Virtual Care During and After the Outbreak

Globally, the SARS-CoV-2 virus remains a serious threat, but in the U.S and many other countries, lockdowns have largely ended as millions return to restaurants, gyms, and travel destinations. However, COVID-19 has forever changed our lives in many ways including the now wide-spread adoption of new medical technologies and practices such as telemedicine for non-emergency care. Telehealth, often synonymously referred to as telemedicine or virtual care, is a method that enables a doctor to provide care without an in-person visit and can involve: phone or video chat, messaging, and potentially remote monitoring. During the initial COVID-19 peak, a 2020 study found that the proportion of telehealth visits grew dramatically – from less than one percent to as much as 80% in places where prevalence was high. Much like teleworking has changed how many of us commute and work, widespread adoption of telehealth has altered the practice of medicine, impacting the provider/patient care experience, medical cost and profit structures, and access to care. Without the burden of emergency necessity, we can now better assess the many benefits, challenges, and costs of telemedicine as an integral part of everyday practice.

The Patient and Provider Experience

Having tried telehealth, millions want to continue using it for many types of non-emergency visits. In a study of 58,500 patients, overall experience among patients with telehealth visits was as positive or more positive than with office-based visits. Also, provider communication on tele-video visits was viewed as slightly more positive than that of in-office visits and slightly more positive than in-office visits for: care coordination, overall rating of the provider, and willingness to recommend to family and friends. An April 2021 article describing a study of 368 telehealth patients in Los Angeles found satisfaction with telemedicine to be high with 77.3% reporting that they look forward to using telehealth in the future, and a study in New York found similar results. In a study of 2,080 patients conducted in March of 2021, when participants were asked about preferences – if costs were not a factor in seeking non-emergency care – 53% reported that they preferred an in-person visit. However, 61.4% of the participants were very willing or willing to use video visits with only 8.5% reporting that they were unwilling. Among the 45% of the participants who had actually used telehealth since March of 2020, only 2.3% reported that they were unwilling to use it in the future. According to a Harris Poll, nearly one-third of all adults have now used telehealth and among patient users 82% were positive or highly positive about the experience, and 76% indicated they were likely to continue using telehealth after the pandemic.

Meanwhile, in a 2020 American Medical Association (AMA) survey among 2,232 physicians surveyed, 85% reported providing care through telemedicine and among those, 60% reported that telehealth enabled them to provide high quality care; 56% were motivated to increase telehealth practice; and 54.2% indicated that telework has improved the satisfaction of their work. A study of 221 healthcare providers, in a November 2021 article, found that 52.9% of respondents stated that they enjoyed providing telehealth visits, and 52.5% reported that telehealth saves time. Newer studies on virtual care satisfaction and utility conducted after the necessity of the pandemic era will provide important data, but there is every reason to expect that patient demand for and provider acceptance of virtual care for many non-emergency scenarios will remain strong in the future especially as access to, payment expectations for, and reimbursement for virtual care becomes more clarified and standardized.

Business Model Viability/Sustainability in the U.S.

Upon the outbreak of COVID-19, new U.S. regulations addressing privacy were instituted which provided a substantial boost to the feasibility of telemedicine using available communication platforms such as Apple’s FaceTime. In the December 2020 International HITLAB Innovators Summit, Linda Malek and Jason Johnson, of the firm Moses and Singer, described the background and ramifications of these important changes. In addition, many large private payers as well as CMS, raised reimbursement including to full-parity level with in-person visits. Since that time, uptake of telemedicine, provided by traditional and virtual care focused providers, increased exponentially. This sudden transformation resulted in legal and reimbursement complications as virtual care was implemented across the states and created challenges for payers as well. The issue was discussed in detail in a February 2022 HITLAB Digital Health Symposium discussion which included Don Jones of Cardiff Blue Ocean Group, Joe Connolly of Visana, and Kevin Ryan of Epstein, Becker, and Green. As the panel described, patient billing costs for telehealth services has varied dramatically and with some providers charging facility fees. Facility fees may have helped traditional providers cover costs during the pandemic but may also have contributed to considerable cost dissatisfaction among some new telehealth users. As traditional, brick and mortar providers with relatively large fixed costs continue to compete with new disruptive “virtual-first” care providers, healthcare consumers have more choices and perhaps lower cost options. As described in a July 2021 HITLAB blog on bundled care, virtual-first providers use a model by which the patient begins accessing care in some form of virtual manner first before defaulting to in-person clinical visits as needed. Several studies have found certain telehealth approaches to be highly cost-effective. However, in the post pandemic environment, more research is needed to determine telemedicine’s overall impact on healthcare system quality and costs across differing structural models and care situations. New regulatory and reimbursement frameworks are being clarified, setting the stage for both types of providers to compete on access and convenience, quality and breadth of comprehensive care, and cost. However, continued and adequate reimbursement of virtual care is critical in order for the field to remain viable, and some payers may already be changing or reducing existing coverage policies for telehealth.

Access to Quality Care

In order to minimize social contact, the advantages of telehealth to increase access to non-emergency care during the pandemic were obvious. In a 2021 AMA survey, 80% of responding physicians indicated that they believed that patients had greater access to care using telehealth. However, moving forward, assessing telehealth’s overall impact on access depends on many factors. Appropriateness for the patient’s care situation is key. However, virtual care can never replace in person screenings and examinations when they are needed. To the extent that telemedicine inappropriately replaces in-person clinic time, access to needed care is arguably reduced. On the other hand, could greater interaction access to healthcare providers through telemedicine ultimately result in greater uptake of evidence-based recommended in-person screenings such as lipid profile tests and colonoscopies? More research is needed.

Health Equity: Geographic, Economic, and Technological Barriers

It is important to better understand what impact telehealth might have on vulnerable populations. A recent study of Medicare data found that telemedicine could improve access to healthcare for people in the most disadvantaged U.S. neighborhoods without worsening disparities. For those living in rural areas without clinical facilities or for those with an inability to travel because of mobility or economic limitations, clearly telemedicine can potentially increase access to certain types of care. However, many people living in rural or low socioeconomic conditions may have limited or no access to high-speed internet technology, electronic communication devices, or even a basic telephone. In a telehealth adoption study, 60% of providers stated that the most substantial barriers to effective virtual care were problems with seeing and hearing due to audio and image quality issues. Recent initiatives to improve and expand broadband access for people living in rural areas or among people with low incomes may help to address this problem.

Making the Right Call

The COVID-19 pandemic has greatly accelerated the adoption of virtual care. Implemented as one of many healthcare tools, and with realistic expectations, telemedicine can provide many important benefits to patients and providers alike. However, virtual care cannot replace in-person examinations or screenings when they are needed. Effective pre-appointment communication is essential for the appropriate application of telemedicine and to ensure patient satisfaction. For the virtual healthcare field to remain viable and meet the needs of patients, payer policies should provide adequate reimbursement for telemedicine and not discourage use indiscriminately. Telehealth can increase access to certain types of non-emergency care and may even have the potential to help address certain health equity objectives. Increased availability of telemedicine itself, however, is no substitute for greater or equivalent access to all forms of clinical, including preventive, care. Finally, research is needed to examine the impact of the practice of telehealth on health outcomes and health disparities over time. While we continue to address the opportunities and challenges of telemedicine, one thing is for certain, millions of patients will continue to demand the new, digital “house call.”