Your typical health care visit used to consist of driving to a clinic or office, filing out some paperwork, and waiting for someone to call your name when your provider was ready for you.
Then, the coronavirus hit. Suddenly many people were attending appointments on the computer or over the phone, and telehealth became a household word.
While telehealth appointments have been around for decades, they were on the periphery of the health care system. After the pandemic made it impossible to deliver health care in the same ways as before, telehealth became necessary, and barriers to reimbursement, technology, and licensure began to fall. Some health systems had to move from small-scale telehealth implementation to 100 percent virtual encounters overnight. Patients soon began seeing their doctors from within their own homes. Even in the inpatient setting, they increasingly interacted with health care providers through iPads. Telehealth’s recent progress is something “that most people couldn’t have imagined,” said Harlan Krumholz, professor of medicine at Yale University School of Medicine.
Before the pandemic, health care providers already recognized that telemedicine was inevitable. But for many reasons—including reimbursement systems, tradition, and patient preferences—hospital systems were still tipping their toes in the water. Much of telehealth had previously been done through a network of health care systems and clinics called a “hub and spoke” model—a system in which specialists (“hubs”) would provide virtual consultations to smaller health centers and hospitals (“spokes”). For instance, a patient might go to a community health center to see a psychiatrist hundreds of miles away. With the pandemic, this model has largely been replaced by a more decentralized direct-to-consumer model, except in geographic areas with limited internet bandwidth where people may need to go to a community clinic, and areas of telemedicine that require more specialized equipment, like for a patient needing an evaluation for a stroke or heart disease.
To the surprise of many, this transition to wide-scale adaptation of telehealth and videoconferencing visits has worked well. Health care organizations have been able to provide safe and arguably more efficient and cost-effective care to patients in their homes. This has also meant more work-from-home opportunities that benefit many health care workers, such as parents with young children. Furthermore, providers get to see inside a patient’s home, which may inform a better understanding of a patient’s life.
Lauren Eberly, clinical fellow of cardiovascular medicine at the University of Pennsylvania Perelman School of Medicine, cites one instance during a telehealth visit when a patient of hers was talking about her medications. When Eberly asked about taking a specific medication, the patient believed she was taking it—but then she showed Eberly her medicine cabinet, which didn’t include that prescription. The patient thought she had all of the medications she needed, but she was actually missing one, which could have had devastating consequences.
“In many respects, [the use of telehealth] will be one of the positive things to come out of the pandemic,” said David Bates, chief of internal medicine at Brigham and Women’s Hospital and a professor of health policy and management at the Harvard T.H. Chan School of Public Health.
A robust, permanent telehealth system could reduce crowding in hospitals, with more patients cared for at home and out of hospitals. It could help permit something that Bates predicts: In the future, more hospital beds can be set up so they can also be intensive care rooms or general care units, instead of just one or the other. This way, hospitals will be able to “flex up” during a period of high demand, like what hospitals in California have experienced during the pandemic.
But the quick telehealth ramp-up hasn’t been perfect. Providers and patients alike needed to quickly become familiar with new tech platforms, and people had difficulty managing video visits, figuring out how to use a videoconferencing application, or maintaining a stable internet connection. Providers may miss nonverbal cues and other subtle aspects of patient visits or be unable to show empathy in traditional, in-person ways, like offering a comforting hand. Some platforms don’t have the best security measures. And if a patient needs some tests, they can’t just happen on the spot.
In a broad sense, the pandemic has provided many health systems with a trial run to adopt telehealth on a wider scale. But, as with any beta release, an improved version is on the way. For telehealth to reach its fullest potential, it will require better forms of patient engagement such as remote monitoring—for instance, ways for people to take at home and then transmit their blood pressure and other vital signs. Health care providers are still learning even the smallest things, like not coming across as flat during a virtual visit. Telehealth platforms will continue to improve in terms of usability, privacy, and security.
For telemedicine to reach its potential, we also need to pay attention to who is getting left behind. Smartphones have helped decrease the digital divide, but there are consistent barriers for many groups in terms of access to technology. For example, people from ethnic and racial minority groups are characterized by lower rates of broadband adoption and computer and internet use. Elderly patients may only have a landline, making video visits not an option.
A recent study of patients scheduled for telemedicine visits during the initial months of the coronavirus pandemic showed significant inequities in accessing telemedicine. Overall, patients who were older, Asian, or non-English-speaking showed lower rates of telemedicine use (including both phone and video). Along the same lines, those who were older, female, Black or Latino, and of lower socioeconomic statuses used video visits less.
“We’re building a new telehealth system—this gives us the opportunity to get things right,” Eberly said. “As we implement it, whether it’s more technology or more innovation, we have to use a framework so we can continue to assess structural inequities in telehealth.”
Telehealth will need more investment. Mercy Virtual Care Center, a largely virtual health care institution, has been a leader in helping organizations think about virtual care. According to Bates, Mercy spends roughly 5 percent of its income on telemedicine, which is significantly higher than what other hospital systems spend—about 0.1 to 0.2 percent of their income—on telemedicine.
“We are substantially underinvested [in telehealth],” Bates said. “It will change going forward, but it’s going to take some time.”
Improving telehealth also requires long-term policy and regulatory reform. Before the coronavirus pandemic, there was almost no reimbursement for telehealth, although it had been effectively implemented in many specialties. After the pandemic was declared a public health emergency, insurance companies and Medicare and Medicaid offered expanded telehealth coverage. Congress, the federal government, and state governments also relaxed patient confidentiality and telehealth regulations. But most of these reforms were issued on a temporary basis for the duration of the public health emergency, and they have already started rolling back even though the pandemic is far from over.
Ideally, reimbursement rates would be the same across all forms of health care (in-person, video, and phone), and not just temporarily so. Without that parity, providers who offer telemedicine like phone visits to marginalized populations are essentially penalized, as they’re reimbursed at lower rates. There is some reason for optimism here, though. For instance, just recently the Protecting Access to Post-COVID-19 Telehealth Act of 2021 and the Telehealth Modernization Act were introduced to Congress with bipartisan support. Massachusetts Gov. Charlie Baker recently signed a health care reform bill that requires behavioral telehealth visits to be reimbursed at the same rates as in-person visits for two years. Without such regulations, there will at most be a patchwork of telehealth coverage across the country. But stakeholders won’t want telehealth visits to proliferate without providing value to patients.
“People are going to be looking for accountability,” Krumholz said. He also pointed out that there will still be pressure on insurance companies to continue to cover telehealth because patients like telehealth visits generally.
According to Joseph Kvedar, professor of dermatology at Harvard Medical School and chair of the board of the American Telemedicine Association, simplicity in reimbursement policies is going to be equally important as payment parity. If it’s complicated, then there could be times when insurers reject a bill or when patients may get a surprise bill.
Besides reimbursement mechanisms, there are other policy areas that need to be updated. For instance, there are restrictions on seeing patients across state lines via telehealth. While such restrictions make sense for seeing a patient for the first time, state licensing requirements may need to be loosened for follow-up appointments that can optimally done virtually. Universal broadband services are also needed.
A major question that will have to drive telemedicine is: When does it really make sense for a provider to see a patient in person instead of on video? Some areas like psychiatry can be well suited for virtual follow-up visits depending on the patient’s need. But others—for instance, seeing a doctor for your vision or hearing—aren’t, given the need for specialized equipment.
Overall, there are still open questions for health care organizations, including how to best use their brick-and-mortar structures and how to triage their patients. But these issues are all solvable. What’s important is that telehealth has and can continue to provide tremendous value to people.
“We’re only going to see its growth. There’s so much still to learn, but it’s an exciting time,” Krumholz said.
Update, March 1, 2021: This article was updated to reflect that Joseph Kvedar is currently the chair of the board of the American Telemedicine Association.