In the wake of the COVID-19 pandemic, telehealth went from something nice to offer to a necessity. Physical and mental illnesses don’t stop because of a stay-at-home order. And an unintended consequence of "social distancing" is a gap in access to care. Hospitals and health care providers acted fast to connect with their patients remotely. Telehealth allows providers to care for their patients while protecting themselves and others from virus transmission.
Telehealth usage has been rising for years, but this crisis has jolted it into the spotlight. According to a study by Sage Growth Partner and Black Book Market Research, 25% of consumer respondents had used telehealth before the COVID-19 pandemic. And 59% said they are more likely to use telehealth now than before. Another 33% said they would leave their current provider for one that offers telehealth.
Parkland Health & Hospital System in Dallas has been using telehealth encounters since the mid-2000s but has ramped up usage since the onset of COVID-19. “We’ve started using virtual encounters more frequently in our outpatient clinics to facilitate safe and high-quality care to our patients while eliminating the risk of infection,” said Molly Case, director of virtual care at Parkland.
Since March, Parkland has also started using telehealth for primary care, pediatrics and specialty services across the system. The health system had roughly 4,500 patients using telehealth per month prior to COVID-19. In April 2020, Parkland saw 46,000 patients through virtual encounters.
When COVID-19 began spreading, Cuero Regional Hospital, a 49-bed facility in southeast Texas, quickly realized that they did not have access to pulmonary services within their current telehealth offerings. They were able to work with Access Physicians, a telehealth physician group and Texas Hospital Association endorsed partner, to provide the specialized telepulmonology services their patients needed.
“Access Physicians worked with us and seven other hospitals in our rural cohort to provide telepulmonology services to reduce costs for all of us,” said Lynn Falcone, CEO of Cuero Regional Hospital. Falcone said that these services could prove even more crucial if larger hospitals are inundated and unable to take in patients from rural hospitals.
Telehealth took off this year as a result of COVID-19, but the benefits stretch far beyond infection control. Telehealth eliminates many barriers that patients face when seeking medical care. In Texas and beyond, there is a shortage of physicians and other critically needed care providers. Being such a large state, many Texans face geographic barriers to access care. In some areas, a patient may have to travel several hours to see a primary care doctor. The disparities in health care across Texas have exacerbated the need for a flexible way of providing care.
Constraints to Telehealth
The technology for telehealth has been around for decades, but there have been delays in adopting it for broader use. Providers have been wary of adopting telehealth due to a variety of barriers. Lack of parity related to lower reimbursement rates for a telehealth visit versus an in-person visit often dissuaded practitioners from offering it. Another constraint was deciding what constitutes permission to conduct a telehealth visit for a new patient and how to establish the physician-patient relationship. HIPAA compliance and ensuring the safety of patient data creates constraints as well.
“Some providers seemed reluctant to be early adopters of telehealth because of constraints particularly around privacy and clinical compliance. There are also more complex issues including services that cross state lines and definitions around how an initial patient relationship gets established between patient and provider,” said Fernando Martinez, Ph.D., chief strategy officer at THA.
In March, the federal government addressed these concerns – among many others – under the . The Act waives most Medicare payment requirements and all recipients are temporarily able to access telehealth services. The Act also loosens credentialing requirements across state lines, ensures parity for treatment and allows for flexibilities around HIPAA compliance.
But why were there so many restrictions to begin with? In addition to privacy and parity concerns, payors – including the federal government – had concerns that telehealth would create new billable charges. To this point, telemedicine and telehealth have been treated as new services. The government and payors have assumed that the new service would drive up the utilization and cost of health care. But amid the pandemic, the government and payors are recognizing telehealth and telemedicine as a modality for delivering care in a more efficient, cost-effective and convenient way. Because of the upward trend of telehealth, payors are starting to come around on using the technology. In a statement in March, Aetna said they believe telehealth is "a critical tool as we face the pandemic and, as a result, a more accepted option for care in the future.”
The government is not so optimistic as some private payors. In a statement to Kaiser Health News, the Centers for Medicaid & Medicare Services raised concerns about widely adopting telehealth. They warn telehealth could “inadvertently unleash a wave of billing fraud and abuse and risk patient safety. Especially if officials yield to industry pressure to make many of the emergency policy changes permanent.”
But health care fraud isn’t unique to telehealth. According to the American Telemedicine Association, telehealth "isn’t more susceptible to fraud than other services one could seek under Medicaid or Medicare."
Fueling the Trend
There are many external factors fueling the trend toward telehealth. These factors have been building momentum for years; COVID-19 kicked everything into high gear.
One of those trends is the generational change in the attitude of consumers. Baby boomers' preferences on how they receive medical care versus millennials are different. Younger generations are more concerned with efficiency and convenience than previous generations. Those under 40 tend to be less concerned about building a long-lasting, multi-generational relationship with a physician than generations past.
The shift towards telehealth is like the shift from brick-and-mortar stores to e-commerce retailers. Young consumers appreciate the convenience and quickness of an online transaction versus going to a physical store to shop. “Younger consumers want a more retail-like experience for health care. Telehealth is a simple enabler that organically delivers that desired experience,” said Martinez.
Today, consumers are also happy to see a nurse practitioner or physician assistant instead of a doctor. Younger generations tend to be more willing to speak to any medical professional who can address their needs and concerns – regardless of if they have MD, PAC or RN behind their name.
The socioeconomic status of consumers also plays a significant role in the rise of telehealth. For some, going to see a doctor would mean calling out sick from work, finding childcare or finding a way to travel to the doctor’s office. These socioeconomic factors have historically made it harder for some to access primary health care. Telehealth reduces those barriers, allowing consumers to seek care where they are without having to interrupt their busy lives.
Patients who generally only interact with a small community clinic can access major networks of health care specialists. Before telehealth, seeing a specialist at a well-known hospital was inconceivable for many Americans. Telehealth opens opportunities for patients suffering a chronic illness that their local doctor didn’t have the resources to treat.
Rural hospitals have begun partnering with larger hospitals to help patients in their communities find specialized care. Cuero Regional Hospital has an accredited stroke program and partners with the Methodist Health System in San Antonio to provide teleneurology to their community.
“If we have a patient who comes in with a stroke or stroke-like symptoms we can do a CT and send the scan to neurologists at Methodist. From there the neurologist can get on a call with the patient and their family to develop a plan of care,” said Falcone.
Telehealth also allows rural hospitals to bring in specialists without having to bring them onto their staff full time. Cuero Hospital often uses telehealth to provide specialists to their inpatients without having to transfer them. According to Falcone, within the first year of their partnership with Access Physicians, they avoided transferring out 100 patients. “Keeping patients in our hospital is huge for a small, rural facility,” said Falcone.
The Spectrum of Clinical Care
While many recent changes are broadly relevant to primary care, these trends apply to specialists as well. From addiction doctors prescribing treatments for opioid dependency after video chat visits to dermatologists helping a patient with severe acne or eczema, clinicians across the country are providing care that was thought to only be possible in person.
Telehealth is creating the best of both worlds for consumers who need personalized care from specialists, but before didn’t have the resources to travel to seek specialized care.
So what types of specialists work well in a telehealth setting? Some illnesses are more complex than others and need an in-person visit. But some chronic illnesses can be monitored and cared for without frequent in-person visits.
“Looking at clinical care as a spectrum from highest to lowest acuity in terms of severity, lower acuity problems are more appropriate for telehealth. As the severity of the health condition moves towards the high acuity end of the spectrum, it becomes more appropriate to move the patient to a more hands-on type of care,” said Martinez.
During the COVID-19 pandemic, cases with both high and low severity benefit from telehealth. Staying home, especially for patients with compromised immune systems, is promoting better health care outcomes.
One medical specialty that has benefited from the surge in telehealth is behavioral health. Virtual visits for mental health have reached new highs. According to a survey by the Kaiser Family Foundation, 45% of respondents said that the pandemic has affected their mental health. Americans coping with COVID-19 are struggling with symptoms of depression, fear, anxiety and isolation. The need for virtual visits with licensed therapists cannot be understated.
Even in normal times, some rural areas rely on telehealth for licensed therapists and psychological services. In DeWitt County, where Cuero Regional Hospital is located, there are no mental health providers. DeWitt is not the only county with this problem. In 2018, 175 counties in Texas did not have a licensed psychiatrist.
“We were able to develop a telepsychiatry clinic to focus on what issues they are facing and how best to treat those issues,” said Falcone. “The telepsychiatry clinic can also help patients find the right medications. This helps our general practitioners manage and track their patients' psych medications.”
Telehealth can fill gaps for hospitals across Texas, allowing patients to get the best care possible right at home.
Hospitals are observing how the surge of telehealth is impacting the relationship between patients and hospitals. “Traditionally, most patients seeking care or surgery at a hospital have come from a proxy relationship with a hospital and a primary care provider. Maintaining relationships with consumers as their relationships with primary care providers change should be a top concern for hospitals,” said Martinez.
The industry moving toward telehealth is a force that creates a paradigm shift in health care. The consumer now has a different idea of how they engage in the health care system. As relationships between consumers and health care providers evolve, hospitals must evolve too.
According to Martinez, the convenience associated with telehealth is a massive marketing opportunity for hospitals. Telehealth allows hospitals to bring in new patients in innovative ways. “Emphasizing the convenience and cost-effectiveness of telehealth is very attractive to consumers of all ages,” he said.
Hospitals are jumping on the telehealth trend to provide continuity of care for their patients. Maybe a patient doesn't have a primary care provider or perhaps they traveled from another city to seek treatment at a particular hospital. Telehealth allows clinicians to follow-up with these patients without them having to come back to the hospital.
According to Case, Parkland has seen a dramatic decrease in no-show rates for follow up and primary care appointments that are done via telehealth. Case also said that offering telehealth as an option for follow up visits could help to reduce hospital readmission rates.
“A standardized process for video and phone follow-up encounters will help a great deal in overall recovery of patients,” said Case. “We’re not having to ask a post-surgical patient to find someone to drive them and walk into the hospital yet again, but we’re still able to keep an eye on common concerns.”
An added benefit is that telehealth enables clinical providers to see their patients in their home environment. Martinez points to recent studies that have shown that social determinants often play a greater role in the health outcome of a patient than clinical intervention.
“The ability to understand the social determinants of health of a patient is key to positive health outcomes,” said Martinez. “Telehealth allows the provider to speak to the patient in their home. It creates a communication channel to discover potential deficits in their social determinants of health, such as lack of air conditioning or food insecurity.”
Hospitals can also use the technology to provide virtual visits between long-stay patients and their family members. When Parkland had to limit visitors during COVID-19, they used existing telehealth technologies to connect patients with their families. “Patients having video chats with loved ones may not seem like it’s a health care thing, but it’s comforting for patients who aren’t able to have regular visitors,” said Case.
Here to Stay
There are limits to video visits, but investments are being made to spur innovation. Tech companies are busy working on telehealth-connected tools like stethoscopes, thermometers and otoscopes. These tools would allow clinicians to screen patients and record vitals while the patient is in the comfort of their home.
“The opportunities that will present themselves over the next several years are going to be at a much faster pace than anyone would have expected. We are going through a transition in the way that health care can be provided and are always looking at ways that we can provide high quality care across the continuum.” said Case.
While COVID-19 has jolted telehealth into the limelight, preliminary studies and surveys indicate that it isn’t going anywhere once the pandemic ends. A report from Frost & Sullivan expects telehealth usage to rise by 64.3% by the end of 2020. That study also expects a 38.2% five-year compound annual growth rate for telehealth.
“I see a positive future for telehealth with increased usage. Changes will follow consumer demand and most, if not all, the historical barriers to adoption will come down,” said Martinez. “This is especially true today given the drastic change in culture, workforce and health care treatment protocols that have been enacted in response to the pandemic.”
These unprecedented times are challenging, but they have given a tremendous opportunity for hospitals and health care systems. From telehealth services to AI-powered temperature scanners to plexiglass boxes to protect clinicians from COVID-19, this public health crisis has brought out the most innovative in health care providers.
COVID-19 has forever changed health care, in more ways than one can count. The road to recovery—for our health care infrastructure, survivors of the virus and those grieving lives lost—is long. But there is hope for the future. COVID-19 has brought providers and innovators together to meet patients where they are and provide needed care during this pandemic. There is much uncertainty right now, but one thing is clear. Telehealth is here to stay.