Telehealth – formally “a provision of health care by means of telecommunication technology” – became much more prominent during the pandemic. Patients have experienced this technology through video sessions with providers, instant messaging, or even remote monitoring of vitals. Physicians have been utilizing this modality before the pandemic for consultations among providers, with the highest usage rate being for radiology consults.
While there have been many benefits from the surge in the use of telehealth as a means for dealing with pandemic restrictions, it is important to reflect. How did we get to this point? What does continued use of this technology mean moving forward? Research on patient health from virtual health visits and legislation related to the use of telehealth pre– and post-pandemic will provide necessary information for decision making.
Until then, we must recognize that this modality has the potential to revolutionize the health care system, save costs, and address various public health issues. Although some may not always acknowledge the reality of healthcare as a business, it is important to look at the supply and demand of services. While telehealth service delivery is seen as beneficial by many providers, if there is no desire on the part of patients to utilize these services then the required technology would be a poor investment. The converse is also true: if there is patient demand for this kind of service and their providers do not offer it, those patients may likely look elsewhere for care.
Even prior to the pandemic, telehealth was an option for care in various health fields. Physicians were utilizing the mechanism for peer-to-peer interactions. This was mostly used in large health care organizations, with only 11.2% of physicians having access to this form of communication. From the patient perspective, telehealth use was minimal with less than 1% of outpatient services being conducted through this modality in 2019. However, only one year later in 2020, the percentage of behavioral health visits being conducted virtually grew to 38.1%.
The growth of telehealth pre-pandemic was evidenced by the number of large group enrollees having telehealth claims increased from 1.6% in 2017 to 2.4% in 2018. What these statistics indicate is that the rise of telemedicine was coming, but the pandemic caused all parties involved to quickly adapt to the shelter-in-place restrictions with little planning. Going forward, it is important to analyze what worked and what needs to be changed so that quality patient care can be assured as telehealth secures its place in the health field.
An early example of utilizing virtual visits in the healthcare field began with addressing the issue of access to care in rural communities. Virtual services were an opportunity to provide lifesaving care as residents in these areas are more likely to die prematurely from the most common causes of the death in the Unites States.
One of the leading arguments for the adoption of telemedicine was that it alleviates barriers patients face such as taking time off work to go to an in-person appointment or finding transportation to such appointments. Rural areas – where residents often lack access to key healthcare services such as primary care providers, hospitals, and low cost health centers – throughout the United States have been given the name “medical deserts”. Every state has at least one designated ‘desert’ leading to 80% of the counties across the country lacking medical infrastructure in some way. To the extent that economic barriers on the part of the patient (travel costs and time required) paired with those on the provider (staffing) are addressed via this mechanism, more patients can receive necessary preventative and specialty care leading to improved health outcomes.
The current administration has acknowledged these potential benefits by earmarking funds in the Bipartisan Infrastructure Law to provide internet access to rural areas, alleviating an important barrier these individuals often face in attempting to utilize telehealth programs. For areas that have yet to gain internet access, the CMS permanently expanded Medicare reimbursement for certain audio-only behavioral health services. These statutes are a step in the right direction to take down barriers in accessing telehealth, with more work to be done.
The pandemic helped jumpstart the rise of telehealth, but the urgent need for this modality has caused many to overlook the issues that have come from trying to incorporate a significantly different method of care delivery in such a short amount of time. With the end of the pandemic in sight, the issues are coming to the surface – the main two being provider reimbursement and state licensing definitions.
Currently, the reimbursement for virtual visits is the same as in-person care, creating an incentive for providers to use lower cost / higher volume virtual care. While a potential benefit of this modality has been lower cost on part of the health care provider, preliminary research has shown that this is only benefiting completely digital health centers. Traditional in-person health centers that have been working to incorporate an option for virtual care are not saving money as their unused exam rooms and supplies are essentially fixed costs. Thus, there is little offset for the additional costs of telehealth technology such as videoconference equipment and application subscription fees. The pandemic also mandated temporary legislation which enabled telehealth to be adopted quickly, but as these statutes are now reaching expiration, the cracks in our current hastily built model are beginning to show.
When the country was in a public health emergency, every state waived some of their state licensure so that it was easier for their residents to access telehealth care. There are multiple reasons for why a patient would desire care from out of their state (e.g., travel emergencies, lack of availability of a required specialty in their area, or the desire to obtain care from a specific provider). As of August 2022, only 14 states have licensure flexibilities still in place. This means it is becoming more difficult for patients across the country to access the telehealth care they may have become accustomed to during the pandemic.
In addition to licensure flexibilities, the public health emergency had an impact on the HIPAA component of virtual care with how audio-only visits comply with HIPAA regulations. During the pandemic, audio-only telehealth was essential for providing care to populations that did not have access to internet for video calls or were reluctant to adapt to the use of video for their visits. Since the public health emergency has been extended to October 2022 the requirements for HIPPA requirements have not been formally established. The U.S. HHS Agency has provided guidelines to providers on ensuring compliance with HIPAA during these calls, but most of the responsibility falls on the covered entities to adhere. If this tool is going to be used to address the areas of the country that rely on audio-only care then more permanent provisions to protect the patient must be put in place.
I recently analyzed the service areas where telehealth was offered versus the types of service for which patients were willing to utilize telehealth. The findings indicated that although there are areas where providers and patients are aligned (e.g. for mental health services), chronic disease care and follow-up visits do not yet have a consensus between patients and providers.
In addition to understanding the desires of both parties involved it is important to ensure the infrastructure will allow for successful implementation. For health organizations to properly utilize this modality, more research must be done so that the money invested into implementing these measures is being used properly. It is vital to give this area the attention it deserves as there is potential for telehealth to revolutionize the healthcare system in America. As with many rapidly changing technologies, waiting too long to enact a set of standards could lead to competing mechanisms that make regulation and oversight difficult; wasted investments on the part of providers; and less-than-optimal outcome for patients.