"The times, they are a-changin'," sang Bob Dylan in his 1963 social-consciousness earworm.
That lyric, a massive understatement considering the effects wrought by COVID-19, is true, nonetheless. The pandemic has forced drastic changes in every aspect of society — our personal lives, social interactions, buying habits, media consumption, employment outlook, government policies, and even the presidential campaign.
"Change" is also the operative word in healthcare. By deferring elective and preventative visits, the spotlight has shifted from in-person patient care to virtual care offered by telehealth and its cohort telemedicine.
"With the arrival of the COVID-19 pandemic, telehealth has finally come of age," said HealthLeaders in an article about telehealth and the COVID-19 pandemic.
In this post, we examine changes that have taken place in telehealth as a result of the virus, explore what that means for the major healthcare industry players, and look at what's in store for the future regarding challenges and opportunities.
Along the way, we will gain insights from Bryan Arkwright, Vice President, Innovation, SCP Health. No one is better suited to address this issue than Arkwright, given his singular focus on healthcare innovation.
Telehealth Changes During the Crisis
Telehealth has taken center stage since the government declared COVID-19 a national emergency. Almost overnight, telehealth providers reported a surge in demand as hurdles to widespread adoption, such as consumer awareness and physician and consumer acceptance, vanished.
"Like a lonely teenager who once struggled to make connections with a broader network of friends and was bound by strict parental controls, suddenly, telehealth has blossomed into the most popular kid in school by becoming an essential tool in the healthcare armament against this pandemic," HealthLeaders said.
Arkwright noted that major vendors are now doing thousands of visits per day, including one who did more visits as of March 2020 than in the first 12 years of operation.
"Before the pandemic, telehealth and telemedicine eked along, but now they’ve jumped up in utilization," he said. "There has always been an increase, but it's been more gradual. No one could have anticipated we would be where we are in terms of utilization now."
To cite a few examples, Charlotte, North Carolina–based Atrium Health reported a 500 percent increase in telehealth usage. Teladoc Health said call volume was up by 50 percent, and Doctor on Demand reported that visit volume was up 15 to 20 percent.
COVID-19 Telehealth Resources
CMS, AMA, and other agencies offer several COVID-19 resources. These include:
- List of telehealth services CMS covers (CMS)
- General Provider Telehealth and Telemedicine Tool Kit (CMS)
- Telehealth Coverage Policies in the Time of COVID-19 (Center for Connected Health Policy)
- Quick guide to telemedicine in practice (AMA)
- Telehealth Coding and Billing During COVID-19 (ACP)
- Special coding advice during COVID-19 public health emergency (AMA)
- Best Practices for Telehealth During COVID-19 Public Health Emergency (National Council)
Telehealth Implications for Key Players
Increased demand for innovative care management solutions like telehealth and telemedicine due to COVID-19 has resulted in a wide array of quick changes for payors, hospitals, patients, and providers alike.
Telehealth Service Changes for Payors
CMS changed access requirements and reimbursement restrictions immediately in response to the outbreak, and many other private payors have followed suit.
Expansion of Telehealth with 1135 Waiver
Chief among the changes is the 1135 Waiver, put into effect on March 6, 2020.
Under the waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country, including patients' places of residence. Further, a range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, can offer telehealth to their patients.
Also, the HHS Office of Inspector General provides flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
"The 1135 Waiver put a lot of things in motion," according to Arkwright. "It temporarily got rid of geographic requirements (previously, Medicare patients had to live in a rural setting, not metro or urban, to utilize telehealth), increased flexibility in the technology healthcare providers could use, and removed the requirement to be an existing patient with a particular provider."
CMS instituted another change on March 30, adding 79 ICD-10 codes, increasing the number to approximately 179, and clarifying statements and frequently asked questions made in the initial announcement.
"The additional codes cover areas such as the emergency room, home health, hospice, NICU, and renal dialysis," Arkwright said. "The most significant for SCP Health and the industry, in general, is that it includes five big emergency medicine codes."
Arkwright indicated that the whirlwind of changes necessitated a lot of interpretation regarding what the rules are at any given time.
"It's been nonstop interpreting what the codes, regulations, and standards cover," he said. "Although it's been a headache figuring out how to put these into effect, what this shows is the White House and other federal agencies are listening."
Changes for Payors Regarding Technology Use
As consumer needs change due to the pandemic, some payors are reorienting their current technologies to fit. Included are expanded telehealth reimbursement approaches to allow alternative video conferencing platforms to conduct telehealth visits. In-network providers can use any form of live videoconferencing for 90 days to connect with patients.
"This opened the gates further to do telemedicine and allowed the telephone to be used," Arkwright indicated. "A lot of mixed tech is being used. As long as it can't live stream to a large audience, it can be used, even if it's not HIPAA compliant."
Humana, for example, already offers video telehealth options for patients but is expanding telehealth channels. UnitedHealth Group augmented its channels to include a broader range of virtual care platforms. Cigna has devoted more of its clinical network toward telehealth platforms, increasing its telehealth team by hundreds of clinicians, and is offering a coronavirus support telephone line for mental and behavioral healthcare needs, including stress and anxiety.
Telehealth Changes and Hospitals
One CMS change that has a significant impact on hospitals has to do with licensure, Arkwright said.
"Hospitals have to license and credential providers to practice medicine at their facility," he said, adding that "medical review boards and staff bylaws can be different from hospital to hospital."
He listed three types of licensure approaches that states are taking, which impacts how each hospital begins to interpret and account for processing and approving a provider to do telehealth: Full permissions (Providers licensed anywhere without any issues on their licenses can practice telemedicine in any state.), more limited, and temporary (a shorter time frame but includes some pieces of limited plus full permissions).
"With compliance standards and licensure, practicing state to state has been tricky," he said. "Several states through the pandemic are providing full waivers (accepting licenses in good standing from any state the provider is previously licensed), others are taking a limited waiver approach, and still other states took a temporary waiver. Full, limited, temporary — it's a mixed bag."
Billing is also an issue for hospitals.
"Medicare is straightforward, but beyond that, if providers are new to a state or hospital, then they are new to private payors as well and have to be enrolled with payors," he said.
Of particular concern to hospitals, emergency department volumes are down 20-40 percent across the country.
A portion of this volume decrease includes people who truly needed emergent or urgent care. Therefore, it is quite dangerous—leading SCP and our partners to remind communities not to shy away from the ED during medical emergencies. That said, another portion of the volume is composed of "minor concerns telemedicine is proving that it can handle," Arkwright said.
Patient Adoption of Telehealth Services
It's fair to say that everyone knows the steps to take to keep COVID-19 at bay (e.g., hand washing, social distancing, sheltering in place, etc.), but patients should also be aware of best practices when making a telemedicine/virtual care visit.
In its article, "Can Telehealth Help Flatten the Curve of COVID-19?" Harvard Health Publishing offered the following instructions:
- Before you call, write down your symptoms, whether you have a fever, and whether you've taken any medicine;
- Be ready to answer a few questions that might seem tedious or irrelevant, such as where you have traveled recently;
- Resist the urge to ask reasonable but nonmedical questions that are time-consuming;
- Keep calls short. Many calls to triage hotlines go unanswered because of high call volume.
Another area where patients can help themselves is by investing in home care technology, said Arkwright, indicating the use of home healthcare devices and apps will likely increase. Examples include:
- Blood pressure cuffs
- Connected Bluetooth weight scales
- Heart monitors
"Home healthcare technology increases the amount that telemedicine can do," he said. "It helps consumer confidence and gives providers so much more to work with and code for. It also improves symptom diagnosis."
Providers and Telehealth
Just as patients need to become accustomed to telehealth best practices, so, too, do providers.
The National Council recommends six best telehealth practices for providers:
- Be strategic in your considerations. Work with your team to think strategically about where opportunities for expanding telehealth are.
- Take time to assess your needs. Understand your current capacity and where your gaps are in terms of equipment, staffing, and patient resources.
- Communicate visit changes to your patients. Let your patients know your organization's telehealth policies during the COVID-19 outbreak.
- Practice using technology first. Whatever application you decide to use, practice with other staff before employing with a patient.
- Create a backup plan. Establish protocols in case escalation of care is required or technology fails.
- Consider appropriate screening tools. If you are still offering in-person appointments, incorporate approaches for screening COVID-19 symptoms before arrival, and protocols for shifting virtual appointments should include a patient's present symptoms.
Future of Telehealth During COVID-19 and Beyond
No significant change comes without challenges and opportunities, and the COVID-19 pandemic is no different. Where telehealth and telemedicine service implementation are concerned, there is reason for concern and cause for hope.
One of the challenges that technology will help overcome is the diagnostic limitations imposed by the lack of in-person visits.
"With the absence of a physical exam and the absence of testing, all that telehealth can really offer patients right now is increased surveillance and an illusion of care that poses new risks for our future health and well-being, as well as the loss of privacy," said an acerbic Stat news article addressing challenges associated with telehealth. "Anything requiring a physical exam that cannot be accomplished by visual inspection through a smartphone camera or a patient's own self-exam can't be done through telehealth."
Patient privacy is yet another concern, according to Stat.
"Since we know that no one actually reads privacy policies or terms and conditions, few users will have any idea that their health disclosures, while technically protected by HIPAA, may also be shared with Facebook, Google, or Twitter," Stat said. It then posited a likely scenario:
A third-party company knows that a user clicks on a particular category of interest on the Amwell "Conditions" drop-down menu, such as "Anxiety" or "UTI." Amwell isn't prohibited from sharing which conditions a user clicks on and uses it to feed him or her ads about those conditions or steer the user to search results on those topics.
Arkwright indicated that the telehealth vendor market could also be cause for concern, citing that pre-COVID-19, vendors downplayed the difficulty of doing telehealth.
"A lot of people are jumping into the market, and it's important that they have good partners and good sources of information, knowledge, and experience during implementation and operation," he said. "Doing a video call is easy, but it's all the behind the scenes logistics and operations that are more complex and require attention to detail.”
Benefits and Opportunities
Not ignoring the challenges, the use of telehealth offers many benefits and opportunities for improving patient experience.
There is no risk of exposure to diseases or spreading sickness since a telehealth visit is generally done from the patient's home. Additionally, it provides better access to care for patients who may live further from a hospital or urgent care facility (an important feature particularly for rural areas where healthcare facilities are increasingly few and far between).
Other benefits include the opportunity to increase physician supply through geographic "load balancing." Health systems can also maximize workforce potential by using quarantined physicians to provide virtual care.
Also, as telehealth services' demand rises, and the online waiting queue for patients increases, the use of chatbots and AI tools can streamline intake processes and make interactions more efficient for providers.
"The telehealth horse is out of the barn and not going back in," Arkwright said. "Private practices, primary care, and hospitals set in their ways and not open to doing things differently are making the change to survive. If they had a choice before, they don't any longer."
If Arkwright's statement describes your situation, contact us. SCP Health's telehealth solutions maximize quality, value, and efficiency by applying convenient, easily navigated telemedicine technology to care delivery.
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