May 5, 2021
Telehealth After COVID
It’s safe to say that the COVID-19 pandemic has done for telemedicine what otherwise would have taken years to achieve. While less than half of health centers reported having the personnel and technology in place to offer telemedicine in a 2019, 95% of health centers were able to quickly shift to using telemedicine in 2020 to care for their patients. Patient populations that would otherwise have been resistant to telehealth adoption were, in many cases, forced to figure out the technology that would allow them to connect to their health care providers when in-person visits weren’t advisable or available. Virtual visit volumes shot up; in April of 2020 as the pandemic began to take hold, nearly half of the Medicare visits that took place were virtual (as compared to pre-pandemic Medicare virtual visit volumes of less than 1%).
With the Public Health Emergency (PHE) declaration came the reduction or outright elimination of many of the barriers that had previously stymied telehealth services. A relaxation of the enforcement of HIPAA with respect to the interfaces used with patients meant that providers could reach patients more easily using apps like FaceTime and Skype. Reimbursements that had previously been reduced to 80% of in-office visits were increased to the full reimbursement, making it more financially viable for providers to offer their services virtually. Additionally, whereas virtual visits were previously only an option for patients that were established with a practice, the relaxation of the guidelines allowed providers to see new patients virtually as well. Government, providers and patients all proved capable of incredible and rapid change and adaptation in the face of the largest health crisis in a century. Most of the changes, however, have been deemed temporary and are likely to expire at the end of the PHE, unless legislators choose to extend some of the provisions.
To project the likelihood of these types of virtual visits continuing post-pandemic, we need to understand the motives, acceptance rates and results of the patient populations obtaining the services. While many specialties made remote care options available, telepsychiatry took off during the pandemic as anxiety and depression became compounded by family loss, financial uncertainty and isolation. Given the nature of a typical mental health visit, behavioral health practitioners transitioned relatively easily to virtual visits as a means to care for both established and new patients. In its Telehealth Adoption Report, athenahealth shared that 33% of mental health visits have occurred virtually since the start of 2020. Aside from providing a means of social distancing, many behavioral health patients have indicated that they like the virtual format, as it allows them to remain in the comfort of their own homes and shields them from the potential stigma of being seen walking into a mental health practitioner’s office. In a limited study, the vast majority of psychiatric patients reported overall satisfaction with their virtual psychiatric visit, and smaller majority indicated that they believed the virtual visit was just as effective as an in-person visit. Telepsychiatry appears to be here for the long run: a survey from Tridiuum indicated that 70% of mental health providers plan to continue with virtual care post-pandemic.
After mental health, primary care was most significantly impacted by the COVID-fueled shift to telemedicine. The reason was simple - visiting a doctor’s office, urgent care center or ER during a pandemic and exposing oneself to other potentially infected individuals proved to be a strong motivation for both patients and providers to experiment with other options for care. Millennials were quick to adopt the virtual format, with 41% of Millennials actually preferring virtual care, according to a recent survey. Less clear is the continued adoption of telehealth from a higher-utilization population: The Baby Boomers. 38% of Baby Boomers reported using telehealth services during the pandemic, according to a Change Healthcare survey. Boomers represent a key market segment in the advancement of telehealth as they are more frequent healthcare utilizers and stand to benefit the most from remote patient monitoring services, such as blood glucose monitors and pulse oximetry. So, while Baby Boomers remain open to continued use of telehealth services, the extent to which they do will depend very much on their outcomes and results, which may not be entirely apparent for some time to come.
Telemedicine, of course, has not been a perfect substitute for traditional in-office care. In fact, 58% of physicians still have concerns about their ability to provide quality care remotely. Ensuring timely testing is another wrinkle in the model. Critics of the modality point out that there has been limited research on telemedicine quality of care as compared with in-office care. Additionally, many practices and health systems don’t yet have the infrastructure to offer telemedicine in a manner that is entirely private and secure. And some communities still don’t have access to adequate broadband coverage, further complicating the telemedicine delivery model.
Despite the current challenges and unknowns, the sudden and forced shift to telehealth has allowed providers and patients to see what is possible with virtual care. Many practices were able to expand access; it was reported that due to the efficiency of the calls and video conferences, providers were able to fit more patient care into their schedules. This allowed for more same-day appointments than are typically available, a key factor in quality and patient outcomes.
No-show rates plummeted as patients had less transportation-related barriers for getting to their appointments on time. Remote patient monitoring became more widely adopted and post-op patients were able to be monitored remotely, reducing their risk of exposure. Telehealth has also been a key driver of reducing emergency room utilization; one study estimated that telehealth eliminated almost 7% of ER visits.
Telehealth is not without its substantial challenges and faces a long road ahead. And while telehealth services will likely subside from their pandemic levels, it is our belief that telehealth utilization will remain significantly elevated from pre-pandemic levels. Millions of patients have had no choice but to at least give telehealth a shot, and a significant majority reported high satisfaction with the service, according to J.D. Power. The most significant - and still unaddressed - issue is how CMS will regulate telehealth services going forward. If virtual visit reimbursements are reduced back to the 80% level, we would certainly expect some downward pressure on telehealth visit volumes. Due to heightened demand, high adoption and preference rates and perceived efficacy, mental health telemedicine services are poised to continue with strong growth. The rapidness with which broader telehealth services will continue to grow is up for debate but - pandemic or no pandemic - telemedicine is here to stay. To compete and thrive, health systems will need to dedicate both human and capital resources to ensure that they have the technologies, strategies, and personnel in place to deploy telemedicine to the masses.