It's 'Telehealth vs No Care'

 When the covid-19 pandemic hit, Dr. Corey Siegel was more prepared than most of his peers.

Half of Siegel's patients — many with private insurance and Medicaid — were already using telehealth, logging onto appointments through phones or computers. "You get to meet their family members; you get to meet their pets," Siegel said. "You see more into their lives than you do when they come to you."

Siegel's Medicare patients weren't covered for telehealth visits until the pandemic drove Congress and regulators to temporarily pay for remote medical treatment just as they would in-person care.

Siegel, section chief for gastroenterology and hepatology at Dartmouth-Hitchcock Medical Center, is licensed in three states and many of his Medicare patients were frequently driving two to three hours round trip for appointments, "which isn't a small feat," he said.

The $1.7 trillion spending package Congress passed in December included a two-year extension of key telehealth provisions, such as coverage for Medicare beneficiaries to have phone or video medical appointments at home. But it also signaled political reluctance to make the payment changes permanent, requiring federal regulators to study how Medicare enrollees use telehealth.

The federal extension "basically just kicked the can down the road for two years," said Julia Harris, associate director for the health program at the D.C.-based Bipartisan Policy Center think tank. At issue are questions about the value and cost of telehealth, who will benefit from its use, and whether audio and video appointments should continue to be reimbursed at the same rate as face-to-face care.

Before the pandemic, Medicare paid for only narrow uses of remote medicine, such as emergency stroke care provided at hospitals. Medicare also covered telehealth for patients in rural areas but not in their homes — patients were required to travel to a designated site such as a hospital or doctor's office.

But the pandemic brought a "seismic change in perception" and telehealth "became a household term," said Kyle Zebley, senior vice president of public policy at the American Telemedicine Association.

The omnibus bill's provisions include: paying for audio-only and home care; allowing for a variety of doctors and others, such as occupational therapists, to use telehealth; delaying in-person requirements for mental health patients; and continuing existing telehealth services for federally qualified health clinics and rural health clinics.

Telehealth use among Medicare beneficiaries grew from less than 1% before the pandemic to more than 32% in April 2020. By July 2021, the use of remote appointments retreated somewhat, settling at 13% to 17% of claims submitted, according to a fee-for-service claims analysis by McKinsey & Co.

Fears over potential fraud and the cost of expanding telehealth have made politicians hesitant, said Josh LaRosa, vice president at the Wynne Health Group, which focuses on payment and care delivery reform. The report required in the omnibus package "is really going to help to provide more clarity," LaRosa said.

In a 2021 report, the Government Accountability Office warned that using telehealth could increase spending in Medicare and Medicaid, and historically the Congressional Budget Office has said telehealth could make it easier for people to use more health care, which would lead to more spending.

Advocates like Zebley counter that remote care doesn't necessarily cost more. "If the priority is preventative care and expanding access, that should be taken into account when considering costs," Zebley said, explaining that increased use of preventative care could drive down more expensive spending.

Siegel and his colleagues at Dartmouth see remote care as a tool for helping chronically ill patients receive ongoing care and preventing expensive emergency episodes. It "allows patients to not be burdened by their illnesses," he said. "It's critical that we keep this going."

Some of Seigel's work is funded by The Leona M. and Harry B. Helmsley Charitable Trust. (The Helmsley Charitable Trust also contributes to KHN.)

For the past nine months, Dartmouth Health's telehealth visits plateaued at more than 500 per day. That's 10% to 15% of all outpatient visits, said Katelyn Darling, director of operations for Dartmouth's virtual care center.

"Patients like it and they want to continue doing it," Darling said, adding that doctors — especially psychologists — like telehealth too. If Congress decides not to continue funding for remote at-home visits after 2024, Darling said, she fears patients will have to drive again for appointments that could have been handled remotely.

The same fears are worrying leaders at Sanford Health, which provides services across the Upper Midwest.

"We absolutely need those provisions to become permanent," said Brad Schipper, president of virtual care at Sanford, which has health plan members, hospitals, clinics, and other facilities in the Dakotas, Iowa, and Minnesota. In addition to the provisions, Sanford is closely watching whether physicians will continue to get paid for providing care across state lines.

During the pandemic, licensing requirements in states were often relaxed to enable doctors to practice in other states and many of those requirements are set to expire at the end of the public health emergency.

Licensing requirements were not addressed in the omnibus, and to ensure telehealth access, states need to allow physicians to treat patients across state lines, said Dr. Jeremy Cauwels, Sanford Health's chief physician. This has been particularly important in providing mental health care, he said; virtual visits now account for about 20% of Sanford's appointments.

Sanford is based in Sioux Falls, South Dakota, and Cauwels recalled one case in which a patient lived four hours from the closest child-adolescent psychiatrist and was "on the wrong side of the border." Because of the current licensing waivers, Cauwels said, the patient's wait for an appointment was cut from several weeks to six days.

"We were able to get that kid seen without Mom taking a day off to drive back and forth, without a six-week delay, and we were able to do all the things virtually for that family," Cauwels said.

Psychiatrist Dr. Sara Gibson has used telehealth for decades in rural Apache County, Arizona. "There are some people who have no access to care without telehealth," she said. "That has to be added into the equation."

Gibson, who is also medical director for Little Colorado Behavioral Health Centers in Arizona, said one key question for policymakers as they look ahead is not whether telehealth is better than face-to-face. It's "telehealth vs. no care," she said.

https://www.medscape.com/viewarticle/987720