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Telemedicine ‘not a perfect solution’ to health care access issues
WASHINGTON — The use of telemedicine has improved access to care for patients in rural areas while saving millions of dollars in travel expenses. However, insurance coverage of telemedicine services remains an issue, and some physicians have concerns about treating patients during virtual care visits rather than in the clinic, according to several panelists at a recent conference about the future of health care.
“Some things are easier to do in person,” Sanjeev Arora, MD, creator of a telemedicine service called Project ECHO, said during the discussion. “It is not a perfect solution.”
Virtual care visits save time, resources
Martin E. Doerfler , MD, senior vice president of clinical strategy and development at Northwell Health in New York, shared the benefits of an emergency telemedicine psychiatry program at his institution, which involves a team of psychiatrists, social workers and nurses on virtual call.
“We have reduced the average wait time for an acute behavioral health emergency consultation from greater than 12 hours to under 45 minutes. Now, a patient who does not need a bed is home with their family,” he said.
Allison Suttle , MD, an OB/GYN by training who is now chief medical officer at Sanford Health, based in Sioux Falls, South Dakota, added that telemedicine is an effective strategy for treating low-risk patients with conditions such as sinus infections, bladder infection, diaper rash and pink eye through virtual care visits, allowing physicians to “prioritize resources to patients who really need them.” It also helps physicians treat patients locally in rural areas.
“We can do infectious disease consults without transferring a patient to a Level 1 trauma center,” she said. “We can do ER consults in the moment. So if you have a patient present to your clinic in a remote community with an injury, we can evaluate and assess the patient locally, and by doing so, we have avoided 26% of transfers ... which is great for patients because they get to stay close to home.”
Virtual care visits have probably saved Sanford Health patients about 10.5 million miles of travel, which has led to $6 million in savings, according to Suttle.
“If you look at telehealth as a tool to overcome the problem of time, which exists throughout health care, now you will see an incredible array of problems in health care that this tool can be pointed at, some of which can achieve success,” Doerfler said.
Arora discussed the advantages of Project ECHO, which provides case-based learning and mentorship to local health care workers caring for underserved patients. In the ECHO model, experts from larger health care facilities, or “hubs,” provide guidance on prevention, screening and treatment strategies to health care providers from smaller clinics, or “spokes.” Physicians from spokes can present cases to physicians from hubs during virtual learning sessions. Currently, there are hubs in 38 countries and spokes in 129 countries. Approximately 78,000 health care providers are mentored through ECHO. Amon them, 60,000 are located in the United States.
“The largest and fastest part of ECHO now is actually not just treating patients, but system improvements and quality improvements,” Arora said, citing a federal government program that uses the ECHO model to improve the quality of care for patients living with HIV.
He added that telemedicine provides “the right knowledge... at the right place at the right time.”
Virtual health care lacks efficiency
Regardless of the intended purpose of telemedicine, its use does come with some disadvantages, the panelists said. CMS does not currently reimburse physicians for all instances of telemedicine; for example, it will only reimburse those telemedicine services that are conducted where physicians and patients “have their feet on the ground” in the same state, according to Suttle.
“If you have to be licensed in the state where the patient has their feet on the ground, that is pretty much impossible, she said. “[Patients] should get health care from their provider, not from some provider in the state where their feet are touching the ground.”
Doerfler agreed that licensure is a large issue that could be addressed with the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, a bipartisan legislation that was reintroduced in the House and Senate in October. The legislation is designed to eliminate the geographic restrictions on CMS coverage of telemedicine services, according to Doerfler.
“It does not wipe it off the books, but allows some discretion,” he said. “Remote patient monitoring is now covered by CMS... whereas using a camera to treat somebody and bill for it is not. This causes a great problem in that it spills over to the private sector, where they say, ‘If it is not a covered service by CMS, we are not covering it either.’”
Doerfler said it will be important to correct insurance coverage issues at the state level.
“Florida recently passed a law that allows a non-Florida licensed physician to maintain a relationship with a patient if it was established outside of Florida by registering their intent to do so,” he said. “Things along that line can make a big difference.”
In addition to challenges with insurance, Arora, who is also a gastroenterologist, said telemedicine can increase physicians’ workloads.
“One of the challenges that I do see in telemedicine is that it is not a capacity builder,” he said. “I am a gastroenterologist. There was an 8-month wait for patients to see me before I started ECHO. Every time I went in front of the camera to do a direct-to-consumer GI visit, I would see one less patient where I lived, and I had a long wait in my own clinic.”
Instead of helping more patients, Arora said the total number of patients receiving treatment in his New Mexico clinic was actually going down.
“I found I wasn’t quite as efficient in seeing a patient when I went in front of the camera as I was when they walked in the clinic,” he said. “The keys to a really successful visit between a doctor and patient are the empathy and relationship building ... that takes a little bit longer to develop with telemedicine without the ability to and make eye-to-eye contact and ability to shake his or her hand.”
Besides weighing those pros and cons, there are other important considerations physicians must contemplate before implementing telemedicine in their practice, panelist Kim Swafford, MHA, group vice president of telehealth and health technology strategy at Providence St. Joseph Health, in Renton, Washington, explained.
“Ensure that there is a value before launching the program ... make sure whatever is done is safe and there is a high quality associated with it from a clinical perspective,” she said.
Suttle also provided some guidance in this area.
“When [you] do telemedicine... always do it from the lens of how is it going to help that patient, who is it appropriate for and how does it keep a relationship with that patient,” she said. “Because at the end of the day, health care is very personal ... and it cannot fix all issues of all patients.” – by Janel Miller
Reference:
Arora S, et al. Telehealth as a population health tool. Presented at: U.S. News & World Report Annual Healthcare of Tomorrow Conference; Nov. 17-19, 2019; Washington.
Disclosures: Healio Primary Care was unable to confirm relevant financial disclosures prior to publication.