As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:
I’m typing this while on voluntary quarantine at the recommendation of the Kansas Department of Health and Environment because of a recent trip to Orange County, Florida. But like many of you, I’m managing to stay busy at home. One of the things I’m doing is providing “peer-to-peer” consultation to other doctors through a platform called RubiconMD [disclaimer: they pay me for the work, but not for advertising or testimony]. Doctors who subscribe to RubiconMD can forward me labs, imaging, and chart notes for patients with tricky hormonal and metabolic problems, and I type a recommendation back to them, potentially saving the trouble and expense of an in-person visit. These so-called “store-and-forward consults,” or “e-consults,” are one form of telemedicine, and they have proven effective enough–saving ~$500 per patient per year in one study–that they are now covered by Medicare.
The more well-known form of telemedicine in which practitioners and patients interact through a screen is referred to as “real-time” telemedicine. Other than the fact that the patient connects to the practitioner through a secure internet platform, telemedicine visits look a lot like traditional in-person medical visits: someone on the patient’s end (the “originating site,” in telemedicine parlance) collects vital signs, the doctor or other practitioner conducts an interview and, with the help of the ubiquitous high-resolution cameras on modern devices and a few on-site gadgets, performs a physical examination. Then the practitioner bills for the encounter as she would any other visit, albeit with a modifier attached to the billing to indicate that the visit was done remotely.
The average patient seen in-person at a physician office spends 121 minutes on the visit: 37 minutes traveling, 64 minutes waiting, and 20 minutes with the doctor. So if you think the idea of skipping the waiting line (not to mention all the coughing and touching) at your doctor’s office is attractive, you’re not alone. Telemedicine visits have a roughly 90% patient satisfaction rate. Kaiser Permanente has seen more patients via telemedicine than in-person since 2017. Local telehealth provider Freestate Healthcare and national providers Access Physicians and Eagle Telemedicine, among others, provide remote physician services at several rural hospitals with no doctors physically on site. In our work with CDC grants around diabetes prevention, we are running a trial of Omada, a virtual diabetes prevention program, to reduce the risk of high-risk patients developing diabetes. More than half of medical schools now offer required or elective training in telehealth to improve trainees’ “webside manner.”
And telemedicine has a growing body of evidence to support its use beyond reduced wait times and patient satisfaction. The Veterans Administration has found that telemedicine use corresponds to a 59% reduction in inpatient bed days and a 31% reduction in hospital admissions.
In spite of this rosy picture, the growth of telemedicine has been slowed by a regulatory system that is not designed for rapid change. Medicare, for example, has historically enforced a “site of service” requirement for telemedicine, meaning that patients seen via telemedicine still needed to travel to a hospital or doctor’s office to get linked to the distant telemedicine practitioner. Medicare has also mandated that patients must be located in a “health professional shortage area,” meaning that patients in areas with more physicians were ineligible to receive care via telemedicine, even if it was difficult for them to travel, and even if they had a highly communicable disease. Laws have mandated that the treating physician be licensed in the state where the patient was located, meaning a doctor licensed only in Kansas couldn’t historically see a patient in Oklahoma. And federal regulators have long restricted the technology that can be used for the interface. You couldn’t simply Skype or FaceTime your doctor, since those platforms were not compliant with the Health Insurance Portability and Accountability Act (HIPAA). This is not, on its face, an unreasonable policy; health data is valuable, so it is not hard to imagine it being the target of hackers.
There has been movement on this in the last year. Medicare Advantage plans began covering telemedicine visits from home earlier this year. But the current coronavirus pandemic is forcing faster changes, probably for the better. This week Centers for Medicare and Medicaid Services (CMS) suspended site-of-service requirements and state licensure requirements for telemedicine, and the Office for Civil Rights at Health and Human Services (HHS) announced that it would waive potential penalties for using lower-security forms of video communication for telemedicine. That is, any live video chat software is acceptable for now. This means that, at least in the short term, you can Skype or FaceTime your doctor (although we still recommend a more secure platform if your doctor can offer one). And you can do it from home. This policy is extending to other insurance carriers as well. I called Aetna, who informed me that they are allowing all visits (with the usual rules on copays and deductibles) to be performed via telemedicine for the next 90 days.
...once people get a taste of life with more easy access to telemedicine, I can’t imagine them going back.
If you or your company want to seek out such secure platforms, encourage patients to talk to their doctors about starting telemedicine visits. We at the Kansas Business Group on Health believe that care continuity is important. Urgent care centers and emergency departments have an important role to play, but encouraging patients to see their own doctors, rather than unaffiliated urgent care practitioners or cash-only telemedicine companies like Teledoc, is good for patients’ care and good for your bottom line. Freestate, Zoom, Doxy, VSee, and many other HIPAA compliant platforms are available to your employees’ doctors. They should consider asking specifically about any platform’s use of business associate agreements (BAAs) to certify there are safeguards against data breaches. Even though FaceTime is now technically allowed to be used as a telemedicine platform, for example, Apple will not sign a BAA. But Skype for Business, again for example, will.
I guess if you are the type of person who tries to find the bright side of things, this blog post is for you. This is just one way that COVID-19 is going to change medicine long-term. For the next few months, telemedicine access will become what its proponents have advocated for for years: a broad-based, broadly covered service that can be provided in the patient’s home on widely available, inexpensive software platforms. This is important not only in the context of a worldwide viral pandemic. It is important because once people get a taste of life with more easy access to telemedicine, I can’t imagine them going back.