As any American who’s had to fax a doctor’s office in the 21st century or fill out multiple paper forms with the same information at each appointment knows, the U.S. health care system has long been slow to adopt technologies standard in virtually every other setting. In a small way, the coronavirus pandemic is forcing the medical establishment into the present.
The technology allowing for remote doctor visits isn’t new. Zoom may be the new big thing, but video calling services like Skype have existed for more than a decade, and Alexander Graham Bell was granted the first patent for the telephone in 1876.
But doctors largely haven’t taken advantage of them, due to both monetary concerns and regulatory burdens. In addition, medical training and culture has prioritized face-to-face consults ― the “laying on of hands” that ancient Greek physician Hippocrates spoke of ― no matter what their health issues may be.
Medical providers, health insurance companies and government programs like Medicare and Medicaid have been resistant to the widespread adoption of technology outside of narrow uses. Those include Medicare patients in rural areas with few doctors being able to speak with remote physicians via video conferencing facilities located within medical clinics and employers offering little-used video hotlines with doctors and nurses as part of their health benefit programs for workers.
Then the coronavirus pandemic came and, with it, social distancing and lockdown guidelines that made traveling to a doctor’s office a risk, perhaps even more so than delaying visits, especially for patients whose ages or chronic health conditions make them more susceptible to contracting COVID-19.
“All of a sudden practices have the ‘Oh, crap’ moment and they’re like, ‘Oh, we’ve got to do this. We’ve got to do this over the weekend,’” said Ateev Mehrotra, an associate professor at Harvard Medical School in Boston. “Changes that we think usually would take a decade happened in sometimes a week because doctors and patients were forced to change quickly.”
The volume of patients seeing doctors, and revenues at physician practices, plummeted in March and April, threatening the livelihood of physician practices. Doctors’ offices responded by ramping up utilization of their rarely used video platforms or by quickly beginning to conduct phone or video consultations.
Practically overnight, telemedicine transformed from almost an afterthought to an integral part of medical practices, in some cases briefly representing a majority of patient visits.
A 4,347% Increase
Telemedicine, also called telehealth, has played a key role in keeping those practices in business, especially since Medicare and many ― but not all ― other payers increased pay rates for telemedicine visits to match those for in-person appointments. Voice and video interactions with doctors also have enabled patients to continue receiving at least some of their care during the pandemic, which physicians said has been convenient and beneficial to patient health.
In March, there were 4,347% more insurance claims filed for telemedicine services than there were in March 2019, according to data analyzed by FAIR Health, a nonprofit health care research organization in New York. Although the number of telemedicine visits has fallen since as patients began returning to doctors’ offices, it’s still higher than before the pandemic, according to data Mehrotra and his colleagues collected for the Commonwealth Fund, a New York-based think tank.
Along the way, many physicians learned that they like it, and so do a lot of their patients, despite the obvious limitations of doctors not being able to physically examine patients and the fact that older patients and those with low incomes may not have access to devices capable of videoconferencing or simply may not know how to use it.
“Telemedicine is somewhat of a genie in the bottle that has been released and is not going back. I think you will see more medical practices retrofit their clinical practices to incorporate that,” said Gary LeRoy, a primary care physician at the East Dayton Health Center in Dayton, Ohio, and president of the Leawood, Kansas-based American Academy of Family Physicians. So far, his clinic only offers telephone visits, but is currently testing a new video system, he said.
“You know that it works now. The medical community has embraced this. The patients have expressed that they like this tool that we’ve had in our toolbox but just didn’t use,” LeRoy said.
The policy changes around payments for video and voice appointments are temporary, but physician groups and the telemedicine industry are lobbying the federal government and private insurers to extend the increased fees, and to continue to pay for telephone appointments, which mostly were not covered before.
“We want to make sure that we continue to expand telehealth provisions and telephonic provisions in Medicare, including lifting geographic restrictions so that we can access the most vulnerable populations, and enhance those telephonic reimbursements,” said Halee Fischer-Wright, a medical doctor who is CEO of the Englewood, Colorado-based Medical Group Management Association, an industry group representing physician practices.
Seema Verma, administrator of the federal Centers for Medicare and Medicaid Services, has expressed support for extending her agency’s coronavirus-related telemedicine provisions.
In the for-profit U.S. health care system, it’s no surprise that money was a big reason why telemedicine had been so rarely available. Money will also go a long way to determining whether physicians will stick with telemedicine in the future.
U.S. doctors in private practice typically earn money on a fee-for-service basis, essentially doing piecework and getting paid for every task they perform. Communicating with patients over voice, video and email typically pays much less than seeing them in person, if it pays at all. For example, a doctor rarely gets paid for the time they spend telephoning a patient to deliver test results or discuss a prescription refill.
“It is hard for anybody, I think, let alone physicians, to be asked to do work that they don’t get paid for,” said Joe Kvedar, a practicing dermatologist who is vice president of connected health at the Boston-based medical and insurance company Partners HealthCare. Kvedar also is president of the American Telemedicine Association, an Arlington, Virginia-based trade group representing health care technology companies and medical providers.
Under normal circumstances, medical providers have to pay hundreds or even thousands of dollars a month to use video services that comply with the complex federal patient privacy rules from the Health Insurance Portability and Accountability Act of 1996, known as HIPAA.
Importantly for doctors, federal authorities have also temporarily relaxed enforcement of rules that would ordinarily require health care providers to use specialized video platforms such as MDLive, Doxy.me and Updox that adhere to patient privacy laws. That freed doctors to use consumer products like Zoom, Microsoft’s Skype or Apple’s FaceTime to speak to patients.
That’s unlikely to continue once the coronavirus crisis subsidies, Kvedar said. Although those consumer services may be at least as secure as platforms designed for health care, consumer companies like Microsoft and Apple won’t be interested in dealing with HIPAA rules, he said. Zoom, however, offers a specialized platform for medical providers, called Zoom for Healthcare.
Art Of Medicine
Beyond concerns about added cost, lower payments and adjusting to new technologies, telemedicine also languished because of reluctance from doctors to adapt their clinical practices out of “inertia,” Mehrotra said. “Everyone’s got their patients, they’re kind of doing their thing, everything is hunky-dory, you’re thinking you’re providing good care. Why would you change?” he said.
Having to adjust to change on the fly has opened many doctors’ eyes to the possibilities of telemedicine and led them to question whether it’s really always necessary to lay hands on patients, Kvedar said.
“In the modern era, I think we need to rethink that,” Kvedar said. “This is what I’ve said to my doctor colleagues: What I would ask you to do is think about what information you need to make a diagnosis or a change in care plan, because that’s your job. And if you can do that without touching the patient, then it’s probably acceptable for telehealth.”
Even though physicians told HuffPost they expect to continue offering telemedicine as a complement to their in-person services, the evidence over the past several weeks shows it’s already being used less frequently as doctors’ offices reopen and patients grow less fearful of being in public.
Even as doctors and patients grow in their acceptance of this technology, there are only so many things a physician and a patient can accomplish remotely.
“This is life and death. You can’t do it all over a telephone or on a video monitor,” LeRoy said. “Certain things, you have to actually touch.”
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