Ramona Midkiff

By:  Cara Murez

TUESDAY, Jan. 5, 2021 (HealthDay News) — In late December, Dr. Ada Stewart asked her staff to check on a patient who had missed an appointment.

She soon learned that the patient had no transportation for the 45-minute drive, so Stewart offered to conduct the appointment by phone instead.

“It still accomplished so much. I was able to see how their diabetes was doing, how they were preparing for the holiday season, how they were really feeling mentally,” said Stewart, a family physician at Eau Claire Cooperative Health Centers in Columbia, S.C., and president of the American Academy of Family Physicians.

That’s just one example of how doctors are using telemedicine – having appointments by phone or video call – to check in with their patients.

Telemedicine isn’t new, but the COVID-19 pandemic has really put the technology front and center, with clinics closing for certain services after state and local governments issued stay-at-home orders to help prevent the spread of the virus.

And even when doctors’ offices were open, some patients avoided in-person appointments due to COVID-19 fears.

Besides giving telemedicine a boost, the pandemic has also fostered the rise of innovative medical services, everything from getting prescriptions by mail to drive-through virus testing and pharmacy-based vaccinations.

Many of those innovative approaches to health care are likely to linger long after the pandemic ebbs, experts say.

“We saw the benefits that telehealth provided,” Stewart said. “People were able to receive access to health care. We were able to reach out to our patients who were afraid to come into the office to be seen. It really afforded that opportunity to still take care of our patients and do so in a safe way.”

Telemedicine also gave physicians the ability to keep their practices, which might otherwise have been shuttered as patients stayed home.

“We had to pivot,” Stewart explained. “We had always talked about telehealth and incorporating it into our practices,” but 2020 brought the technology to the fore.

The American Academy of Family Physicians distinguishes between telehealth and telemedicine. Telemedicine, the academy says, is using technology to deliver care from a distance, whereas telehealth is the technology and services to provide that distance care.

Prior to the pandemic, telemedicine was already growing in the United States, especially in mental health services. But it still only reached a small minority of patients, about 4% of the population, according to Lori Uscher-Pines, a senior policy researcher at the nonprofit RAND Corporation, which works to impact policy through research and analysis.

Restrictions on telemedicine delivery were a major barrier to growth. For example, many insurance providers would only reimburse telemedicine visits under specific circumstances.

However, “at the start of the public health emergency, payers across the board really relaxed restrictions on telemedicine, so patients could be served at home and that would support social distancing and help patients continue to get the care that they need,” Uscher-Pines said. “As a result, we’ve seen telemedicine use really skyrocket.”

Enhancing, not replacing, in-person care

A study recently published in JAMA Network Open evaluated how health services changed in March and April 2020, during the early part of the pandemic in the United States, among 6.8 million people covered by commercial insurance.

The study found that use of in-person medical services dropped by 23% in March and 52% in April, and that telemedicine services grew by more than 1000% in March and more than 4000% in April.

That doesn’t mean telemedicine completely replaced in-person care: The increase in telemedicine only offset about 40% of the decline in office visits.

Prior to the pandemic, Deidre Keeves and her team at UCLA Health in Los Angeles had been trying to get physicians to increase their use of video visits with modest success, averaging about 100 visits per day for several months. But from March through May of 2020 they jumped to 3,000 to 4,000 visits per day, Keeves said.

More recently, UCLA Health doctors were doing about 2,700 telemedicine visits a day. Keeves said she expects that pace to continue averaging that number, even once the pandemic is under control.

She sees telehealth as beneficial for patients, who save on time and travel, as well as for physicians, who can reach a geographically wider population.

“We think that telehealth is here to stay. Our patients are expecting it. Our doctors are very happy with it, and it’s a great avenue for care,” said Keeves, who is director of connected health applications at UCLA Health. “We’re expecting that about 20% of our volume is going to continue to be through telehealth.”

In-person visits continue to be necessary anytime a person needs a procedure, such as a biopsy, lab test or vaccine injection, Keeves said. Telehealth works for follow-up visits, medication instructions and talking with a mental health provider.

UCLA Health is located in Southern California, a current crisis area for COVID-19. Keeves said staff are also monitoring some coronavirus patients at home with the use of pulse oximetry (which measures blood oxygen levels) and regular check-ins with clinicians.

“We at UCLA Health don’t feel that video visits are a replacement for in-person care,” Keeves stressed. “We are not using technology to replace the doctor-patient relationship. We’re using technology to supplement and support that relationship.”

Direct-to-consumer safety valve

What’s known as “direct-to-consumer” telemedicine was also growing even before the pandemic, Uscher-Pines added. That involves scheduling a visit with a doctor who works for an online-only service provider. It’s typically used when someone has a minor acute illness, not a severe condition.

Uscher-Pines was an author on a study that appeared recently in the Journal of Medical Internet Research. The study focused on the experiences of one such telemedicine supplier, called Doctor On Demand, a national telehealth service provider.

Researchers compared data from February to June in 2019 and February to June 2020. They found that total visit volume increased from March through April 7, 2020, by 59% above the baseline, before declining to 15% above the baseline through the week of June 2, 2020. The growth wasn’t typically fueled by COVID-19 concerns, but rather by visits for issues of behavioral health and chronic illness.

In this way, “telehealth services may play a role as a ‘safety valve’ for patients who have difficulty accessing care during a public health emergency,” the study concluded.

Pharmacies also fill gaps

Other innovations that have expanded during the pandemic range from drive-through COVID-19 testing to pharmacy-based vaccinations for younger children.

In August, the U.S. Department of Health and Human Services (HHS) authorized state-licensed pharmacists to vaccinate children age 3 and up. That followed a U.S. Centers for Disease Control and Prevention report, issued in May 2020, that found a “troubling drop” in routine immunizations for children.

“What I love about pharmacy is we’ve really stepped up to be a very essential access point for people when a lot of other things might have been closed,” said Sandra Leal, president-elect of the American Pharmacists Association and executive vice president of SinfoniaRx, which works with health plans to do comprehensive medication reviews with patients via telehealth.

Another change Leal noted is that pharmacists can now conduct COVID-19 testing within their communities. In April, HHS allowed licensed pharmacists to test patients for COVID-19.

As the pandemic forced office closures, SinfoniaRx’s team worked with patients to do not only the usual work of ensuring they had no medication questions, but also talking about COVID-19.

“We’re finding that so many people have so many questions around COVID and the pandemic, and vaccines and when they’re going to be available to them,” Leal said. “We’re really trying to address those concerns.”

Ordering prescriptions by mail is a service that’s been around for a long time, Leal said. In May, the Wall Street Journal reported that mail-order prescriptions had risen 21% over the previous year during the last week in March. Yet, Leal said patients are concerned about postal delays, which can be a big problem for people with certain conditions, such as people with type 1 diabetes who need insulin.

Future depends on policy

The COVID-19 pandemic has highlighted health inequities, and the shift to a broader acceptance of telemedicine is an opportunity to improve health care in the United States, Stewart said. She would like to see telemedicine continue, along with the technology infrastructure to ensure that health care is equitable.

Uscher-Pines said that it may be difficult to return to the pre-pandemic status quo, with its focus on office visits, because providers and patients are now familiar with and appreciate the convenience of telemedicine.

“I think that what ultimately happens with telemedicine really depends on how the policy environment evolves,” she said. “There is a lot of action going on at both the state and federal level right now on telemedicine policy, and a lot of strategizing on what should stay permanent and what should go back.”

More information

The U.S. Centers for Disease Control and Prevention has more on telemedicine during COVID-19.

SOURCES: Ada Stewart, MD, family physician, Eau Claire Cooperative Health Centers, Columbia, S.C., and president, American Academy of Family Physicians; Lori Uscher-Pines, PhD, senior policy researcher and research quality assurance manager, RAND Corporation; Deidre Keeves, PT, director of connected health applications, UCLA Health, Los Angeles; Sandra Leal, PharmD, executive vice president, SinfoniaRx and president-elect, American Pharmacists Association; JAMA Network Open, Nov. 5, 2020, online; Journal of Medical Internet Research, Dec. 15, 2020, online; U.S. Department of Health and Human Services, Aug. 19, 2020; American Pharmacists Association, Nov. 4, 2020; Wall Street Journal, May 12, 2020

In a letter to Congressional leaders, several telehealth groups have asked that emergency measures enacted during the coronavirus pandemic be kept in place through 2021 as Congress continues to work on long-term coverage.

December 15, 2020 – Telehealth advocates are lobbying Congress to get something done before the end of the year to ensure continued access to and coverage of telehealth services during the coronavirus pandemic.

In a letter last week to Congressional leaders, the group called for the extension of connected health flexibilities during the public health emergency through the end of 2021. This would keep in place emergency provisions that remove geographic restrictions to telehealth, allow the patient’s home to be an originating site for telehealth services, give the Health and Human Services department the authority to approve telehealth services and providers and enable federally qualified health centers (FQHCs), rural health clinics (RHCs) and critical access hospitals (CAHs) to be reimbursed for telehealth.

“Since many of these needed policies are contingent upon the PHE, millions of Americans risk losing access to vital health care services unless you and your colleagues takes specific actions,” the letter states. “Additionally, the continued risk of telehealth flexibilities ending with each subsequent 90-day renewal of the PHE adds additional uncertainty to an already strained health care delivery system. Patients and their health care professionals should not have to worry if they will be able to continue to receive or deliver necessary care.”

The letter is the latest salvo in the ongoing battle to make these emergency measures permanent, so that healthcare providers can continue the momentum seen in telehealth use past the COVID-19 emergency and plan long-term telehealth strategies.

Some states and even a few payers have taken that action, while many others are waiting on the federal government to take action.

Congress has been flooded with dozens of bills seeking permanent expansion of telehealth access and coverage, and has in the past included some measures in pandemic relief and stimulus packages, but there’s no guarantee that another bill will be passed or that any telehealth legislation would be included in it.

The Centers for Medicare & Medicaid Services, meanwhile, has advanced telehealth, mHealth and remote patient monitoring coverage in its 2021 Physician Fee Schedule, though critics have said the new guidelines don’t go far enough, and that Congress needs to take the lead.

The letter is signed by the American Telemedicine Association, Healthcare Information and Management Systems Society (HIMSS), Alliance for Connected Care, eHealth Initiative, College of Healthcare Information Management Executives (CHIME), Connected Health Initiative, Health Innovation Alliance and Personal Connected Health Alliance (PCHA).

“There is no time like the present for passing needed common sense permanent reform to ensure telehealth services remain a lifeline for millions of Americans in rural and underserved communities after the public health emergency is rescinded,” ATA CEO Ann Mond Johnson said in a press release accompanying the letter. “Absent the timely enactment of permanent policies, we urge Congress to extend these temporary flexibilities for as long as possible, to at least provide one year of certainty and enable patients to continue to receive care when and where they need it.”

By Dawndy Mercer Plank | December 17, 2020 at 6:06 PM EST – Updated December 17 at 7:46 PM

COLUMBIA, S.C. (WIS) – In this year of firsts because of the pandemic, doctors are seeing a greater number of patients through a computer screen.

Telehealth or telemedicine is a virtual visit with your doctor that’s gaining in popularity as this two-way video communication has now become the preferred choice for some patients.

When at Lexington Medical Center’s Saluda Pointe Urgent Care, you’ll hear “I’m Dr. Crump. I’ll be taking care of you today, virtually.”

Call after call, Dr. Todd Crump spends a chunk of his day seeing his patients through a computer screen.

“We didn’t have a whole lot of telehealth within my hospital, but it’s become very popular now that COVID’s come to town because people are just afraid to go to a facility and risk catching COVID,” said Dr. Crump.

In fact, telehealth visits are becoming just as prevalent as in-person visits not just because of avoiding exposure to COVID, but because of the convenience factor.

Dr. Crump says it’s really been a game-changer, especially for working parents.

The most common virtual condition Dr. Crump sees? Sinusitis.

“Folks come into the screen and say I get a sinus infection every year when the weather changes,” said Dr. Crump.

All ages are using the telemedicine option. Dr. Crump has people in their 70s using it — though he says his nurses sometimes have to help walk the older generations through the technology.

“I’ve had a patient log in and say, ‘I’m going to be the easiest patients you’ve had today. I have a rash.’ Holds it up to the camera. And I can actually take a picture of it and put it in her chart and then send a steroid cream to her pharmacy,” said Dr. Crump.

For the Lexington Medical Center network, there are two requirements to use the urgent care visit. A patient must have an LMC MyChart account. That’s the hospital system’s electronic health record. The patient must also confirm he or she is physically located in South Carolina at the time of the virtual visit.

You do not actually schedule a virtual visit. They are on-demand visits. That means a patient puts him or herself in a queue to request the visit. Then, the healthcare provider is notified that a patient is waiting. The staff will notify the patient when the doctor is ready.

Since the onset of the COVID-19 pandemic, Congress and the Centers for Medicare & Medicaid Services (CMS) have dramatically—but temporarily—expanded coverage and reimbursement for telehealth services.

On December 1, CMS issued the final calendar year (CY) 2021 Medicare physician fee schedule (MPFS) final rule and interim final rule, including several changes to Medicare Part B telehealth payment policy. The rule makes coverage of certain services permanent, extends coverage for certain other services through the end of the calendar year in which the public health emergency (PHE) ends, and clarifies which services CMS will not be adding to the Medicare telehealth covered services list on either a permanent or temporary basis. The rule also finalizes some changes to coverage of remote physiologic monitoring services and finalizes extending the temporary flexibilities around virtual supervision through the end of 2021.

Despite these changes, the rule also illustrates the limitations that CMS has in broadly expanding coverage and reimbursement given statutory restrictions. Without further congressional action, statutory restrictions on geographic sites, originating sites, eligible technologies, eligible providers, and federally qualified health centers (FQHCs) will come back into effect at the end of the COVID-19 PHE. And with these limitations will come decreased telehealth utilization. Based on the telehealth experience gained during the pandemic, Congress may seek to make permanent—or at least extend on a longer-term basis—certain of these flexibilities.

Telehealth Flexibilities Adopted During the Pandemic

Most of the changes implemented during the pandemic are in effect only for the duration of the Department of Health and Human Services (HHS) PHE. As there are significant statutory restrictions on how telehealth services can be delivered and paid for in Medicare, to enact these flexibilities, the Administration relied on Section 1135 waiver authority, which allows HHS to waive or modify certain Medicare requirements during a federally declared emergency (among other flexibilities).

Principal changes include:

• Lifting the geographic restriction that beneficiaries must be located in a rural area;
• Permitting beneficiaries to receive telehealth services from their homes;
• Allowing a broader range of providers to deliver telehealth services (e.g., physical therapists, occupational therapists, speech-language pathologists);
• Adding coverage and payment for audio-only forms of telehealth;
• Enabling FQHCs and rural health centers to serve as eligible distant sites (i.e., where the provider is located); and
• Expanding Medicare telehealth coverage to more than 100 additional services.

Currently, the HHS PHE is set to expire on January 20, though it has been renewed several times and likely will be extended again. While CMS has taken swift and bold action to expand telehealth coverage and reimbursement, once the HHS PHE expires, so too do most of the flexibilities HHS has enabled.

In the final CY 2021 MPFS, the Administration took steps to make some of these flexibilities permanent and to extend others further, though a permanent extension of the full range of telehealth flexibilities introduced during the PHE would require congressional action.

Final CY 2021 Medicare Physician Fee Schedule Rule—Telehealth Provisions

Changes to Covered Medicare Telehealth Services

The final rule makes a number of changes to the Medicare telehealth covered services list. A range of services will be permanently added to the list, including group psychotherapy, low-intensity home visits, and psychological and neuropsychological testing. In addition, CMS will extend temporary coverage for certain services through the end of the calendar year in which the COVID-19 PHE ends, including high-intensity home visits, emergency department visits, specialized therapy visits, and nursing facility discharge day management. Finally, certain services that have been covered on a temporary basis during the PHE will not be covered on a permanent basis once the PHE ends. This includes services such as telephonic evaluation and management services, initial nursing facility visits, radiation treatment management services, and new-patient home visits. Notably, after significant public comment on the proposed rule supporting the addition of more services to the list of services covered through the calendar year in which the PHE ends, CMS extended coverage for several additional services that it had proposed ending coverage for at the end of the PHE.

Other Changes to Medicare Telehealth Services

In addition to the changes to the telehealth covered services list, CMS is finalizing a change to the frequency limit for subsequent nursing facility visits provided via telehealth—these are typically visits provided by an admitting physician to a patient in an inpatient nursing facility. Currently, CMS only reimburses for one Medicare subsequent nursing facility visit via telehealth every 30 days. In order to enable more frequent telehealth visits on a permanent basis, CMS is revising the limit and will reimburse for one subsequent nursing facility visit via telehealth every 14 days. This will allow for more frequent use of telehealth while keeping a frequency limit in place to ensure that providers are not disincentivized from providing in-person care.

The final rule also permits additional types of providers—licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists—to bill for brief online assessment and management services, virtual check-ins, and remote evaluations, and the rule adds new codes for these services.

Changes to Audio-Only Services

Federal law provides that Medicare telehealth services must be delivered via a “telecommunications system.” CMS has long interpreted this to preclude audio-only technology. Accordingly, prior to the PHE, the only audio-only services that CMS covered were communication technology-based services (CTBS) such as virtual check-ins, which are not considered Medicare telehealth services. However, during the PHE, recognizing that in-person visits pose a high risk of infection exposure and that not all providers and patients have access to video technology, CMS established temporary coverage for audio-only telephone evaluation and management (E/M) visits. In the MPFS, CMS is finalizing that at the end of the PHE, coverage for these audio-only telephone E/M visits will end given the statutory language regarding “telecommunications systems,” but CMS will add an additional CTBS virtual check-in code during CY 2021 for longer audio-only visits.

Changes to Remote Physiologic Monitoring Services

CMS finalized as proposed several changes to coverage of remote physiologic monitoring (RPM) services. At the conclusion of the PHE, CMS will once again require that practitioners have an established patient relationship in order to initiate RPM services and that practitioners must collect 16 days of data in each 30-day period in order to bill for those services (during the PHE, CMS is only requiring two days of collection for every 30-day period). CMS also finalized that practitioners may furnish RPM services to beneficiaries with acute conditions—previously coverage had been limited to beneficiaries with chronic conditions. In addition, CMS finalized that consent may be obtained at the time the RPM service is furnished; that auxiliary personnel (including contracted employees) may furnish certain RPM device setup and supply services; that data from the RPM device must be automatically collected and transmitted rather than self-reported; and that for the purposes of discussing RPM results, “interactive communication” includes real-time synchronous, two-way interaction such as video or telephone.

Changes to Enable Direct Supervision by Interactive Telecommunications Technology

Typically, CMS requires that “incident to” services can only be provided under the “direct supervision” of a supervising physician or practitioner. “Incident to” services permit nonphysician practitioners to bill certain services under the physician’s supervision, and “direct supervision” typically means in-person supervision. CMS finalized as proposed a policy to allow, on a temporary basis, virtual supervision using “interactive audio/visual real-time communications technology” (i.e., two-way live video), by revising the definition of “direct supervision” to include virtual presence. This will allow “incident to” services to be provided if furnished under the supervision of a virtually present physician or nonphysician practitioner in order to reduce infection exposure risk. CMS will continue allowing virtual supervision through the later of the end of the calendar year in which the PHE ends or December 31.

This year has been full of unforeseen challenges. The pandemic has forced us to adjust many aspects of our daily lives as we adapt to a new normal. While technology has played a vital role in our push towards safe and effective vaccines and treatments for COVID-19, we have also come face to face with two long-standing issues: the digital divide and federal regulations that have not kept up with the pace of technological advancements.

We know the coronavirus has led to people ignoring other medical symptoms, or not seeking treatment when they previously would have, due to fear of contracting the virus. In May, a poll showed about half of Americans delayed care because of the pandemic. In September, the Centers for Disease Control and Prevention (CDC) found that number was still more than 40 percent. It is heartbreaking to know people are jeopardizing their long-term health, and in some cases even losing their lives, because they are afraid to go to the doctor.

The digital divide has exacerbated this issue, as far too many Americans find themselves unable to access telehealth options. South Carolina has long led on telehealth policy and innovation, hosting one of just two federally-recognized Telehealth Centers of Excellence in the nation at the Medical University of South Carolina. We know how effective telehealth can be, especially for our seniors. But there is clearly more work to be done.

This year, I have worked with my colleagues on both sides of the aisle to introduce a number of proposals to address ongoing broadband challenges right here at home, such as the State Fix Act. If enacted, these bills would be game-changing for the estimated 650,000 South Carolinians who currently lack access to high-speed internet. Unfortunately, even as we continue working to improve home broadband infrastructure, outdated federal laws and regulations continue to constrain patient access to telehealth services, especially for our older and more vulnerable populations.

More than one million South Carolinians are enrolled in Medicare, where extensive restrictions on geographic location, distant and originating sites, provider-type, and services covered limit many seniors’ ability to take advantage of telehealth offerings. I have worked with my colleagues on the Senate Finance Committee to develop and advance the CHRONIC Care Act, substantially expanding access to additional telehealth benefits for most seniors enrolled in Medicare Advantage plans. But Medicare Advantage only serves about a quarter of Medicare beneficiaries, and rigid rules remain in place for traditional Medicare plans. That means 75 percent of those utilizing Medicare in our state, almost 800,000 people in total, are seeing their access to telehealth hindered by outdated and unneeded red tape.

Thankfully, early in the pandemic, Congress passed the CARES Act. One of the things the CARES Act did was create new flexibilities for telehealth coverage and payment under Medicare. However, these flexibilities are temporary. Unless Congress acts to extend some of the core Medicare coverage and reimbursement expansions beyond the end of the pandemic, whenever it may come, hundreds of thousands of seniors in South Carolina will be unable to receive covered care through virtual health technology. Nationally, that number will be in the tens of millions.

For that reason, this month I wrote a letter to Congressional leadership emphasizing how important it is that we permanently expand telehealth coverage. We have a roadmap for this, outlined in the CONNECT for Health Act, which would help to protect our seniors by modernizing Medicare payment policies. I supported this legislation before the pandemic began, and will continue pushing for its enactment as vaccines begin to help us turn the tide on COVID.

Expanding telehealth access will require a multi-pronged approach that both bridges the digital divide and secures sustainable payment and coverage policies across various programs. However, enacting the CONNECT for Health Act would help us put lessons learned from the pandemic into immediate action and improve our health care system for Americans from all walks of life, particularly with regards to our seniors and those living in rural or underserved communities.

I will continue to prioritize legislation that grants South Carolinians – and all Americans – access to telehealth services. It’s not just about learning lessons from this pandemic, but ensuring we are better prepared the next time we face a public health emergency, whenever or whatever that may be.