Digital doctors: What role will telehealth play after COVID-19?

When the COVID-19 pandemic started to sweep through the United States, primary care physicians saw the number of office visits either dramatically drop or cease all together. Between lockdowns that encouraged people to stay home and fearful patients who didn’t want to risk potentially exposing themselves to the virus, many doctors saw their livelihoods threatened as appointment cancellations piled up.

As a result, the Centers for Medicare & Medicaid Services changed Medicare payment policies to reimburse telehealth visits for a wider range of care, and some Health Insurance Portability and Accountability Act (HIPAA) restrictions were temporarily loosened to make it easier for doctors to communicate with their patients through whatever devices they chose. Prior to the pandemic, telehealth would only be reimbursed by Medicare for limited circumstances, such as patients living in rural areas with little access to care. The communication changes removed requirements for patients to only use often clunky HIPAA-compliant platforms, opening up the ability to use smartphones and increasing consumer convenience. Most private payers also followed Medicare’s lead and changed their reimbursement policies.

“The fear from patients and the change in payment policies really drove and facilitated an incredibly high spike in demand for telehealth,” said Anders Gilberg, senior vice president, government affairs, for Medical Group Management Association.

Practices with telehealth capabilities quickly ramped up their capacity, while others installed the technology needed to conduct remote visits. According to the Medical Economics® 2020 Telehealth-EHR survey, more than 77% of doctors surveyed used telehealth for the first time because of COVID-19.

“It was a lifeline [for] medical practices,” Gilberg said. Patients and doctors alike embraced the technology and the convenience, and practices began to collect income again.

Gabe Charbonneau, M.D., a family physician in Stevensville, Montana, saw the number of in-office visits plummet early in the pandemic. “We really quickly ramped up doing telemedicine, and about half of our visits were on Zoom,” he said. “Because it was such a financial hit, there was a lot of pressure for us to figure out how to get people back in for visits.”

The pandemic quickly proved that telehealth could be a lifeline for practices.

“If there’s a silver lining to this pandemic, it’s the advances made in telehealth,” said Thomas Ely, D.O., president of the American Osteopathic Association.

But as the intensity of the pandemic wanes and people are becoming more comfortable returning for office visits, the future of telehealth is in question. “We had practices at one point that were almost doing 100% telehealth visits, but that has come down considerably, even though the payment policies from Medicare are still in place,” Gilberg said.

Charbonneau saw his practice’s telehealth visits drop as patients shifted back to in-office visits. “Some days, we might have two or three telehealth visits, if that,” he said.

When the public health emergency ends, so will the changes that have made telehealth viable, Gilberg says. “In order to make telehealth permanent, it needs to have a viable reimbursement structure behind it, and it’s only going to be permanent if Congress steps in at the federal level.”

While there is interest from both Democrats and Republicans in making such changes, there are unanswered questions about telehealth in the long term.

Is Congress really committed to telehealth?

Despite telehealth being a great solution to some challenges the pandemic created early on, there are still questions that Congress will want answered before making any permanent changes to reimbursement for telehealth.

“I think Congress may not necessarily be looking at full, permanent telehealth coverage, but perhaps an effort to cover it beyond the public health emergency, and then [Congress can] study what its impact is on utilization, cost and quality,” Gilberg said. “It still remains to be seen whether you can provide the same quality of service without a hands-on approach with the patient.”

In some areas, such as behavioral health, where a physical examination may not be needed and a patient might be more comfortable not being in a doctor’s office, it might be an easier sell to Congress to allow for more telehealth. The same goes for chronic care management, where a simple check-in may be all that’s required.

But will telehealth still have the same appeal if it’s more difficult to use once the public health emergency is over?

“It’s likely to be limited to HIPAA-compliant platforms, so no more just dialing up your physician on FaceTime or Zoom or something like that,” Gilberg said. “Consumers today, they demand a certain degree of convenience, so there’s that aspect. Then there’s also, especially among the Medicare population, I think they trust that when they go to the doctor they prefer a hands-on examination,” he said.

Congressional leaders, who have already expressed concerns about rising health care costs, also have to wrestle with the idea that a more convenient telehealth service might be unaffordable.

“One of the reasons that telehealth expansion in Medicare hasn’t really become a reality yet is because there has been a concern that if you have broad coverage, that it would increase volume and potentially increase unnecessary care, because it’s just too convenient,” Gilberg said. “The Congressional Budget Office believes it would increase Medicare volume on the physician side and therefore potentially drive up costs of the program to the government. The other side of that is, if you can do some of the preventive things more conveniently and keep patients out of the hospital, that will, in the long run, save money from expensive in-patient types of utilization.”

Even if Congress makes telehealth policy changes permanent, reimbursement rates would likely be lower for virtual visits than they are now. “CMS determined that physicians would largely [have lower] overhead costs and fewer practice expenses when they utilize telehealth, even though I don’t think most medical practices would agree with that,” said Gilberg, who added that the reimplementation of all HIPAA requirements would necessitate using a compliant platform, which entails vendor costs to the practice. “And prior to the pandemic, telehealth visits were reimbursed less than in-person visits, at least in Medicare.”

What private payers think about telehealth

Most private payers tend to follow whatever Medicare does when it comes to reimbursement, so when Medicare boosted telehealth, most of them did the same. While private insurers remain interested in telehealth, it may not be a boon for private practices, even if they decide to continue reimbursement after the public health emergency ends.

“There are different types of deals and relationships, not necessarily among physician practices and health plans, but instead, they are associating themselves with telehealth vendor platforms that they might have a financial interest in,” Gilberg said. “If you’re a patient, you would call in and maybe get a doctor or maybe talk to a physician assistant or nurse practitioner you haven’t seen before. That raises concerns about continuity of care and other issues if telehealth isn’t covered in the future with an existing physician practice contract and patients are steered to a platform that is either owned or managed by a health plan.”

Telehealth may not be a boon for doctors, even though it provides a way to easily monitor the health of patients with chronic conditions. “It doesn’t necessarily mean that every one of those telehealth visits is going to be compensated on a fee-for-service basis,” Gilberg said. A practice is more likely to receive some form of capitated payment for each patient, so while the technology makes it easier to check in with patients, that telehealth time won’t necessarily be compensated.

Kishlay Anand, M.D., M.S., founder and CEO of Akos, a telehealth technology company, sees telehealth playing a vital role in managing chronic conditions and reducing medical spending on hospitalizations. “It will become part of the care continuum where, basically, care will start at home,” Anand said. “You will still be able to see your provider and still go to the hospital, but for that high-risk chronic care group, using telehealth and virtual care management is going to be mainstream going forward, and that’s critical to bending the cost curve in health care.”

Advocates for telehealth point to banking as the model health care is following, albeit at a much slower pace. A decade ago, almost all banking was done in person at branches. Today, the simplest transactions are mostly done online with the branches handling more complex needs.

Anand estimates that one-third of visits eventually will be virtual. “Basically, what you are doing is incorporating telehealth as a methodology in the complete care management, and it becomes another access point for patients,” he said.

Ely agrees that 25% to 30% of primary care patients can be evaluated using telehealth with satisfactory outcomes, but work remains to be done. “Physicians are going to have to develop best practices for using this technology, and the use of the technology must be incorporated into medical education,” Ely said. “What is still needed, however, is to ensure compensation is commensurate with the type of service provided.”

Anand adds that telehealth parity laws that many states have passed will help ensure physicians are compensated for virtual visits at the same rate as in-office visits. Telehealth also may be necessary to help with the pending shortage of primary care physicians. “We all know that primary care as a gatekeeper concept works very well,” Anand said. “As health care moves from a churn-and-burn, fee-for-service model to a more value-based model, I think primary care will need to use technology and a virtual high-touch approach to manage the population more efficiently and cost effectively.”

Is telehealth a worthy
long-term investment?

COVID-19 has boosted the acceptance of telehealth for both patients and physicians, but the unknowns about reimbursement and long-term patient enthusiasm make it a challenging bet for cash-strapped practices. Will the investment pay off?

“It’s definitely going to decline some from where it is right now,” said Jeremy Gabrysch, M.D., founder of Remedy, a virtual care provider based in Austin, Texas. “Providers are going to be…more eager to see patients back in the clinic, and patients might even gravitate toward that a little bit. But I don’t think that we’re going to go back to where we were.”

And moving back to only in-person visits might hurt a practice’s long-term outlook, he adds. “We should be careful about swinging too far back to the old status quo, because there are these younger patient groups who are wanting this kind of virtual care,” Gabrysch said. “And actually, people across all generations have found that telehealth is very convenient and that they still are very connected to their doctor, even when they connect to them by video. We don’t want to lose this opportunity.”

Anand sees a future where physicians can’t ignore telehealth as an option, because it will play a vital role in doing well in value-based care. “Telehealth is going to be critical, and any primary care physician [who] wants to provide better access to care and move toward value-based initiatives needs to look at and invest in telehealth as part of moving from the fee-for-service model,” he said.

Gilberg sees potential, but he believes a lot rides on reimbursement for general acceptance.

“I expect longer term that you might see greater take up again, especially for something [such as] behavioral health, as opposed to other services where you really need to see a patient to maybe do some diagnostic testing,” Gilberg said. “If the patient demand isn’t there, and the payers are not supporting it, it is highly unlikely that physicians and medical practices will be able to supply it because their margins are already small. Once we emerge from the pandemic, telehealth is going to be largely contingent on payer coverage as well as patient demand.”