The COVID-19 pandemic rages on.
As cases in the United States skyrocket, one of the most foreboding possibilities of COVID-19’s rapid growth is the potential to overwhelm hospital capacity. Hospitals in cities like New York are already underwater, relying on hospital boats (“70,000 ton message[s] of hope and solidarity”) to keep them afloat, and on retired providers as well as prematurely graduated medical students to staff those beds.
In tandem, telehealth has rapidly evolved from a “nice to have” to a “need to have” for U.S. health systems.
Telehealth: from hype to hope to here, overnight
This timing is prescient, as the technologies for telehealth have existed for several decades (at varying levels of sophistication) with modest uptake to-date. From 2005 to 2017, only one out of every 150 doctor visits and one in every 5,000-10,000 specialist visits were conducted via telemedicine.
A major catalyst to uptake was the federal government’s announcement two weeks ago that restrictions on the use of telehealth for Medicare would be temporarily lifted. That policy change included expanding coverage across specialties and settings; waiving co-payments; and loosening HIPAA privacy requirements (such as prohibiting ubiquitous teleconferencing technologies like Apple’s FaceTime).
Accordingly, telehealth—overnight(ish)—is finally mainstream.
At America’s largest health systems, adoption of telehealth has accelerated rapidly: at Massachusetts General Hospital, the weekly number of virtual appointments has multiplied 10-20 times in the past weeks, while at NYU Langone Health, staffing was increased fivefold to handle the rush of new appointments. Teladoc, the U.S.’s largest virtual-care provider, is now reporting over 100,000 appointments weekly.
The diversification of telehealth use cases
The proliferation of telehealth via pioneering health systems has spawned unique use cases rarely seen before in the landscape of U.S. healthcare.
These use cases cut across numerous settings: emergent care, intensive care, triage, and monitoring, to name a few. Outside the hospital setting, domestic initiatives such as Houston’s Project Emergency Telehealth and Navigation (ETHAN) has provided a precedent for the use of telemedicine by paramedics and EMTs in first-response. These sorts of programs have actively been pioneered by startups such as RapidSOS in response to COVID-19.
At the gateway to the hospital (the emergency room), building on work by Jefferson Hospital in Philadelphia, health systems including Kaiser Permanente, Intermountain Health, and Providence Health have adopted programs for tele-intake to minimize contact between providers and patients under investigation (PUIs) for COVID-19.
Upon admission to the hospital, telehealth is being used for monitoring patient status while also ensuring the safety of health providers. Such technologies are proving exceptionally important given wide-scale shortages of personal protective equipment (PPE).
At Washington State’s Providence Regional Medical Center Everett (the site of the first COVID-19 case in America), programs for telemonitoring of ICU patients were built from the ground up in six weeks. Startups like EarlySense are combining multimodal sensors with audiovisual capabilities to enable remote detection and evaluation of clinical deterioration on non-intensive wards.
Following discharge from the emergency room or the inpatient units of the hospital, telescreening tools like TytoCare are enabling physicians to conduct exams and deliver care remotely that previously would have required in-person contact. In the case of discharge from the emergency room—given the volatile clinical course of COVID-19—methods for streamlined and regular check-ins are critical to monitor symptoms and guide the need for more intensive treatment.
Likewise, given recovery from the disease can potentially be tumultuous (especially after ICU care), these technologies are essential for mitigating what has been deemed the “post-hospital syndrome” and ensuring long-term health after discharge from inpatient care.
Here — but there, or everywhere?
While the near-overnight expansion of telehealth in diverse forms is positive news, barriers remain to its widespread dissemination in this country. To move from the prototyping stage at the meccas of modern medicine to a widely useful tool across healthcare settings, telehealth must seek to solve what has been deemed the “last mile problem.”
The last mile refers to the non-technological, practical elements of local care delivery. As with telehealth, when these practical elements of care delivery are inadequately addressed, they inhibit providers from implementing new technologies for patients. In the case of telehealth, the last mile can be grouped into four domains: those related to (a) coverage and reimbursement (b) legal concerns (c) clinical care and (d) social challenges. The federal government’s policy change this month took major steps forward to resolve some legal concerns, including limitation of tort liability and allowing common teleconferencing platforms that may not be strictly HIPAA compliant.
However, considerable obstacles to the uptake of telehealth persist across the other three domains, especially for the 86.5% of Americans not on Medicare. To effectively combat COVID-19, telehealth must also reach these 281 million individuals in the under-resourced nooks and crannies of the U.S. As the virus becomes more pervasive across the country, rural health systems are depending heavily on these technologies to manage the imminent surge of cases.
The essentials to expanding telehealth
In terms of coverage for patients, only 36 states mandated coverage of telehealth services in insurance plans as of April 2019. For those with mandatory coverage, out-of-pocket copays typically ranged $50-80 per appointment. Alternatively, certain plans waived copays, but only following an annual fee for premium services—premiums which may well rise going forward.
All of these costs will hinder the use of telehealth in non-Medicare patients amidst the present outbreak.
While in the past two weeks, some private insurers such as United Healthcare (covering 45 million Americans), Humana (39 million), and Aetna (13 million) waived copays on telehealth services, the privates covering the remaining hundreds of millions of Americans must follow quickly. States can help accelerate this by following the lead of Massachusetts, which last month required all insurers to cover telehealth.
In terms of reimbursement to providers, only 20% of states required payment parity for telehealth to ensure—if telehealth was covered at all—it is remunerated at rates approximating in-person visits for similar diagnoses. This disparity has made adoption of telehealth undesirable and/or untenable for health systems, since the reimbursement rates for telehealth average 20-50% lower than for comparable in-person service.
The challenges to adoption of telehealth are further heightened for independent practices, who must pay subscription fees to use standard telehealth platforms, but simultaneously experience revenue decreases of some 30% upon integrating telehealth. To make adoption of telehealth financially feasible for health systems and individual practices amidst the COVID-19 outbreak, states once again should follow Massachusetts in seizing the opportunity to enforce payment parity by private insurers.
Finally, in terms of clinical care, issues abound in the minutia of how and where telehealth can be performed. In terms of how telehealth is performed: while these services should integrate with the existing workflows of clinical practice, insurance rules currently hinder this. For example, e-visits and check-ups are only permitted for “existing” patients rather than for new patients presenting with mild symptoms or fleeting concerns, who may not require a full work-up (this is the case even under the recent CMS policy).
Moreover, asynchronous methods such as “store-and-forward” consultations and remote patient monitoring—exactly the sort of efficient and highly-scalable pathways integral to the flexible provision of care to the dispersed masses—are restricted in most states.
Additionally, where telehealth can be conducted is hamstrung by “origination site” policies banning these services in patient homes but for a select few conditions (such as stroke assessment and opiate rehabilitation). Such arbitrary, excessive regulations make the widespread utilization of telehealth unrealistic. Also, state-by-state licensing requirements prevent physicians from providing care across borders (for reasons rooted in nineteenth-century concerns of medical quality gaps between states).
To promote the care of COVID-19 patients in epicenter regions, states should follow the lead of New York and Florida to suspend out-of-state licensing bans, allow license transferability, or at least expedite licensing through “licensure compacts” in allied states.
Finally, in terms of social challenges, considerable access disparities exist between demographic groups. For example, according to the National Telecommunications and Information Administration’s 2018 survey, vulnerable populations such as the elderly were 21% less likely to have internet access and almost 50% less likely to conduct videocalls; the poor were 34% less likely to communicate with doctors online; and other demographic minorities (such as Hispanic ethnicity or lower educational attainment) were also less likely to have access to and/or use telehealth technologies.
Since these populations are more likely to face the sorts of comorbid conditions and social determinants of health that heighten mortality from COVID-19—and less likely to have levels of health literacy allowing them to reduce their risk of transmitting infectious diseases like coronavirus—inequalities in telehealth access bear important implications on the country’s ability to flatten the curve of COVID-19.
One of the single best interventions to augment access for these individuals is expanding the scope of practice of non-physician health providers. These providers have their wings clipped by arcane laws fiercely defended by state medical associations that require their “supervision” by physicians for most cases of patient care. This is despite analyses since the 1980s exhibiting the capability for non-physician healthcare providers (such as nurse practitioners and physician assistants) to provide services as high quality as those of physicians.
Liberating various allied health practitioners (including also registered nurses, pharmacists, dentists, paramedics, and social workers) to screen, diagnose, treat, and prescribe with increased autonomy would undergird telehealth’s capabilities as a “force multiplier” in the setting of COVID-19. They can also unleash the potential of startups such as The MAVEN Project which provide platforms for peer-to-peer consults between specialty and generalist health providers in emergency settings.
In geographically dispersed states such as California—where allied health providers are expected to provide half of all primary care appointments by 2030—these policies are especially vital. Bills designed to facilitate these programs like the California Assembly Bill 890 that remains stalled should be endorsed to protect patients across the state from the insidious diffusion of COVID-19.
In summary, the early responses by federal and state agencies to COVID-19 have made progress to promote the uptake of telehealth. However, as the virus expands its siege across the country, more comprehensive solutions are urgently needed to equip the creators, users, and beneficiaries of telehealth with the arsenal they desperately require to vanquish this invisible enemy. Accordingly, pen-and-paper may be the most important technologies for bolstering telehealth today. Letters to senators, in the near-term, may be the most potent ammunition we’ve got.