How will PCPs use telehealth after the COVID-19 pandemic?

Thirty-five percent of adults in the United States who were surveyed said they would consider leaving their primary care physician for qualified physicians providing on-demand telehealth services.

This percentage was even higher — 50% — among Generation Z and millennials, according to the data. Older adults also expressed interest in telehealth services, with 48% of respondents aged 65 years and older reporting that they will likely continue to use telehealth after the COVID-19 pandemic.

The data are from a series of surveys conducted by The Harris Poll from March 15, 2020, to March 15, 2021. Each survey was administered to a nationally representative sample of about 2,000 U.S. adults.

The results further showed that Hispanic respondents (52%) were most likely to consider using on-demand telehealth as a replacement for their PCP, followed by Black respondents (43%), Asian respondents (40%) and white respondents (32%).

About half of all the respondents said that telehealth appointments are useful for inquiring about medical questions (53%), reviewing test results (48%) and refilling prescriptions (46%). However, only 34% said they use telehealth when they are ill, and just 15% use it when their child is ill.

Most respondents (76%) reported that they would miss in-person visits if their PCP switched to mostly telehealth, and 42% said they prefer a hybrid model — “a mix of both telehealth and in-person” visits, according to the survey.

The role of telehealth in primary care

G. Caleb Alexander, MD, a practicing internist and professor in the department of epidemiology at the Bloomberg School of Public Health, and colleagues reported that in 2019, less than 2% of primary care visits in the U.S. were conducted through telehealth.

Now it accounts for a much larger proportion of visits, with one-fifth of primary care clinicians using phone or video for at least half of their patient encounters during the pandemic, according to a survey conducted by the Primary Care Collaborative and Larry A. Green Center. Among more than 750 primary care clinicians in the U.S. and Guam who responded to the survey, 45% said they are encouraged to use telehealth because patients “really like it,” and 67% are encouraged to use it to meet patients’ needs. Still, 46% of clinicians said they are concerned about misdiagnoses because of the lack of in-person care, and at least one-fifth of patients lack access due to limited computer literacy (57%) and broadband (35%).

Before the pandemic, Yalda Jabbarpour, MD, a family physician in Washington, D.C., and medical director of the Robert Graham Center for Policy Studies, and colleagues estimated that 69% of primary care office visits required an in-person encounter. The researchers used data from the 2016 National Ambulatory Medical Survey to assess the proportion of primary care visits that were amenable to telehealth.

“Most in-person need is driven by wellness visits, though treatment of certain acute and chronic conditions also requires in-person visits,” Jabbarpour and colleagues wrote in the Journal of the American Board of Family Medicine.

The researchers noted that about 90% of immunizations and annual wellness visits occurred in primary care offices, as well as one-quarter of pelvic exams and one-third of Pap tests. Patients with chronic conditions, including hypertension, coronary artery disease and diabetes, “were less likely to have visits amenable to telehealth modalities,” the researchers wrote. Some potential reasons for in-person visits include foot exams among patients with diabetes, as well as neurological and retinal exams, according to the researchers.

“Although telehealth is appropriate for certain visits and likely will be integrated into practice post-COVID-19, it cannot replace traditional care for all primary care-sensitive issues,” Jabbarpour and colleagues wrote.

Benefits and limitations

Rita K. Kuwahara, MD, MIH, an internal medicine resident physician caring for patients at a federally qualified health center and a member of the Healio Primary Care Peer Perspective Board, recently conducted a small quality improvement project to evaluate the opportunities and limitations of telehealth. She found that there were “certain conditions that lend themselves to telehealth, others where an office encounter would be preferable, and others where hybrid options would be ideal.”

Kuwahara said that interim telehealth check-in visits to adjust medications in between scheduled in-person visits may work well for a subset of patients with diabetes or hypertension who have resources to regularly monitor their glucose and BP at home.

“For patients who do not have a glucometer or a BP cuff at home, it becomes much more challenging, even for brief follow-up phone or video telehealth appointments to determine if a patient’s medications require further adjustment following an in-person PCP visit,” she said.

Kuwahara also warned that telehealth is not ideal for evaluating certain symptoms such as chest pain, shortness of breath, loss of consciousness, ear pain, sore throat and musculoskeletal pain, and “phone-only visits make it practically impossible to evaluate symptoms such as rashes.”

“Those sorts of conditions are much more conducive to face-to-face encounters, where you can better evaluate a patient by performing a physical exam and have the option to check blood pressure, conduct an in-office EKG or provide a point-of-care service or testing, such as checking HbA1c or urinalysis, in order to better manage the patient during the office visit,” she said.

Telehealth may also pose a challenge to providing high-value care, as physicians may be more likely to order extra tests or overprescribe medications such as antibiotics because they were unable to conduct a physical exam or did not have access to point-of-care testing, Kuwahara said.

“For patients who choose telehealth visits over in-person office visits, we must develop robust systems to support hybrid models of care to ensure that patients with telehealth appointments still get necessary in-person follow-up services such as lab testing and immunizations following their virtual visit,” she said.

For example, Kuwahara stressed that patients “must be given clear instructions and reminders regarding where to have their ordered testing, imaging, and/or vaccines performed, and clinics must partner with pharmacies and testing sites to ensure that services such as vaccinations, labs and imaging ordered by the physician but performed at off-site locations have automated processes to communicate vaccine administration records and/or test results back to the patient’s clinic.”

While telehealth visits may eliminate transportation barriers for some patients, Kuwahara said that many patients lack access to high-speed broadband internet services. She also noted that many of her patients do not have smartphones or cell phone plans that include adequate monthly data or talk time allowances, “making it much more difficult for these individuals to engage in telehealth care.”

“For these patients, video visits often fail due to an unstable internet connection or patients’ lack of access to electronic devices with a camera, and these visits must be switched to phone-only audio visits due to technical issues,” she said. “In addition, for patients whose primary language is not English, video visits often fail because patients cannot hear the phone interpreter who is connected to a video call, and these visits must be switched to three-way, phone-only visits to ensure that the patient, provider and interpreter can all hear and understand one another to prevent medical errors from occurring. Further, patients with hearing impairment often struggle with telehealth appointments, making virtual visits much more challenging for them.”

Regarding the benefits of telehealth, Kuwahara noted that in addition to eliminating transportation barriers for some patients, video visits give physicians the opportunity to develop “a more comprehensive understanding of the patient by essentially allowing physicians to perform virtual home visits, enabling them to better understand the social factors contributing to patients’ health outcomes.” Physicians can better understand medication routines, obtain a more accurate medication reconciliation and provide nutrition counseling that is specific to the food in patients’ homes, “if patients are able to show their physicians which medications and doses they currently have at home, how they organize their medicines or pillboxes and what foods they have recently been eating at home,” Kuwahara said. The presence of housing or food instability can also become apparent during these visits, allowing “physicians to better support their patients by linking them with social workers to address patients’ social determinants of health,” she added.

“I think finding a balance between the benefits and limitations of telehealth care is what is most important,” she said. “Once we know what that balance is, having the flexibility to provide the best care to patients and be able to practice in a hybrid environment will be vital, and ensuring that there are policies to support all those initiatives will be critical.”

Continuation of telehealth support

From Kuwahara’s perspective, now that physicians and patients have had more experience with telehealth, it is here to stay in some capacity; however, one constraining factor is whether policies will allow telehealth reimbursement to continue beyond the public health emergency.

“There needs to be action from Congress, but HHS also has power to determine which telehealth provisions are allowed once the current public health emergency ends,” she said. “There are some pieces of legislation that have been introduced to address issues of ongoing telehealth support, both during the public health emergency and also afterwards. There is a lot of interest in allowing telehealth to continue, but whether or not this will be something that is here to stay and to what extent will be based on what is allowed in terms of policies that are implemented.”

In December 2020, CMS announced that 60 of the 144 telehealth services that were newly offered during the COVID-19 pandemic will become permanent, including services for group psychotherapy, cognitive assessment and care planning, psychological and neuropsychological testing, and domiciliary, rest home or custodial care services for established patients. In addition, CMS finalized a list of services that will be included under Category 3, which consists of services added during the pandemic that will remain covered until December 21, or until the end of the calendar year when the COVID-19 public health emergency is declared over. These telehealth services include home visits for established patients, certain ED visits, nursing facilities discharge day management, critical care services, inpatient neonatal and pediatric critical care, and physical and occupational therapy services.

CMS also finalized the decision that direct supervision in telehealth visits can be provided with interactive audio and video technology through the end of the year that the pandemic ends or December. The public health emergency was previously set to expire on April 21, but HHS Secretary Xavier Becerra extended it for at least another 90 days through July 21, according to the Primary Care Collaborative. CMS told Healio Primary Care that there have been no changes in its telehealth policies since the December 2020 announcement.

Kuwahara said that legislation has been introduced in the House and Senate to support the continuation of telehealth services. One provision that is critical to include from a health equity and patient safety standpoint is ensuring that permanent policies are in place beyond the current public health emergency to allow reimbursement for audio-only phone visits that do not require a video component, according to Kuwahara. During the current public health emergency, she said that “allowance and reimbursement for audio-only telehealth visits has been vital to providing necessary care to patients with limited access to broadband internet services and for patients whose primary language is not English, where it is necessary to engage phone interpreters in a three-way call during the encounter.”

“It’s really important to advocate for our patients when it comes to providing telehealth services in ways that allow equitable access to care,” she said. “It is important for physicians and other providers to speak to their members of Congress and with the leadership at HHS to describe the current issues that their patients face, as well as advocate for the importance of providing ongoing coverage of allowances such as audio-only telehealth services for patients beyond the public health emergency. Maintaining a hybrid model of audio, video and in-person office visits would likely be the most beneficial route so that we can best tailor care to our patients’ needs to reduce existing inequities and improve our patients’ health outcomes.”

References:

Alexander GC, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2020.21476.

CMS. Final policy, payment, and quality provisions changes to the Medicare physician fee schedule for calendar year 2021. https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1. Accessed April 2, 2021.

Jabbarpour Y, et al. J Am Board Fam Med. 2021;doi:10.3122/jabfm.2021.S1.200247.

Primary Care Collaborative. Primary care & COVID-19: Round 27 survey. Available at: https://www.pcpcc.org/2021/03/22/primary-care-covid-19-round-27-survey. Accessed May 10, 2021.

Primary Care Collaborative. Public health emergency extended. Available at: https://www.pcpcc.org/2021/04/29/public-health-emergency-extended. Accessed May 10, 2021.

The Harris Poll. The great awakening. Available at: https://theharrispoll.com/wp-content/uploads/2021/03/Harris-Poll-COVID-1-year-FINAL-3.pdf. Accessed May 10, 2021.