COVID-19 and Embracing the New Norm of Telehealth
By Dr. Gordon Wilhoit and Chase Jones
As the COVID-19 or coronavirus pandemic spreads through the population, increasing numbers of healthcare workers and providers have tested positive or have been exposed and find themselves quarantined for 14 days testing the capacity of an already overtaxed delivery system. We have long seen the data that shows increased ER and Urgent Care visits have as much to do with decreased same day office appointments as patient choice. However perhaps this crisis will provide some clarity along another pathway of innovation promoting value-added care and accomplishing the Triple Aim.
I recently spoke with a provider -- full disclosure, this provider happens to be my daughter -- practicing on the front line in the epicenter of Boston. Her hospital had already had numerous COVID-19 positive patients when she treated a local physician with mild malaise, a fever spike, sore throat, dry cough, and vague GI complaints. The resulting patient tested negative for strep and influenza, but then positive for coronavirus. By protocol, my daughter was quarantined at home for 14 days. During this stretch, she opted to return phone calls from her patients, triaging those who could be treated over the phone and those who had symptoms requiring face to face evaluation.
Her large primary care clinic decided to have all providers in the same quarantine boat return all calls to the office under the same protocol. “After 3 days making calls I heard from the clinic that it was lessening the burden on those providers still on site,” she said recently about the experience. “We all knew asymptomatic and mildly symptomatic patients were far better off for themselves and others to avoid the ER and the office if possible. We set up drive by testing at the office and treatment over the phone. The elderly with stable chronic illnesses, especially diabetics with glucometers and hypertensives with blood pressure cuffs at home, could get good care and have their meds refilled over the phone.”
She also spoke on the experience as a provider with the new norm of treatment of her patients: “At first I felt bad about my approach to the patient as it didn’t include the best tool in my bag: the ability to look eye-to-eye and touch and examine them. Over time I spent almost as much time listening to them say ‘thank you for how convenient it was’ as I did addressing their questions. I also gradually became more comfortable with providing telephone care to certain patients that didn’t really need to be seen. It will certainly change the way I practice in the future.”
As of 3/17/20, President Trump has temporarily waived all regulations regarding delivery with HIPAA compliant devices, restrictions on originating sites, and even allowed the physician to waive copay collection requirements without fear of penalty. Despite the advancement of COVID-19, however, telehealth was a 2020 emphasis of direction for US healthcare before the pandemic started.
Telehealth, or the provision of some healthcare remotely, will need further study with ‘best practice’ protocols and processes defined; however, in the meantime it appears a crisis has shown a way to deliver high quality care at a significant reduction in cost with increased patient satisfaction and convenience, all while resulting in increased open access in the office for those more complex patients in need of more hands on care. The next steps for greater adoption of telehealth are financial considerations for providers to incentivize shifting a greater amount of care in this direction.
The topic became even more relevant in a letter written from Secretary of Health and Human Services Alex Azar to all respective state governors, with a plea for direct deregulation at the state levels of any hurdles for adopting telehealth in the COVID-19 pandemic:
“Specifically, I ask that you take immediate action to 1) Allow health professionals...to practice their professions...either in person or through telemedicine; 2) Waive certain statutory and regulatory standards not necessary for the applicable standards of care to establish a patient-provider relationship, diagnose, and deliver treatment recommendations utilizing telehealth technologies” [1]
How can the changes in telehealth affect our healthcare system, or more importantly your practice, as we continuously shift towards value based care? The following suggests quick takeaways that encourage adoption to help now and in the future.
● Telehealth visits are reimbursed as an office visit1: The expansion of the 1135 waiver in the March 17, 2020 reinforces the behavior change of fully adopting telehealth by making it financially equivalent for the following codes:
○ 99201 -- 992015
○ G0425 -- G0427
○ G0406 -- G0408
● Telehealth reimbursement has vastly been deregulated, helping both you and your patients outside of COVID-19[2]: CMS has quickly shifted rules to encourage a greater adoption by patients and telehealth with what they will now pay for, including new changes to encourage quick adoption.
○ Accessing telehealth visits from home, eliminating previous limitations
○ Connecting with their own smartphones with potential HIPAA penalties waived
○ Eliminating the need for an existing relationship with a provider to get reimbursed
○ Waiving the penalty for eliminating patient’s cost-sharing obligations
● Telehealth isn’t constrained to a full ‘visit’ any longer1: CMS’ introduction of both ‘virtual check-ins’ and ‘E-visits’ in 2019 encourages the continuous use of telehealth with reimbursement to non-traditional forms of shorter check-ins for established patients.
○ Virtual check-ins can have broad range of modalities with the hope that patients can have greater communication with their doctors and avoid unnecessary trips to the doctor's office with codes G2012 and G2010
○ E-visits are communications between a patient and their provider through an online patient portal with codes 99421 -- 99423 and G2061 -- G2063
There is a vast amount of questions to be answered coming out of COVID-19, but one of the few truths that we do know is that the delivery of healthcare and the population's response to contagious transmission avoidance will forever be changed. Dr. Thomas Lee wrote on this thought in a recent New England Journal of Medicine Catalyst Innovations in Care Delivery op-ed: “We are actively redesigning the way we deliver care to do what is best for our patients during this time of crisis. Some aspects of that redesign will likely persist after the crisis has passed.”[3]
In this change, we can now know that the redesigning of telehealth will make it a tool that is here to stay. If my daughter recognized in two weeks that the shift affected the way she will practice medicine in the future, telehealth will assuredly be the tool to lead us into this new future.
The redesigning of our healthcare system started before this pandemic, but in some parts COVID-19 will also equip all practices with the ability to care for patients in less costly and healthier environments, while also getting the proper reimbursement to reinforce this drastic change.
[1] https://www.ptcommunity.com/wire/aanp-applauds-administration-call-combat-covid-19-pandemic-expanding-access-np-provided-care
[2] https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
[3] https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0076?cid=DM88773_&bid=170918768