An Expert Weighs In: Is Telemedicine Here to Stay After the Pandemic?
“I think we need to recognize the underlying issues with the digital divide and how the government can address those issues in ways that will make [telemedicine] accessible for everyone. I think in addition to saying, ‘Let’s make all of the [regulatory] changes permanent,’ which has come about from Covid, let’s go a step further and really make this a system that can work for everyone.”
Tara Sklar, JD, Professor of Health Law at the University of Arizona
When you think of telemedicine or telehealth, you probably think of Zoom calls with your physician or therapist. But the term has actually been around since the mid-20th century, when radios were used to provide medical advice for patients on ships, and two-way televisions were first used to conduct video consultations.
By the time the 21st century rolled around, the practice still wasn’t being utilized at a very high rate. Despite the fact that video-based telemedicine appointments have been available for years, according to a 2017 study, 82 percent of U.S. consumers still did not use telemedicine.
The lag in adoption comes down to a couple of different factors. Perhaps most prominent is the fact that people are simply unaware that a virtual visit with their medical provider is even an option. According to a consumer study from J.D. Power, 37 percent say they do not know if telemedicine is offered by their health provider or health system.
There’s also the issue of coverage. Patients are apprehensive about the expense of booking a telemedicine appointment with their doctors. Depending on your insurance company, you could be paying much more for your telehealth appointment than you would for a traditional, in-person appointment.
But the situation changed when Covid-19 struck. In March 2020, the Trump administration waived telemedicine requirements for Medicare patients. Previously, Medicare was only allowed to pay clinicians for telehealth services under certain circumstances, for example, if a patient lived in a rural area and didn’t have easy access to care. Since March of 2020, beneficiaries from any geographic location have had access to services from their homes.
Most states also temporarily changed their licensing requirements for doctors, so that a doctor in one state could diagnose a patient in another state.
The Office of Civil Rights has also temporarily allowed the use of apps like FaceTime and Skype to conduct telehealth transactions. And the Drug Enforcement Administration has issued guidance allowing approved providers to prescribe certain controlled substances without first having an in-person visit.
As a result, the overall use of telehealth surged by more than 3,000 percent when comparing October 2020 data to the same month the year prior.
While these measures are temporary, lawmakers are proposing changes to preserve the newfound accessibility that these loosened restrictions have granted.
In January, the Protecting Access to Post-Covid-19 Telehealth Act of 2021 was reintroduced in the House, which would allow patients’ homes to count as “eligible distant sites,” so that recipients of Medicare can continue to receive reimbursements for telemedicine services after the pandemic has passed.
Meet the Expert: Professor & UA Program Director Tara Sklar
Tara Sklar is a professor of health law and the director of the health law & policy program at the University of Arizona. Her research examines the role of laws, regulations, and policies in influencing the health and well-being of older adults.
Professor Sklar holds a master’s in public health law from the University of Texas Health Sciences Center and her J.D. from the University of Houston Law Center. Sklar’s research has appeared in the New England Journal of Medicine, Journal of Empirical Legal Studies, and Jurimetrics, among others.
As an advocate for telehealth, Professor Sklar graciously shared her perspective with MHAOnline. She stated that the recent surge in remote services is long overdue:
“We’ve had this technology for a very long time and it’s been stifled for political reasons, status quo, and inertia,” she said. “But one of the silver linings of Covid is that we finally got to this point where regulations are being relaxed.”
While future legal barriers to telehealth remain unsolved at this point in time, experts agree that even after the pandemic has passed, it’s hard to imagine that the “telehealth genie will go back into its bottle,” according to the Harvard Gazette.
Since telehealth seems like it’s here to stay, we talked to Professor Sklar about the pros and cons of the virtual future of healthcare.
The Advantages of Telemedicine
One of the main advantages of telehealth is the fact that it has kept doctors, patients, and administrative staff safe by reducing unnecessary in-person interaction, which has been a boon during the era of social distancing, but there are more perks that telehealth offers that are worth considering.
Remote Access to Services Saves Time
“For some people, it’s a huge burden to go to the doctor, in terms of the time it takes to get there and the amount of time you wait,” Sklar said.
A study released by Harvard Medical School found that the average total visit time for typical in-person medical visits was 121 minutes (about two hours.) This includes 37 minutes in travel time and 84 minutes in the clinic, only 20 minutes of which were actually spent face-to-face with a doctor.
For working people, going to an in-person doctor’s appointment requires requesting time off. Many people simply can’t afford to lose a day of work to go to the doctor’s office and end up putting their health on the backburner. A telehealth appointment, which takes an average of only 13 to 15 minutes, can be taken during a lunch break.
“This also has a big impact for older adults because it is difficult for them to travel,” Sklar added. “They’re often reliant upon a family member or paid caregiver to take them to appointments. As a result, a lot of appointments are just missed entirely.”
Since the onset of the pandemic, it’s evident that older adults have benefited from this technology. Nearly half of Medicare primary care visits were provided via telehealth in April of 2020, compared with less than 1 percent the preceding February.
Patients Have Access to a Wider Range of Doctors
For every 100,000 rural patients in the U.S., there are only 43 specialists available. To break that down, every specialist is responsible for more than 2,300 patients. Because of this high demand, patients experience long wait times or may end up traveling hours or days to see the correct specialist in person.
But with telemedicine, patients in rural areas can make virtual appointments with specialists great distances away, balancing out supply and demand.
“No matter where he or she lives, they can access so many more opportunities and providers, perhaps providers that are more demographically similar to them,” Sklar said.
This is especially beneficial to minorities, who may have unique needs when it comes to their medical providers.
“Previous generations of people of color or those with LGBTQ+ status never had access to such an array of providers and specialists and different healthcare professionals,” Sklar pointed out.
Studies show that patients who share the same racial or ethnic background as their physician are more likely to have a positive experience in the healthcare system. This is backed by the fact that minority doctors are more likely to take more detailed notes about patients from their own backgrounds.
The Challenges of Telemedicine
While telemedicine can benefit certain demographics, there are some areas where the technology doesn’t measure up to traditional, in-person care.
Physical Examinations Are Limited
The first and most obvious disadvantage of telemedicine is the fact that some medical issues simply cannot be resolved over the phone or video. Patients still need to go to the office for things like diagnoses, imaging tests, blood work, and gynecologic or urologic exams.
However, technology is capable of accomplishing a surprising amount outside of the office. Clinicians can now listen to a patient’s heart and lung sounds, examine their eyes, and evaluate skin lesions or burns through telemedicine platforms, with the help of Internet of Things (IoT) technology.
“Something else being considered as we’re rolling out telehealth is this idea of ‘near home’ sites, where you start with a telehealth visit, but patients are able to get tests performed near their home location,” Sklar said.
For example, when a patient is feeling ill, they could make a virtual appointment with their primary care physician to discuss symptoms and narrow down the possibilities of what their ailment could be, which would be followed up by a trip to a nearby clinic to collect samples for testing, with a subsequent virtual follow-up to consult on care.
Pay Is Lower for Doctors
Another major con of telemedicine is the fact that doctors are not always paid the same amount for telehealth visits as they are for in-person visits.
As of December 2019, only 10 states have payment parity laws that require insurers to pay the same amount of money for a virtual visit as an in-person visit. (The states with true parity are Arkansas, Delaware, Georgia, Hawaii, Kentucky, Minnesota, Missouri, New Mexico, Utah, and Virginia. California is slated to join them next.)
“Without payment parity, a health plan could unilaterally decide to pay network providers for telehealth services at 50 percent of the reimbursement rate that health plan pays the provider for an identical in-person service. This is not a theoretical risk,” a report from Foley and Lardner said.
This disincentivizes providers from offering telehealth services. Unless the disparity is addressed, telemedicine will not reach its full potential.
Services Are Dependent on Access to the Internet
Another downside to telemedicine is that it requires access to the Internet, as well as some kind of device (like a smartphone, laptop, or tablet). Forty-two million Americans don’t have access to an Internet connection, which is about 13 percent of the population—hardly a negligible fraction.
Much of the population of people that do not have Internet access are either older people, racial minorities, or those at an economic disadvantage. Unfortunately, these are the demographics that are most at risk for health problems.
Some communities have taken it upon themselves to address this issue. For example, the Veteran’s Health Administration established a tablet loan program to help veterans with digital access needs. Meanwhile, Washington State has established Wi-Fi hotspots for those that need broadband access.
The Future: A Hybrid Model of Healthcare Services
While there are advantages and disadvantages to telehealth, it would seem that the pros outweigh the cons. According to surveys, more than half of all consumers say they will use telehealth more often after Covid-19 than they did before, and 92 percent of providers said they expect to continue offering video appointments even after it is safe to see patients in person.
Like other traditionally in-person transactions that have seen virtual alternatives emerge, such as online banking and online shopping, there will still be times when consumers will prefer to schedule an in-person visit, but virtual appointments will be more frequently utilized. This offers physicians and patients the best of both worlds.
However, there are still some kinks to work out before we see a true hybrid model of healthcare come to fruition. State medical boards have traditionally restricted physicians from practicing out-of-state, but this is rapidly changing, Sklar says.
While regulations are in place mainly to protect patients, they also hinder one of the biggest benefits of telemedicine: its ability to connect patients with specialists who may live far away.
There is an effort to reduce these interstate barriers that will lead us closer to the future hybrid model. The Interstate Medical Licensure Compact is an agreement between participating U.S. states to work together to significantly streamline the licensing process for physicians who want to practice in multiple states. The Compact currently includes 30 states, the District of Columbia and the Territory of Guam.
“The Compact makes it a bit easier [for physicians] to practice between states, but there’s still a fairly rigorous process to apply, which is a barrier for those willing to do it,” Sklar said. But she thinks that over time, we will see more states join the Compact.
Will this trend toward reducing regulations gloss over the quality of care in its effort to increase access? That question is still yet to be answered.
All things considered, Sklar said, “I think we need to recognize the underlying issues with the digital divide and how the government can address those issues in ways that will make it accessible for everyone. I think in addition to saying, ‘Let’s make all of the [regulatory] changes permanent,’ which has come about from Covid, let’s go a step further and really make this a system that can work for everyone.”