Accelerating Demand and Usage of Telehealth: COVID-19

As COVID-19 continues to roll tsunami-style across the globe, strains on health care delivery systems are mandating innovative approaches to taking care of the needs of infected patients while maintaining ongoing care for patients with other medical needs.

One approach emerging as a key tool to meet the added demands of health care during a pandemic is telehealth. 

On March 17, President Trump expanded coverage of telehealth for Medicare beneficiaries during the COVID-19 outbreak. Just days before, Congress had appropriated $500 million to expand telehealth services during the pandemic as part of its first $8 billion spending plan. 

Already covered by a number of state Medicaid programs, Medicare Advantage plans, and private insurers, the expansion of telehealth coverage under traditional Medicare fee-for-service beneficiaries promises during the pandemic, to rapidly increase the numbers of providers and patients using telehealth, as well as the potential for its continual use once the outbreak subsides. 

Evidence on its rapid increased use is already evident, with major health systems reporting substantial increases in demand for telehealth services that are already putting a strain on the technical and provider infrastructures in place to meet the demand. 

What undoubtedly will emerge from the accelerated use of telehealth will be the need for further information on the benefits, challenges, and policy issues of adopting this mode of health care delivery across populations and sectors. As pointed out in an August 2019 issue brief by the Milbank Memorial Fund on the evolving policy landscape of telehealth services in the United States, adoption of telehealth historically has outpaced the evidence to support its use. In fact, according to the report, more than 100 state and federal bills related to telehealth implementation have been introduced annually in the last several years.

What We Know

Telehealth refers to the use of telecommunications and digital communication technologies (eg, live video conferencing, mobile health apps) to deliver health-related services such as medical care and self-care as well as provider/patient education and information services.

Although often used interchangeably with telemedicine, telemedicine generally refers only to direct medical services rendered to patients geographically separated from providers. 

For physicians, telehealth can facilitate access to education and training (eg, meet continuing medical education and maintenance of certification requirements), provider-to-provider communications (ie, enable care teams to share information), and address primary care provider shortages in such areas as prisons, rural communities, and underserved urban centers. For patients, telehealth offers access to medical care via primary care physicians and specialists in areas with a shortage of providers as well as access to educational and support avenues to, for example, manage chronic conditions such as diabetes by using glucose monitoring devices. 

“Telehealth can be very helpful for patients who have difficulty getting to appointments because of travel distance or functional limitations, and this enables doctors to check in with their patients more regularly,” said Michael L Barnett, MD, MS, assistant professor, health policy and management, Harvard T.H. Chan School of Public Health. “Also, many patients with complex conditions have mental health issues as well, and telehealth can be a very convenient way to deliver talk therapy of various sorts.”

An additional advantage of telehealth, said Mei Kwong, JD, executive director, Center for Connected Health Policy, The National Telehealth Policy Resource Center, is to help monitor patients with chronic diseases, such as diabetes and hypertension, to intervene when problems arise to avoid hospitalization or readmission.

Limited but Growing Evidence on Outcomes 

To date, much of the clinical evidence on telehealth seems to come from its use to manage patients with mental health issues. A systematic review published in 2016 found that patients with a broad range of mental health disorders had improved symptoms and quality of life when getting their care through telehealth, and data suggesting an associated cost savings.

A 2016 report by the Agency for Healthcare Research and Quality, that mapped the evidence for patient outcomes from systemic reviews of telehealth, found sufficient evidence to support the effectiveness of telehealth for three areas of health care: psychotherapy as part of behavior health, communication and counseling for patients with chronic conditions, and remote patient monitoring for patients with chronic conditions.

For primary care, the evidence is more limited. A systematic review of studies of telemedicine for primary care published between 2005 and 2015 found that use of telemedicine was considered feasible and accepted by providers and patients, with more acceptance by patients. The review found more evidence for outcomes such as clinical attendance, provider adherence to protocols, use of service, and patient compliance (called intermediate outcomes in the study) than clinical outcomes (health outcomes). Given the outcome data available, the reviewers concluded that interventions via telemedicine are at least as effective as traditional care and that, although cost analyses varied among the studies, data show that telemedicine is increasingly shown to be cost effective.

A more recent systematic review and meta-analysis of the effectiveness of telemedicine on diabetes, dyslipidemia, and hypertension published in 2020 offers more data on clinical outcomes but overall underscored the limited data on these outcomes. Based on studies largely published after 2015, the review found that telemedicine had significant and clinically relevant reductions in glycated hemoglobin levels in patients with diabetes and higher reduction rates were found in recently diagnosed patients with higher baseline glycated hemoglobin levels. However, telemedicine had no significant impact on blood pressure and quality of evidence was too low to assess the effect of telehealth on lipid outcomes.

Barriers to Adoption

Prior to COVID-19, adoption of telehealth has been slow. According to a JD Power Telehealth Satisfaction Survey, only 1 in 10 Americans used telehealth as of July 2019 and 75% of those polled said they did not have access or were unaware of telehealth as an option to care.

Dr Barnett, who published a research letter in JAMA in 2018, reported that the use of telemedicine in a large commercially insured population remained uncommon in 2017 despite significant increases for primary care between 2016 and 2017. He said that multiple factors likely explain the slow uptake of telemedicine (prior to COVID-19). “Reimbursement and regulatory policy have been very complicated, highly variable, and restrictive prior to COVID-19,” he said. “On top of that, I think most patients and providers were largely not aware of its use or felt a need to go to use it.”

An analysis published pre-COVID-19 by Definitive Healthcare also highlighted regulatory policy and reimbursement as barriers to adoption, along with cost (ie, financial investment in the technology) and concern over losing continuity of care if patients get care via different providers over telehealth.

Further barriers pointed out by Ms Kwong include the lack of knowledge by plans and providers about how to implement telehealth, how to equip patients to use it from home, and knowing the right patient populations for which it is feasible.

The Antidote to Barriers: COVID-19 

One of the conclusions of the AHRQ report was the need to address barriers to telehealth and promote broader implementation—such as triaging urgent care. This seems prescient at this moment in history when health care clinics and hospitals around the country are switching to telehealth in response to COVID-19.

One key barrier being addressed is reimbursement. “We’ve seen many insurance companies, including Medicaid programs, and Medicare quickly expand coverage of telehealth during this crisis, which was a critical first step to broader expansion,” said Brian Hasselfeld, MD, interim medical director, office of telemedicine, Office of Johns Hopkins Physicians. 

He also said that some states have taken action to break down barriers to state rules and regulations around telehealth and provider licensing to make it easier to use telehealth to care for patients across state lines. “We continue to hope that more states will act similarly,” he said.

Ironically, a new barrier to implementation may be the sudden acceleration of usage and a drain on technology. “Telemedicine vendors are overwhelmed and catching up,” said Dr Barnett. “You still need video equipment, which seems scarce with everyone working from home, and many patients may not be comfortable having visits by phone or video especially older patients or those who are hard of hearing.”

According to Dr Hasselfeld, the steps needed to turn on telemedicine capabilities include: identifying a technology platform, communication with patients about different types of care, training providers, understanding the insurance and reimbursement rules, and understanding state and federal rules and regulations including provider licensure and scope of practice restrictions.

He cited efforts at Johns Hopkins to scale up telehealth efforts during this period, including using pre-visit telephone calls to troubleshoot, pre-visit patient portal messages with instructions, and developing patient-facing video tutorials. 

“At Johns Hopkins, a significant percentage of our outpatient volume transitioned to telemedicine…as we look to meet the public health goals of physical distancing, with thousands of visits per day being done by video and telephone,” he said.

Industry Adjustment

With the increased use of telemedicine and telehealth over the last several weeks, many restrictions and guidelines have been adjusted to ensure patients and providers are able to make the most of the platforms. Reimbursement and payment structures have also been adjusted. 

According to the American College of Physicians (ACP), “Patients can be at home and non-HIPAA compliant technology is allowed.”

HHS announced toward the beginning of the crisis that restrictions and penalties related to HIPAA compliance would be lenient in the use of telemedicine for the duration of the outbreak. 

ACP continued, “there is no cost sharing for COVID-19 testing. In addition, to encourage use by patients, Medicare is allowing practices to waive cost-sharing (copays and deductibles) for all telehealth services, and much prior authorization activities are being paused.”

The American Medical Association has issued new coding guidance for patients receiving care virtually. 

Whether or not telehealth will continue to expand after COVID-19 is unknown, according to Ms Kwong. “I don’t know how many of the changes to telehealth policy will stay after the crisis because many of the changes have been emergency based, but I think during this emergency people are going to recognize how valuable a tool telehealth is for providers.” ν