Some will say 2020 was the year that everything changed, but in reality, it will be 2021 that determines our new healthcare reality. Virtual care advanced quickly—and under duress—last year. How will we learn from the seismic shifts in care delivery we experienced thanks to COVID-19? How can we help providers and innovators embrace the transformation? How will we solidify these gains?
Dad’s Story: Telemedicine Pioneer
We think of telemedicine as a relatively recent invention—only made possible by the internet and smart phones—but I had my first taste of it 60 years ago. As a physician who was trained in the importance of placing your hands on a patient to diagnose and heal—I have become an ardent advocate for telemedicine after decades of seeing it improve care.
My earliest experience was with my own physician-father. When I was a young boy about 8 or 9 years old, the telephone would ring in my parent’s bedroom in the middle of the night three to four times a week. Dad was trained in what was then still the young specialty of cardiology. As one of our region’s few cardiologists, providers in rural Tennessee relied on his expertise. Each time the phone would ring, Dad would calmly speak with a nurse or a doctor, and after learning the patient’s symptoms, would place the receiver on a clunky, antiquated device on his bedside table that would read out the little blips of an EKG machine on a continuous strip of paper. Dad would look at that EKG to make a diagnosis and instruct a course of treatment. He was on the pioneering front of using telemedicine, using remote technology and monitoring, to connect to patients all over the middle third of the state.
Years later in the 1980s, I relied on telemedicine in my own practice as a heart transplant surgeon to manage the chronic immunosuppressive care of my heart recipients all over the country for months after their transplants. And as the only doctor in the Senate in the 1990s, I spearheaded major investments in programs establishing expensive T1 lines to Native Americans on reservations which allowed us to provide real-time telehealth to vulnerable populations in remote areas.
Today, as a partner and board member, I am heavily involved with Teladoc Health, Livongo, and a virtual dental care company, Smile Direct Club. In my 60-year journey with telemedicine, I have never been more optimistic about our future as I am today.
We are at an inflection point. The sheer scaling of telehealth services that took place across the country over the course of the pandemic has been astounding. The explosion of virtual care is the single most transformative—and most constructive—advancement to emerge from the COVID-19 crisis.
Providers and health systems have tirelessly stepped up to the challenge of adopting and proactively engaging patients in virtual care:
- Pittsburgh’s UPMC saw video visits, which were averaging 20-30 a day pre-pandemic, grow to 6,000 a day at the pandemic’s height.
- Kaiser Permanente—which already had a relatively large telehealth presence with about 15% of scheduled outpatient visits conducted virtually—saw that figure skyrocket to 80% in the early spring.
- The Centers for Medicare and Medicaid Services (CMS) shared that between mid-March and mid-October over 24.5 million out of 63 million Medicare enrollees—more than a third—received a telemedicine service.
- And we at Teladoc Health have seen utilization stabilizing at a level 40% higher than before COVID.
Now, providers are planning and financially budgeting for a larger percentage of virtual care, an estimated 10 – 30% of total patient visits post-COVID.
This is a seismic shift in the culture of telehealth. The culture of doubt, of fears around privacy, of inadequate reimbursement, of the unknown, was replaced by a culture of confidence and trust, a culture which values convenience, affordability, and rapid access to quality care. All this in the safe environment of home, eliminating the risk of COVID spread.
With this change, providers are increasingly comfortable conducting virtual visits and are seeing the benefits. A recent American Medical Association survey of nearly 1,600 physicians and other health professionals found that 60% reported that telehealth has improved the health of their patients and 80% indicated it had improved the timeliness of care.
Similarly, Americans are increasingly at ease with virtual visits, with one recent HIMSS survey showing 77% of consumers willing to use some form of telehealth post-COVID, and 41% preferring it.
This cultural acceptance is already greatly enhancing mental and behavioral health access, substantially improving patient convenience and experience, increasing patient adherence, and expanding reach to regions with provider shortages.
How, then, do we preserve and expand the gains made when this public health emergency comes to an end?
How Policy Has Shaped and Will Continue to Shape Virtual Care
We must recognize that the rapid progress was made possible by emergency regulatory measures that speeded access and reimbursement for telehealth services, making physician adoption feasible, and removing traditional bottlenecks in administrative decision-making.
Medicare offered payment parity and waived geographic restrictions. Medicaid expanded coverage, including coverage of audio-only care.
CMS added 144 additional services that could be furnished via telehealth and relaxed physician interstate licensure, waiving Medicare and Medicaid’s requirements that practitioners be licensed in the state where they are providing services. And HIPAA data privacy rules were relaxed, allowing providers to use non-HIPAA compliant telehealth platforms, like FaceTime and Skype.
Importantly, private insurers followed the federal government’s lead, waiving cost-sharing and expanding telemedicine programs.
The Centers for Medicare and Medicaid Services, the Administration, and the private sector should be commended for responding so quickly and so comprehensively to meet the rapidly changing needs of our healthcare communities during the pandemic.
But now we must make these gains permanent.
Many of my former Congressional colleagues—Democrat and Republican—are in favor of doing just that. Some needed policies were included in the year-end spending and COVID-19 relief package. Funding was increased for the Federal Communications Commission’s telehealth work and expansion of broadband, and Medicare expanded coverage for telemental health services.
But I agree with American Telemedicine Association President Ann Mond Johnson: “The noticeable lack of permanent reform or a guaranteed extension of the telehealth flexibilities in this relief package is disheartening for the millions of Americans who relied on telehealth to access care, and our healthcare providers still on the frontlines of the pandemic. We believe arbitrary restrictions on telehealth must be permanently removed to make way for a modernized and more accessible healthcare system.”
I served 9 months in an equally split, 50 to 50, Senate. With a razor-thin Democratic majority in the Senate that is subject to filibuster, I’m frequently asked where we might see bipartisan agreement in health policy in 2021. Telehealth is unquestionably at the top of that list.
To continue this progress, we need to permanently allow telehealth access regardless of patient and provider location and codify the broader range of practitioners including physical therapists, occupational therapists, and speech language pathologists to provide Medicare telehealth services. Congress should also address cross-state licensing barriers, though this will be a more challenging area to navigate.
Federally Qualified Health Centers and Rural Health Clinics—community-based health care providers that support underserved populations—should be authorized to continue to offer telehealth after COVID and reimburse all forms of communication equally if providers can meet the same standards of care.
While the Administration has done a good job, there is a risk that broad telehealth deployment—if not carefully designed—could replicate the barriers of the traditional bricks and mortar health system that produce disparities.
One glaring example is a bias in some of the new authorizations for two-way video communications. If we discriminate against telephone (without video) users, for example, we will leave behind rural communities without access to broadband, as well as minority and other lower-income populations that may not have more expensive smart phones with two-way video capabilities.
Finally, while I believe most regulatory changes made to advance telehealth and virtual care during these extraordinary times should be made permanent, parity in payment is one that should be revisited following the crisis. Undoubtedly, payment parity was necessary to motivate physician participation. But since many overhead costs are eliminated in virtual transactions and thus result in overall cost savings, these savings should flow to the patient as well as the provider.
To reiterate, we are at an inflection point. And inflections bring new challenges, and inflections demand changed perspectives—changed understanding, and changed behaviors on our parts. We have the opportunity to embrace these changes and unleash an exciting new frontier of virtual care, with the public sector reimagining regulatory guidelines to allow private sector innovation to rise to meet patient demand and improve care for all.
This op-ed is based on remarks I delivered on January 12, 2021 at the American Telemedicine Association EDGE Policy Conference. A video of the full remarks is available online.