Telemedicine: What’s Ahead in 2022?

How will it affect procedures performed and products used by clinicians?

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March 2022 – The Journal of Healthcare Contracting

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Telemedicine soared in 2020 due to the pandemic. Usage has plateaued since then, but it’s a safe bet it’s not going away. And with it comes questions. What role will it play in urgent care and chronic care management? Will it lead to fewer in-person visits, or more? Will it change the type – and number – of procedures performed in the clinic? How about the type – and volume – of medical supplies, devices and equipment used there?

“We don’t pretend to read all the tea leaves; but we believe the right ecosystem is a hybrid model,” that is, a combination of face-to-face and virtual visits, says David Houghton, M.D., MPH, chief of the Division of Movement Disorders at Ochsner Health in New Orleans and head of the health system’s telemedicine and digital health initiatives. “That means providing the level of care that is appropriate every time and providing patients with accessible and available technology that complements the important patient-provider relationship.”

Video or audio telemedicine can offer access to a clinician for patients who lack transportation or who can’t take time off from work, according to researchers from Kaiser Permanente Division of Research, Oakland, California. “Still, it is unclear whether telemedicine visits adequately address the patient’s clinical concern, are more likely to require subsequent follow-up outpatient care, or are more likely to be followed by a serious health event that requires an emergency department visit or hospital stay,” they wrote.

Legislative and regulatory boost 

Regulatory and legislative adjustments in response to the pandemic boosted telemedicine in early 2020. The Centers for Medicare & Medicaid Services used emergency waiver authorities to expand access to telehealth services, including waiving geographic restrictions and allowing beneficiaries to receive telehealth in their homes. Additionally, the HHS Office for Civil Rights relaxed enforcement of Health Insurance Portability and Accountability Act (HIPAA) privacy requirements for videoconferencing.

Physicians enrolled in the Medicare program licensed in any state were granted the authority to provide telehealth services to people anywhere in the U.S. if the state allows it. The waivers also allowed physicians to practice from home. What’s more, CMS’ Interim Final Rule allowed for payment for audio-only evaluation and management (E&M) services. In November 2021, CMS announced it would continue to reimburse providers for extended Medicare telehealth services through Dec. 31, 2023.  

These regulatory changes brought about desired results. The Department of Health and Human Services reported that The share of Medicare visits conducted through telehealth in 2020 increased 63-fold, from approximately 840,000 in 2019 to 52.7 million. And in July 2021, McKinsey & Company released a report showing that telehealth utilization had stabilized at levels 38X higher than before the pandemic.

American Medical Association 2020 survey data demonstrates a dramatic upswing in the use of telehealth between 2018 and 2020:

• In 2020, 79% of physicians worked in a practice that used telehealth compared to only 25.1% in 2018.
• The percentage of physicians who used telehealth to manage patients with chronic disease or to diagnose or treat patients also increased (9.9% to 59.2% and 15.6% to 58%, respectively).
• Twenty percent of physicians said their practice used remote patient monitoring, up from 10.4% in 2018.
• Sixty-seven percent of physicians worked in a practice that used phone call visits with patients in 2020.
• Fifty percent of physicians were in a practice that used telehealth to provide care to patients with acute disease and 34.3% to provide preventative care.

All that said, a plateauing of usage has occurred. In September 2021, FAIR Health reported that telehealth utilization, measured as a percentage of all medical claim lines, fell from 5% to 4.5% nationally from May to June 2021. By comparison, telehealth utilization rose 2% nationally the previous month, following decreases each month from February to April.

Other changes from May to June 2021 involved the top five telehealth diagnoses:

• Joint/soft tissue diseases and issues rose from No. 4 to No. 3.
• Acute respiratory diseases and infections rose nationally from No. 3 in May to No. 2 in June.
• Urinary tract infections appeared in fifth place among telehealth diagnoses in the South in June 2021. This was the first time since the start of the pandemic in March 2020 that this diagnosis appeared on any regional or national list, although it had been common on the lists prior to the pandemic.
• Mental health conditions remained in the No. 1 spot among telehealth diagnoses.

An uptake among clinicians

“Clearly telehealth has been embraced by physicians of many specialties and their patients,” says Christopher Garofalo, M.D., owner of Family Medicine Associates in South Attleboro, Massachusetts, and chair of the Massachusetts Medical Society Committee on Sustainability of Private Practice. “We saw a large increase in the use of telehealth visits in our private family medicine practice, using the visits for both acute and follow-up care.” (In March 2020, the Massachusetts Medical Society co-founded The Telehealth Initiative, designed to support physicians implementing telehealth. Other co-founders were the American Medical Association, Florida Medical Association, Texas Medical Association and the Physicians Foundation.)

“At the start of the pandemic we used telehealth to provide some Medicare Annual Wellness Visits, as the physical exam is quite limited, and even for some annual checkups for adults and well-child checks,” says Garofalo. In 2021 the number of telehealth visits decreased to around 10% to 15% of all visits and were conducted only for acute and follow-up care. Even so, he predicts that telehealth visits “will be overall higher than prior to the pandemic, but not as high as we saw early on in the pandemic.”

Garofalo saw a greater uptake of telehealth among his primary care colleagues than among subspecialists. “That’s to be expected, as primary care has a smaller number of visits that are procedures,” he says. Even so, he saw office notes from most of his subspecialists, especially, early in the pandemic, as most elective procedures were on hold. Certain subspecialists, such as GI and neurology, had more telehealth visits than more “hands-on” specialists, such as those in dermatology and orthopedics.

“One of the great advantages of telehealth is that it often brings us directly into the home environment of the patient and their family,” says Garofalo. “We can ask them to get their medicine bottles and look at them, rather than relying on hand-written notes. We can ask them to move the phone or the laptop camera to give us a view of their environment, which can help inform us if there a lot of clutter or poor lighting that may increase their fall risk. We can take a virtual look into their kitchen cabinets and refrigerator to help assess dietary habits.”

“One of the great advantages of telehealth is that it often brings us directly into the home environment of the patient and their family.”

Impact on in-office visits

Ochsner Health’s Houghton has found that telehealth – including remote monitoring – has improved the quality of in-person primary care visits. “I know the work done by the digital medicine team has taken care of the patient’s most pressing conditions, so I can focus on the immediate reason for the visit, whether it’s back pain, an orthopedic issue or a behavioral health issue. I can focus on the patient-doctor relationship, because I know that the other work is being done continually.” And it’s being done better, he adds. “Because of digital medicine, we don’t just work with a handful of blood glucose readings; now we have dozens. We have 30 or 40 times the amount of data and we can manage the patient not only reactively, but proactively.”

“I know the work done by the digital medicine team has taken care of the patient’s most pressing conditions, so I can focus on the immediate reason for the visit…”

Telemedicine may lead to fewer diagnostic procedures in the office. Kaiser Permanente researchers reported in November 2021 that laboratory tests or imaging were ordered in 59.3% of office visits, compared with 29.2% of video visits and 27.3% of telephone visits. Medication was prescribed more often in the clinic – 60% of visits compared with 38.6% by video and 34.7% by telephone. The differences could be due to patients choosing to see their doctor in person when the severity of their medical complaints was higher, they said.

Regarding other diagnostic tools, such as EKGs, stress tests or pulmonary function tests, “I haven’t seen these types of diagnostics move out of the office setting,” says Garofalo. “Some test results, such as PFTs, are much improved by having office staff educate and coach the patient. I also am not sure that EKGs will be replaced in the traditional sense. While a single-lead EKG reading on a remote device can be helpful for very basic monitoring of certain conditions such as atrial fibrillation, patients with acute cardiopulmonary symptoms will still require a 12-lead EKG in the office to help triage and determine best medical management.”

Kinks

Telemedicine is an evolving science, with kinks to straighten out. A survey-based study published in December 2021 showed mixed feelings about telehealth visits on the part of older patients with chronic kidney disease as well as their care partners and clinicians. Patients reported concerns that their home diagnostic equipment was not as accurate as professional equipment at the clinician’s site, and they complained of a loss of social connection with their clinician.

Meanwhile, clinicians in the survey viewed telehealth as compromising quality care due to an inability to conduct physical examinations and laboratory tests, including inaccurate edema and blood pressure measurement. They also reported poorer telehealth experiences with older patients, those from low socioeconomic status, patients with limited health literacy or a hearing impairment, and non-English-speaking patients.

Both clinicians and patients in the survey noted technical challenges too, such as spotty internet connectivity and application issues. However, all described telehealth as more convenient, less costly, and more efficient for patients than clinic visits. “Our findings … suggest that telehealth may best supplement rather than supplant in-person visits for patients who are older and chronically ill,” said the study’s authors.

One of the pre-pandemic limitations that hampered the use of telehealth was lack of reimbursement from payers, including Medicare and Medicaid, says Dr. Garofalo. “For telehealth to remain a successful option for physicians and patients, it is imperative that a telehealth visit be reimbursed at parity and in the same manner as an in-office visit.”

“For telehealth to remain a successful option for physicians and patients, it is imperative that a telehealth visit be reimbursed at parity and in the same manner as an in-office visit.”

When asked what impact virtual care might have on point-of-care testing, lab expert Jim Poggi of Tested Insights LLC says, “I think it depends on whether the physician practice is offering the virtual visit or whether the patient is using one of the many ‘pop-up’ online services. Will telehealth and virtual visits change where patients receive future care? Probably to some extent. They are a new gateway to healthcare, for sure. I have concerns about whether they impede progress on antibiotic stewardship and how broadly telehealth visits are used.”

More than 23,000 patients have voluntarily opted to use Ochsner Health’s telemedicine and virtual medicine initiatives. Participation is voluntary on the part of physicians too. Rather than making them mandatory, Dr. Houghton and the Ochsner team intend to continue encouraging participation by presenting ongoing proof that the programs work. High HEDIS scores for telehealth visits are testament to their effectiveness and patients’ experience of care. “When physicians see this, they ask, ‘Why wouldn’t I want my HEDIS scores to be better?’”

Among Ochsner’s patients, satisfaction with telemedicine is high, as reflected in net promoter scores, which measure the loyalty of customers (patients) to an organization. “Some of the early euphoria around telemedicine has waned, as both patients and providers became more experienced and critical,” says Houghton. “But our scores have remained high, even among our most vulnerable patients, including those who are economically disadvantaged and those with comorbidities. The fact that the programs offer a lot of touches has been the driver,” he says. “We will never have to make participation a requirement.”