ARE TELEHEALTH VISITS THE "NEW NORMAL" FOR HEALTHCARE DELIVERY?

ARE TELEHEALTH VISITS THE “NEW NORMAL” FOR HEALTHCARE DELIVERY?

Pat Stricker, RN, MEd

Healthcare Consultant

Former SVP of TCS Healthcare Technologies

Looking back on the past year and a half led me to think about how the healthcare industry reacted to the COVID-19 crisis when cases and deaths rose to unimaginable numbers. Essential workers and healthcare professionals worked extra hours and in different departments or healthcare settings to provide care for the overwhelming number of patients who were critically ill. Professionals from all across the country volunteered to go to areas needing help to assist or provide relief for local staff. And federal and state regulations were changed to allow these things to occur.  

Another process that quickly changed was Medicare’s coverage for telehealth visits. Before the pandemic, the Centers for Medicare & Medicaid Services (CMS) only paid for telehealth visits for beneficiaries who lived in rural areas, and there were restrictions on where they could receive services and which providers would be paid to deliver them. Soon after the COVID-19 public health emergency was declared in March 2020, CMS enacted temporary waivers to quickly expand telehealth services. These waivers allowed telehealth visits to be done by video calls or a simple telephone call to handle more visits and make it easier for beneficiaries to access medical care in their home, minimizing potential exposure to COVID-19 in healthcare settings. The waivers also allowed any healthcare professional, federally qualified health center or rural health clinic that was eligible to bill Medicare to be reimbursed for telehealth visits.

Many provider offices/clinics had access to video equipment, and many organizations already had some policies and procedures written as well as technical processes developed for their initial programs, so it was relatively quick and easy to set up the operational processes for these visits. By doing so, offices were able to have limited on-site visits for those who needed to be evaluated in-person, while continuing to handle more routine or follow-up visits using telehealth. Not only did these visits reduce the number of patients who needed to be seen in the office, but they also allowed the limited available healthcare personnel to perform other tasks.  

2020 truly was a transformative year for telehealth! Telehealth visits had been gaining a little momentum over the past decade, but it was growing at a very slow pace. The immediacy, interest, expansion and innovation provided by the immediate needs that COVID-19 introduced provided the impetus to drive the process. It was simple: The goal was to find a way to handle more patients while reducing office hours, maintaining social distancing and making sure that providers would be reimbursed for all the telehealth visits. Other factors also included the need to reduce healthcare costs and manage an increasing number of patients with chronic diseases. With all those things in place, it was time for telehealth to step to the forefront. Telehealth visits had already shown that they could generate costs savings of $19-121 per visit by re-directing patients away from expensive ER visits, shortening hospital stays, transitioning care and reducing readmissions, while at the same time offering improved patient care and outcomes. Now it was time to prove it.  

Telehealth (Virtual) Visits: Increase in Visits, Awareness, Use, and Access

Telehealth is defined by the American Telemedicine Association (ATA) as “the use of digital technologies to deliver medical care, health education and public health services by connecting multiple users in separate locations.” Telehealth includes telemedicine and services such as assessment, monitoring, communications, prevention and education. It involves a broad range of telecommunications, health information, videoconferencing, and digital image technologies.” Its definition is broader than that of telemedicine, which is described as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.” It includes a variety of applications and services using two-way video, smartphones, wireless tools and other forms of telecommunications technology. ATA has historically considered the two terms to be interchangeable, encompassing a wide definition of remote healthcare. Patient consultations via video conferencing, live videos, transmission of still images, e-health including patient portals, remote patient monitoring, continuing medical education, consumer-focused wireless applications, the Internet of Things and nursing call centers are all considered part of telemedicine and telehealth. For purposes of this article, the term telehealth will be used since the article is focused primarily on telehealth visits.

Increase in Telehealth Visits 

• The use of telehealth visits began immediately after the pandemic started when offices/clinics were cutting back hours and lockdowns were being implemented.  Telehealth visits at the end of March 2020 were up 154% compared with the same period in 2019, and the number of telehealth primary care visits increased 350 times over their pre-pandemic levels. These unusually high levels for telehealth visits stabilized as the year went on and wound up to be 38 times higher than before the pandemic.     
• A study looked at more than 600,000 telehealth visits from 2015 to 2020. It found that telehealth visits increased 39.3% per year from 2015 through 2019 and then jumped to 108.5% in 2020 during the pandemic. The six-year increase in telehealth visits was 669.6% or an average of 53.2% per year. 
• Fair Health, an independent, non-profit, healthcare organization analyzed healthcare claims and found that telehealth claim lines in the U.S. rose 2,938% from November 2019 – November 2020, an increase from 0.2% to 6.01%. 
• A telehealth white paper, A New Decade for Telehealth, describes the rapid rise in telehealth adoption. It states that 58% of healthcare leaders say they place a high priority on telehealth services, with 86% saying it is a medium to high priority. This white paper has excellent information for those who may be thinking of starting or increasing their telehealth capabilities. It includes: what is driving telehealth adoption beyond COVID-19, what opportunities are available for providers to use telehealth, what is required to support telehealth’s growth and what IT infrastructure requirements are needed to ensure organizations can support current and future growth of telehealth services.

Awareness of Telehealth Visits  (KFF Report - Figure 3) 

The Kaiser Family Foundation surveyed 52.7 million community-dwelling Medicare beneficiaries who had routine providers from July 2020 through the fall of 2020. (The report breaks down the percentages based on age, race, Medicare/Medicaid, Number and Types of chronic conditions, and Urban/Rural).

• Prior to the COVID -19 pandemic, 18% of patients said their provider offered telehealth visits.
• After COVID-19, 64% (33.6 million) said their provider offered telehealth visits. 

Use of Telehealth Visits (KFF Report - Figure 4)

• Only 0.3% of Part B Medicare beneficiaries used telehealth services in 2016.
• The number of patients with at least one telehealth visit has increased by 57% since the start of the pandemic. Visits by those with chronic illnesses have increased by 77%.
• Nearly half (43.5%) of primary care visits in April 2020 were telehealth visits, compared to 0.1% reported before the pandemic.
• Most telehealth patients during the pandemic were adults between the ages of 18 to 49 (69%), and women accounted for 63% of the total.
• 45% (14.9 million) of the 64% who said their provider offered telehealth visits had a telehealth visit since July 2020.
• No significant differences were noted for those from rural (43%) vs. urban (45%) areas.
• Beneficiaries that were more likely to have a telehealth visit included:
  • Medicare beneficiaries under age 65 who had a long-term disability had a telehealth visit (53%) compared to 42% for those 65-74 and 43% for those 75 or older. 
  • Black and Hispanic beneficiaries (52%) and only 43% for white beneficiaries.
  • Beneficiaries who were enrolled in both Medicare and Medicaid (55%) compared to 43% of those enrolled in Medicare only.
  • Beneficiaries with 6 or more chronic conditions compared to those with 0 conditions (56%) or 1 condition (33%).
  • Beneficiaries with specific chronic conditions such as: diabetes or a heart condition (50%); emphysema, asthma or COPD (54%); depression (55%); or immunocompromised (59%).

Access to Telehealth Visit (KFF Report)

• 56% accessed telehealth using a telephone only.
• Only 42% of Black beneficiaries and 34% of Hispanic beneficiaries owned a computer.
• Nearly one-third of seniors over the age of 65 did not have internet-connected devices (computer, smartphone, or tablet).
• 65% of beneficiaries 75 and older had a telephone-only visit compared to just 52% of those aged 65-74. The findings likely indicate those 75 and older lack internet access (74% vs. 89% for those 65-74); do not own a computer (56% vs. 74%); and do not own a smartphone (53% vs. 80%).
• Six in 10 (61%) Black and Hispanic beneficiaries had a telehealth-only visit, compared to 54% of white beneficiaries. This is likely related to Black and Hispanic beneficiaries having less access to the internet (69% and 67%) than white beneficiaries (86%); not owning a computer (42% and 34% vs. 71%) and not owning a smartphone (63% and 61% vs. 72%).
• Those in rural areas were more likely to have a telephone-only visit (65%) compared to those in urban areas (54%). This likely reflects lower internet access in rural areas (78%) vs. urban areas (84%) and less ownership of computers (58% vs. 66%) and smartphones (60% vs. 72%).
• 52% of patients said they had at least one issue that makes it hard to access telehealth, and 35% said they had at least one technology issue.
• Households with incomes of $50,000 or more were 45% more likely to have broadband internet access than households with incomes of less than $25,000 or those with a Medicaid recipient or someone with a disability.

Patient Satisfaction

The satisfaction levels for telehealth visits are among the highest for the healthcare, insurance and financial service industries. The top three satisfiers were convenience, the safety of being seen at home and speed of access.

Patients rated telehealth visits similar to in-person visits, according to a recent study published in the Journal of Medical Internet Research. 

The Cleveland Clinic surveyed 426 adult patients who had telehealth visits in the summer of 2019.  The survey stated that "telehealth visits facilitate healthcare access and relationship-building, contributing to satisfying relationship-centered care, [which is] a crucial aspect of contemporary patient experiences."

• Most patients (92.9%) said they felt their telehealth clinician was interested in them as a person.
• Nearly 82% agreed or strongly agreed that their telehealth visit was as good as an in-person visit.
• Most patients (90.9%) agreed that their virtual visit made it easy to get the care they needed.
• 92.7% found the technical interface easy to use and 94.8% said they felt comfortable using it.

Comments from Patients and Physicians

Patient Comments

Telehealth is being received favorably by patients. Utilization has risen significantly among Medicare beneficiaries and those with chronic illnesses.

• 75% of patients expect telehealth to be a standard part of their care moving forward.
• Most patients (83%) say they would like to continue telehealth visits after the pandemic, and 28% say they would even be willing to pay for them out-of-pocket.
• 50% of patients said they would switch providers to be able to receive telehealth visits.

Physician Comments

• 48% of physicians say they are using telehealth visits to care for patients.
• More than three-quarters of physicians said telehealth helps them provide better care.
• 64% of physicians who provide telehealth visits say they conduct them from home.
• Female physicians are adopting telehealth at a faster rate than men. 10% of women physicians were using telehealth visits in 2019, and 24% were using them in 2020.
• 57% of providers view telehealth more favorably now than before the pandemic.
• 64% say they are more comfortable using telehealth now.
• Nearly two-thirds of physicians said the lack of integration with their EHRs is a barrier to their adoption of telehealth services.

Although most studies have shown positive responses to telehealth visits, we need to be mindful that these programs may not work as well with older people who are used to in-person office visits. They have always valued developing personal relationships one-on-one with a person. This is more difficult to do on a scheduled, regimented call that tends to be more technical and with less social interaction. Perhaps developing a hybrid model beginning with an in-person visit first and then followed by virtual visits might be helpful, as it would allow a relationship to be developed and give the patient more time to get used to the technology before jumping into telehealth visits.  

Some older patients may not be accustomed to using technology, like computers and smartphones, or they may have physical or cognitive limitations that could affect their ability to feel comfortable using telehealth visits. A JAMA study conducted in 2018 showed that 38% of all older adults in the U.S. were not ready to engage in telehealth visits. Yet telehealth visits can be more advantageous for these types of patients since they do not need to worry about arranging transportation to the office or getting someone to go with them. However, they are often apprehensive about “change” and the use of technology. Taking extra time to work with them to make sure they are confident in knowing how to use the technical equipment and are ready for the telehealth experience may help to ease them into this transition.  

Conclusion

The use of telehealth technology can be an effective tool for case managers to use to effectively manage caseloads, improve responsiveness to clients’ changing medical conditions and monitor a patient’s progress.  Field case managers who meet with patients face to face should be able to manage a larger caseload if telehealth visits were used at certain times. Given the potential for increased efficiency and productivity, as well as less travel time and reduced travel costs, it could be more cost-efficient. Future research is needed to verify these assumptions.   

Telehealth visits were the perfect solution for the pandemic when lockdowns were imposed and social distancing was required. They were relatively quick to implement and easy to use, and they have become a standard care delivery model for primary care. However, we now need to see if these types of visits will remain a staple of the healthcare system.   

The pandemic public health emergency is expected to last until the end of 2021. When it ends, the Medicare emergency waivers will revert to the rules and regulations that existed before the pandemic unless policymakers extend or permanently change the coverage to allow these more relaxed rules. Since telehealth visits provide a more efficient, cost-effective way to manage and monitor patients, there is every expectation that these rules will be extended.

Think how telehealth visits could help case managers in working with patients. Wouldn’t it be nice to see what your patient looks like so you can develop a closer relationship?  Wouldn’t it be nice to see what the patient’s lesion looks like instead of having him describe it to you? Or be able to see how the patient is performing a procedure?  Telehealth (virtual) visits have the potential to change the way we perform case management and how we work with patients. It expands our horizons.  Let’s hope telehealth visits become our “new normal.”        

Reminder:

Don’t forget, if you were unable to attend the recent CMSA Virtual Conference,

   you can still register and take advantage of the CEUs from the many session available online, including several on telehealth.

Session recordings will be available until August 31. 

	Pat Stricker, RN, MEd

Pat is the former Senior Vice-President of Clinical Services for TCS Healthcare Technologies. Pat has over 25 years of experience in medical management, holding senior management positions responsible for clinical product development; clinical content, education, and curriculum development; operational management of UM, CM, and DM programs; clinical sales support and marketing; and clinical consulting. Through the years, Pat has worked on numerous CMSA national committees and work groups, e.g. Case Load Calculator, Integrated Case Management, etc. She worked for Consulting Management Integrators (CMI) as the product manager responsible for implementing CMSA's online Educational Resource Library and Extended Conference offerings, and as the creator of the avatar movie scenarios for CMSA's innovative Career and Knowledge Pathways educational program. Pat has a Bachelor's degree in Health Education & Management and a Master's degree in Adult Education and Curriculum Design. 

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