Policies in response to COVID-19 have brought about awe-inspiring growth in telehealth services. However, there are multiple remaining telehealth issues that all levels of government need to be aware of.
In all likelihood, many Americans never considered telehealth an option before COVID-19. But between mid-March and mid-June of 2020, more than 9 million Medicare beneficiaries have used a telehealth service, according to data from the Centers for Medicare and Medicaid Services (CMS).
To put that number in context, only about 13,000 beneficiaries would use telehealth services during a given week before the pandemic.
“One of the first steps CMS took in response to the COVID-19 public health emergency was to temporarily expand the scope of Medicare telehealth to allow Medicare beneficiaries across the country — not just in rural areas — to receive telehealth services from any location, including their homes,” wrote CMS Administrator Seema Verma in Health Affairs. “CMS also added 135 allowable services … [and] ensured that health care providers like physicians were paid for these telehealth services at the same payment rate as they would receive for in-person services.”
Adam Perzynski, an associate professor of medicine and sociology who works for MetroHealth Medical Center in Cleveland, said the telehealth explosion is unlike anything he’s seen in health care.
“I had a conversation just a couple of months ago with a guy who directs telehealth for one of Ohio’s largest telehealth systems,” Perzynski said. “In February, they had done 50 primary care telehealth appointments. By the end of April, they were doing 5,000 a week.”
Kim Almkuist, a family nurse practitioner in Wilson County Medical Center in North Carolina, treats teachers and kids at two school-based health centers. Because she can’t be at both centers during a given day, she began utilizing telehealth about two years ago.
“It’s a lot more efficient than in office,” Almkuist said. “It takes less time. I can see five or six patients in the amount of time that I can see four in the office.”
Almkuist works in a “very rural county,” where residents may have to drive 20 to 30 miles to get to a hospital and potentially wait hours to find out whether they’re sick. As such, telehealth has been a boon to such citizens — not to mention how much it has helped Almkuist, who once had to take off work to drive 45 miles to take her daughter to specialized therapy.
“I don’t have to take off of work to drive her there,” Almkuist said. “Then I think about the populations who can’t take off of work or drive.”
Before COVID-19, telehealth service had to be done through authorized audiovisual technology to avoid Heath Insurance Portability and Accountability Act (HIPAA) violations, but after the infection crisis started, the U.S. Department of Health and Human Services said it would waive HIPAA penalties if telehealth was delivered through non-public applications such as Facebook Messenger and Zoom.
In other words, care providers are now able to see more of their patients through everyday technology, and vice versa. Almkuist hopes that future policy, particularly in regard to reimbursement, doesn’t make telehealth an impossibility for certain patients.
“The patients are not going to be happy … if we don’t offer telehealth after COVID,” she said.
Moreover, a recent Arizona Daily Star article identified a fear among residents in Tucson, Ariz., that medical insurance organizations might decide to stop covering video and telephone visits.
“Reimbursement drives everything, sadly,” Almkuist observed.
Even with today’s expanded possibilities for telehealth, not every citizen has the technology to take advantage of telehealth service.
“There’s an assumption among the medical community that everyone has a device,” said Angela Siefer, executive director of the National Digital Inclusion Alliance.
Siefer pointed out that even someone has access to a device and a suitable application, that doesn’t mean they have the digital skills to take advantage of the telehealth option. Siefer believes it’s the responsibility of everyone — including educators, the health-care system and state local government — to be aware that people may not know how to properly use tech.
“With digital literacy, the work is never done,” she said. “You know why? Technology keeps changing. Even if you’re telling seniors how to use Facebook and a telehealth app, those will things will change.”
Another issue is Internet access and quality. Almkuist said although cellphones with data plans allow some of her rural patients to receive telehealth service, the imagery is less clear, and there will be lags.
In some cases, families without Internet at home may not be able to get broadband service due to COVID-19.
“The workarounds don’t work anymore,” Siefer said. “The workarounds were going to the public library, going to businesses like McDonald’s … There were ways to get Internet before, but now they’re dangerous because you’re exposing yourself [to potential infection].”
A lack of high-speed Internet in some communities, whether due to cost or poor infrastructure, means that many of MetroHealth Medical Center’s patients are forced to receive health service via telephone.
“The only reason we rolled out a phone system is we have tens of thousands of residents who don’t have Internet access in Cleveland,” Perzynski explained.
Perzynski has been doing research on telephone visits. While he has found that such visits can be effective if “they’re treating [a] person who has symptoms or fear of COVID-19,” there are other cases where using a phone may not work as well.
“A picture’s worth a thousand words, maybe more so when a doctor’s looking at a wound,” he said.
While broadband is a significant issue in rural areas where the infrastructure is simply not where it needs to be, both Siefer and Perzynski believe that urban areas have gotten the short end of the stick when it comes to broadband policy and funding.
Perzynski said some urban citizens only have access to a measly download speed of 768 kilobits per second.
“What is the plan for these urban communities that haven’t really received investments to upgrade [speed] levels … On that policy end, we’re way down,” he said. “That would be about the worst grade that you could give.”
Siefer said the whole broadband discussion has favored rural over urban for years.
“I do think it has a lot to do with those who are making decisions,” she said. “It’s totally unintentional. It’s that unintentional bias. We just think people are like us. ‘We have Internet at home. Don’t they?’ That kind of assumption.”
Regardless of whether someone lives in a rural or urban area, not all telehealth sessions are created equal. Almkruist’s organization only provides telehealth service to existing patients in order to ensure quality care. Almkruist said there’s a phenomenon that she calls “doc in a box” telehealth where a $100 visit may last less than a minute and leave the patient feeling utterly dissatisfied.
“That’s an area that we have to be careful with,” she said.
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