to largely minor conditions such as sinus infections or unique circumstances such as connecting neurologists to rural hospitals that lack specialized care.

The pandemic lockdowns closed doctors’ offices and delayed nonemergency care for millions of Americans. Some clinics scrambled to acquire technology platforms to deliver remote care. Others employed rarely used video programs to reach patients in their homes.

Remote visits among Medicare patients surged through the end of March, prompting Centers for Medicare and Medicaid Services Director Seema Verma to say she “can’t imagine going back.”

After emergency legislation eased Medicare payment restrictions and allowed doctors to practice across state lines, some predicted a significant portion of Americans will choose to get care remotely as stay-at-home orders lift.

“There will be a wave of ongoing adoption and increased acceptance, even as the pandemic begins to wind down,” said Wyatt Decker, CEO of OptumHealth. “I think the shift is permanent.”

For years, telehealth has been considered the future of medicine – it just never became the present. Then, as the COVID-19 pandemic shut down doctors’ offices and clinics across the country, telemedicine suddenly became the only way patients could see their doctors and vice versa. Visits skyrocketed.

In Massachusetts, Blue Cross Blue Shield paid for about 200 televisits a day before the pandemic and up to nearly 40,000 a day in recent months.

“It’s just been a really extraordinary moment in the history of health care in the United States,” said Andrew Dreyfus, CEO of Blue Cross Blue Shield of Massachusetts. “There’s a consensus that this is a silver lining” to the pandemic.

A Commonwealth Fund report shows telehealth visits peaked in mid-April, then began to decline as restrictions loosened and people returned to in-office visits. Nearly 14% of medical visits were virtual in mid-April, but that dropped to less than 8% by mid-June, the report said.

Doctors in nearly every specialty “Zoomed” into patients’ homes to look at sore feet, consult about problems and offer advice on coping with new stresses and long-standing concerns.

Joe Kvedar, a professor of dermatology at Harvard Medical School and president of the American Telemedicine Association, said doctors who were “curious at best” about telehealth now plan a post-pandemic hybrid of in-person and virtual care.

“The big change that we are witnessing now is that your own doctor is on board for the first time,” Kvedar said. “That’s a big deal.”

At Mass General Brigham, about 60,000 appointments each week are virtual visits, compared with an average 400 each week in February.

Medical groups and patient surveys suggest, for the most part, virtual visits were successful. In a survey of more than 30,000 Americans, 42% of patients who used telehealth found it very effective and 55% said it was safer than conventional medicine, according to the consumer insight group Piplsay.

Of course, there are challenges. Patients have to awkwardly hold up phones to body parts.

It’s clearly important for patients to develop relationships with their doctors, Dreyfus said. “The laying of hands, so to speak, has been a critical part of medicine since its inception,” Dreyfus said.

If today’s clinician has to be covered from head to toe – with mask, face shield and gown – to protect against COVID-19, “it may not feel that personal,” Dreyfus said. “It may be that a clinician in a traditional white coat might seem more personal and up close,” even if the doctor is available only via video.

For some visits, such as pediatrics, most of the process can be done via a video call. A nurse or technician could come to the house, if necessary, to deliver a shot or draw blood. “Can we use this moment to unlock greater creativity in how we organize care and how we deliver care?” Dreyfus asked.

In some ways, telemedicine has the potential to improve doctor-patient relationships, said cardiology fellow Lauren Eberly at the University of Pennsylvania’s Perelman School of Medicine.

Recently, when a patient couldn’t remember which medication she’d stopped taking, Eberly asked her to walk over to her medicine cabinet, open it and turn the camera around. Together, the two went through the woman’s medications, figured out that the one she’d stopped taking was really important and quickly ordered a new prescription.

Eberly said video visits allow her to look into patients’ homes, getting insights into their medical challenges. Family members who wouldn’t have come to an office visit can weigh in on their loved one’s condition.

Ken Duckworth, medical director for behavioral health at Blue Cross Blue Shield of Massachusetts, said mental health care is better online now than in person for the majority of patients.

In addition to avoiding the risk of infection, telehealth visits with a therapist are easier to schedule and less stressful, without the need to find child care, leave work or rush to an appointment.

“The no-show rate is virtually zero, which is not true in office-based practice,” he said. “This is an extremely efficient, novel thing for a lot of people.”

Some people appreciate the intimacy of a call in which both the client’s and the caregiver’s homes are visible. Duckworth said Blue Cross therapists have made breakthroughs with clients during the pandemic, because of this increased intimacy.

Research supports the idea that video therapy visits are just as effective as in-person ones, he said. Patients with opioid use disorder have done well with telehealth, according to a Pew Charitable Trusts report.

“Mental health is uniquely suited to a tele-transaction,” Duckworth said. “We’re not supposed to touch patients. There’s not an exam component. Facial expressions – interpreting emotion might be harder with a mask.”

The exceptions are patients anxious about technology. Someone with schizophrenia who has paranoid delusions about technology is probably better off getting telephone or in-person counseling, Duckworth said.

Research will have to show exactly where and when telehealth is best used or avoided, he said.

But there’s no going back. “I don’t think the mental health field will ever be the same again,” he said. “I think it’s very positive to have this option.”

Unequal access

Eberly and her Penn colleague Dr. Srinath Adusumalli completed a study showing not everyone benefits equally from telemedicine. Women, older people, people whose first language isn’t English and those with the lowest incomes are least likely to show up to their scheduled telemedicine visits, the study found.

About 3,000 patients were scheduled to visit their Penn cardiology clinic from March 16 to April 17. Of those, slightly more than half didn’t show up. In looking at patients who were least likely to make it, the researchers found they were older, female, less likely to speak English and more likely to live in a household earning less than $50,000 a year.

Adusumalli said he’s a big fan of telemedicine, but “we have to continually evaluate that it’s reaching everyone we intend for it to reach.”

“There’s definitely a lot of advantages, so we really want that to be something for all patients,” Eberly said.

Their team set up a “chatbot” in English and Spanish that can walk patients through the process of setting up and launching an appointment. For patients without access to appropriate technology, they envision establishing neighborhood kiosks staffed by people who can help make the visits work and maybe upload medical data from the person’s phone.

Some companies provide only telemedicine, which means patients get access to a doctor but probably not one they’ve had a relationship with over years. On eClinicalWorks, whose telehealth practice burgeoned from 50,000 minutes a month to 2 million minutes a day during the pandemic, patients can see their own doctor.

Vulnerable kids ‘we worry about’

Quinn Howell, 6, knew the difference between work and play.

The eastern Kentucky boy would follow strict instructions in class and twice-a-week, three-hour therapy sessions for autism. At home, he’d relax with family, make scrambled eggs or enjoy his favorite television shows.

That is, until March, when the COVID-19 pandemic disrupted his workhome routine and challenged hardfought gains. Instead of in-person sessions pivotal to Quinn’s development, he began remote therapy via an iPad.

For his mom, a teacher busy with her own work duties, it seemed like an impossible task.

“I can’t even get him to sit down long enough to eat a full meal,” said Alex Howell, Quinn’s mother. “How am I going to sit him down to do therapy sessions?”

In late March, Quinn’s clinic in Ashland, Kentucky, switched to remote occupational and speech therapy services. Rather than two three-hour sessions at the clinic each week, Quinn completes 45-minute sessions each day, and twice a week, he does two sessions.

Though he initially struggled to stay focused at home, he’s made strides with the shorter sessions and rewards for completing tasks. With the help of a new speech device, he uses full sentences when communicating with his therapy team. Instead of repeating “Oreos,” he says, “I want Oreos.”

Howell worried her son, who has been in therapy since he was a toddler, would lose gains. Not only does he need to do remote therapy, he also had to complete school from home.

“I have been shocked how much progress he has made in this transition,” Howell said.

Other patients at Pathway, a community mental health care center serving rural Appalachia communities in eastern Kentucky, might face other obstacles, said Tiffany Diehl, Pathways’ autism and developmental disabilities program coordinator.

Pathways installed telehealth technologies at 16 outpatient offices and residential units in the region through a $930,000 UnitedHealth Foundation grant. About 70% of clinic patients are eligible for Medicaid, the federal-state government health program for low-income residents. Many live in communities with a monopoly internet provider or rely on government-issued cellphones that limit data use.

Some can go to health departments or libraries to access internet connections, but that can be an expensive proposition for a family facing job loss or other financial obstacles.

“We have some kids on our caseload we worry about,” Diehl said.

Avoiding ‘telehealth cliff’

Such rapid change wouldn’t have happened if not for public health emergency measures to ease long-standing barriers. Congress temporarily eased the “originating site” rule that limited Medicare payments to rural areas, or areas with a designated physician shortage.

Governors signed executive orders requiring private health insurers waive co-payments and pay telehealth at the same rates as in-person visits. States overwhelmingly have allowed doctors and other licensed clinicians to provide care across state lines, even if they’re not licensed in the patient’s home state.

Finally, the federal government eased restrictions on the types of technology programs doctors can use. In addition to Zoom, doctors use Facetime and Google Hangouts – accessible programs to quickly care to patients.

Kvedar expects the federal government will tighten requirements on technology platforms to ensure they safeguard patients’ medical information, as required by the Health Insurance Portability and Accountability Act, known as HIPAA.

He said other temporary measures must become permanent to sustain telehealth’s momentum. In testimony before a congressional committee last month, he warned of a “telehealth cliff” and disruptions to convenient care unless Congress takes action.