Telemedicine has become increasingly popular over the last decade, and the coronavirus pandemic established the trend as a key part of health care going forward.
“It’s not new — we’ve heard about telehealth for almost probably two decades or so,” Jonathan Wiik, principal of healthcare strategy at TransUnion Healthcare, told Yahoo Finance. “Unfortunately like most things in the world, it comes down to money. What COVID did that was unique from anything else is that it forced health care to happen in a remote fashion. Because at that point, there were so many unknowns when COVID first happened back in March, when they shut airplanes and restaurants and everything down.”
Telehealth visits increased by 50% year over year during the first quarter of 2020, according to the Centers for Disease Control and Prevention (CDC). And by the middle of July, telemedicine visits accounted for just 21% of doctor visits, a 69% drop from April, according to Epic Health Research Network, an electronic health record company, as doctor offices began opening again.
Despite the drop from the initial peak, Wiik said, telemedicine is “here to stay at a higher rate because people realized they could go there and it’s still something they could do.”
The coverage problem
After many primary care offices were forced to shut down or limit their visits to only COVID-related patients, insurers began waiving fees and deductibles for telehealth services.
But as the country reached fall 2020, some began stopping those waivers: Anthem (ANTM) and UnitedHealthcare (UNH). It’s unclear if other insurance companies will follow suit, particularly as the U.S. continues battling another wave of the virus.
Wiik, who previously worked in the health insurance industry, explained why insurance companies often shy away from providing coverage for telehealth in the same manner they do for other services.
“Part of it is there’s a lot of fraud in health care and a lot of medical documentation that has to happen to ensure that the care that’s being billed is the care that’s being provided,” he said. “Insurance companies wanted to reimburse less of a rate for an outpatient visit. There wasn’t what’s called ‘payment parity’ between an in-person visit and a telehealth visit.”
He continued: “You can do telehealth visits, but we’re going to pay $20 instead of $100. So hospitals and physician clinics had a choice, ‘Well, do I want to see people in person for $100 or see them remotely for $20?’ I’m just throwing numbers out there … I know that they’re substantial, and I know they’re that far apart.”
According to Wiik, insurance companies are of the view that remote service is not “as intense as a service that’s face to face.”
“You don’t have the ability to manipulate a joint or listen to someone’s heartbeat or have them cough and move their legs around or touch their neck and do an assessment,” he said. “Those things are all questions that you would ask: ‘How are you feeling? Do you have a fever? Do you have any trouble breathing? When was the last time you had your blood pressure taken?’”
The Consolidated Appropriations Act, 2021 allocated approximately $250 million towards the FCC’s telehealth program. Additionally, several states have taken their own steps towards providing reimbursements to insurers for telehealth coverage.
Connecticut requires payment parity for telehealth services until March 15. Minnesota has expanded telemedicine access for CHIP, Medical Assistance, and MinnesotaCare enrollees until June 30, 2021. But there are still more than half of the U.S. states that don’t have their own coverage regulations in place.
Wiik noted how some health care companies and hospitals have begun sending patients tools that allow them to self-administer treatment or check their blood pressure so the doctor can see it virtually.
“That starts to create more of a parity in services,” Wiik said. “But I think payers didn’t want to necessarily just pay for a conversation, if that makes sense, at the same rate that they pay for an actual assessment. That’s why there’s a difference in payment and, I argue, difference in utilization before COVID happened.”
‘If telemedicine services aren’t rolled out in a very careful, targeted way...’
While telemedicine has been a safe option for people avoiding in-person visits because of the pandemic, it’s also proven to be a major tool in expanding access to health care in rural and urban parts of the U.S.
“The policy around telemedicine prior to the pandemic was more focused on increasing access to care for rural populations,” Lori Uscher-Pines, a senior policy researcher at the RAND Corporation, told Yahoo Finance. “Rural populations often are lacking providers. So telemedicine is a great way to bring providers in to serve communities.”
Prior to the pandemic, telehealth usage had already been steadily rising since 2010, when only 35% of hospitals utilized some kind of telehealth system. That number jumped to 76% in 2017, according to the American Hospital Association (AHA), with much of it concentrated in rural areas.
“I think we know access is an issue with rural communities and that’s clear, [but] it’s not necessarily not an issue with urban communities,” Uscher-Pines said. “Telemedicine advocates have claimed that it’s important that access be opened up for both rural and urban residents, primarily for that reason that the access isn’t just based on rural or not rural access challenges.”
Both Uscher-Pines and Wiik agreed that telemedicine has the potential to reduce health disparities and improve health equity. A study of 140,000 telemedicine records in New York City by the Journal of Informatics in Health and Biomedicine found that 13% of Black New Yorkers used telemedicine between March and April 2020, up from 8% the year prior.
The concern, Uscher-Pines said, “is if telemedicine services aren’t rolled out in a very careful, targeted way, they actually could increase disparities and access, because in order to participate in telemedicine, you need a device, you need wi-fi, you need digital literacy. So while telemedicine as an innovation in health care delivery has this promise, you have to be really careful in the actual implementation and making sure that you’re targeting the underserved and supporting them in accessing the services. So you can inadvertently increase disparities in access because of the digital divide unless you’re careful.”
‘I’m qualified in Virginia, but I’m suddenly not qualified according to D.C.’
Many Americans deferred non-COVID-related medical visits amid the pandemic, which sparked concerns from health care providers who worried that their patients would be missing routine but necessary visits.
And while telehealth gave these patients a means for still getting their visits in, a peer-reviewed study published in the Journal of Medical Internet Research found that telehealth’s popularity was fueled more by visits for behavioral health issues and chronic conditions.
Elizabeth Brokamp, a licensed professional counselor who runs the Virginia-based Nova Terra Therapy practice, has been a therapist for over 20 years but said she’s seen an “unprecedented” number of clients and potential clients over the past few months.
“People are struggling,” she told Yahoo Finance. “Even people who feel like they have a really good handle on their health normally are finding it really difficult to manage.”
Brokamp is now offering telemental health services, but has found herself in a snag with state regulators, as she can’t offer services to those based out of other states that she doesn’t have a license in — even if the services are virtual.
“For most professions, licensing is done on a state-by-state basis,” she explained. “Your doctor has to have a medical license. They get licensed in states as well, but other professions are managed by states too. Land surveyors are licensed by a state. The state just wants to ensure that anybody that’s practicing within its borders is doing so ethically, that they have knowledge of how well you’re educated, all those types of things. ... But what doesn’t make sense is that I’m qualified in Virginia, but I’m suddenly not qualified according to D.C., or I’m suddenly not qualified according to Florida just because I haven’t filled out their piece of paper.”
Because of this, Brokamp created a MoveOn.org petition calling on Congress to develop a national approach to licensing telemental health providers so that they won’t hit snags like this again the next time there is a crisis. The petition has garnered over 45,000 signatures so far.
“I understand that they want a say over things, but it just seems like, especially with telemental health, given that state lines don’t matter the same way they used to, it’s an awful lot of burden to place on people who are looking for counseling and on counselors to say, ‘You live on this side of the arbitrary border, so I’m not allowed to work with you,’” Brokamp said. “I feel like there ought to be a better way.”
Her petition caught the attention of a lawyer from the Institute for Justice (IJ), a nonprofit libertarian law firm. Brokamp explained to the lawyer how she’s had to turn down potential clients who are based out of Washington, D.C. because her telemental health license doesn’t extend there.
“If I were actually at my in-person office, they could drive around the Beltway for 5-10 miles and come to my office, and it would be no problem,” Brokamp said. “But because we’re doing telemental health and they’re presumably sitting in their house in D.C. and I’m in Virginia, it’s not allowed.”
Brokamp filed a lawsuit on her behalf last month against the District of Columbia, alleging that their laws not only restrict her ability to speak with D.C. residents about topics that one would talk about with “a life coach, mentor, self-help guru, religious leader, or close friend.” The complaint calls these laws “substantially overbroad” and “substantially underinclusive.”
“For counseling in particular, it’s a problem because we have an absolute ethical obligation not to abandon clients,” Brokamp said. “The term ‘abandon’ is obviously open to interpretation, but for most counselors, that means if somebody has been working with me, I have to do my best to make sure that they get served, that I’m providing them with what they need if they’re having a mental health emergency.”
She continued: “Unless we’ve discontinued our services for some other reason, I need to make sure that I’m available to them. And I’m concerned about people being denied access to care because of some arbitrary insurance thing, as opposed to the two of us deciding, ‘No, you’re really doing much better. You don’t really need to come to counseling anymore, which is a therapeutic decision.’ I don’t want it to be a decision made by some office somewhere where it doesn’t have anything to do with someone’s actual condition.”
Adriana is a reporter and editor covering politics and health care policy for Yahoo Finance. Follow her on Twitter @adrianambells.