The Future of Telehealth: A Less Rosy Outlook

The future of telehealth is too uncertain.

It is clearly too early to speculate about life after the COVID-19 pandemic. But one question that many are seeking to answer is this: what is the future of telehealth, once the public health emergency has ended? While Seema Verma, the Centers for Medicare & Medicaid Services (CMS) administrator, previously noted in the Wall Street Journal that “the genie is out of the bottle,” what telehealth looks like post-COVID-19 is far from certain.

Privacy
The immediate widespread adoption of telehealth would not have happened without the decision by the Office for Civil Rights (OCR) to use enforcement discretion to allow the use of non-HIPAA-compliant communication technologies such as FaceTime and Skype. This permitted providers to immediately start conducting visits with patients. Once OCR has determined that the HIPAA privacy requirements must again be met, providers that choose to continue telehealth visits must adopt a compliant solution. Furthermore, the complexity for the patient will be increased. They may have to log on to a patient portal (where is that post-it note with the username and password?) and navigate to the correct screen. For the patient already challenged by FaceTime, the prospect of adding several steps to the process is not appealing.

Cost
With HIPAA compliance come increased complexity, and possibly, increased cost. Nothing in life is free. As we are all aware, Apple’s FaceTime, Google’s Hangouts, and other “free” means of communication collect demographic information from a user’s account, although not directly from the encounter, that can be used by these tech giants for other income-producing activities. Many electronic health record (EHR) systems have telehealth capacity, but there may be additional costs. There are some no- or low-cost standalone solutions, but there may be limited capacities – or other “catches,” such as advertising or use of deidentified patient data for other purposes. Some may even recall that one major EHR vendor paid a $145 million fine for reportedly embedding alerts to increase physician prescribing of a certain medication. If a provider that has been providing telehealth visits without any additional overhead cost now has to pay for that service, they may think twice about it.

Reimbursement
With little other choice, CMS is allowing providers to bill telehealth visits with the standard visit codes based on the usual place of service, and will reimburse these telehealth visits at the same rate as in-person visits. This provides payment parity for independent physicians who bill their office visits with place of service (POS) 11, but for employed physicians who bill with POS 19 or 22, the telehealth payment is only for the professional fee – a rate that is significantly lower than that of POS 11. In addition, there is no payment for the facility fee that usually accompanies an office visit by the employed physician, which increases revenue to the employer significantly. While independent physicians could continue with no change in revenue, it is unlikely that health systems employing physicians will be able to continue providing telehealth visits without some provision for facility costs. It is also unlikely that CMS would continue to reimburse these visits at the same rate as an in-person office visit. The codes approved for telehealth visits prior to the COVID-19 pandemic had significantly lower relative value units (RVUs), with payment rates in the $15-25 range. This is a far cry from the office visit payments of $75-150. CMS would have to adopt new codes or adjust based on modifiers and develop new payment rates. With that, providers will need to determine if the new rates are sustainable.

Regulation
While the declaration of a public health emergency allowed CMS to issue emergency waivers for many regulations, once the waivers expire, things will go back to standard operating procedures. And that means that any substantive change will have to go through the formal rulemaking process, with drafting by CMS staff, review by the Office of Management and Budget, publication as a proposed rule, a mandated comment period, and then a second review and finally publication of a final rule, with an effective date at least 60 days later. Since the 2021 fiscal-year and calendar-year rules are already in process, it may not be until 2022 that broad new uses of telehealth would be formally allowed. This also assumes that sufficient statutory authority would support significant updates. By that point, most physicians will be back to doing things the “good old-fashioned way” and may resist another change to a process they have once again grown comfortable using.

Quality
Many people have chosen to make use of food-shopping services during the pandemic, ordering online and having groceries delivered to their home or unloaded curbside. But it is not until they unload the groceries that they realize that some of the tomatoes are bruised and the apples are not the size they prefer. The same thing occurs in medical care. Patients who say they are breathing fine are found to be hypoxic and tachypneic. That little bit of swelling of the legs can actually be significant edema with overlying cellulitis. The easily obtained EKG can demonstrate a new cardiac arrhythmia as a sign of worsening heart disease. No one ever admits their true weight. Much can be learned about a patient by seeing them walk into the exam room, interact with the staff, and observing them rising up from a chair and stepping up to the exam table. There are also exam elements that cannot be gleaned remotely, such as loss of sensation from neuropathy. Converting many visits to telehealth may result in delayed presentations of diseases that would have been identified if an in-person visit was conducted. Discussions about advance directives and difficult conversations about new diagnoses are best done in person.

Socialization
While certainly not a medically necessary reason for a visit to a physician, for many of my patients, the trip to the doctor was a highlight for them. As people age, retire, and start to lose friends and loved ones, they see their doctor visit as a chance to get dressed in nice clothes, get out of the house, and spend time among others. My patients shared pictures of grandchildren, brought their favorite recipes for my wife to try, and when we were lucky, brought us homemade treats or vegetables from their garden. Seeing this side of our patients would never have happened via a computer screen. While optimally, patients should not spend long periods of time in the waiting room, many of my patients struck up conversations with other people there, helping alleviate some of their loneliness and lack of personal contact they experienced living alone.

I am certain that post-COVID-19, there will be increased telehealth use, but it is unlikely to fulfill the hype that has come with its rapid adoption during this pandemic.

Time will tell the story.

Programming Note: Ronald Hirsch, MD is a permanent panelist on Monitor Mondays. Listen to his live reporting every Monday at 10-10:30 a.m. EST.