Due to the rapid spread of coronavirus in the United States, clinicians and hospitals were forced to find a new way to serve their patients. At a stressful time like this, insurers, policymakers, and hospitals looked to telehealth or telemedicine to ensure that patients were able to receive proper care in their homes.
Over the past year, many people in the United States were under shelter in place orders. Thanks to telemedicine, patients were able to receive care while maintaining social distance, potentially avoiding urgent care centers and overburdening emergency departments, and reducing the risk of exposure to coronavirus. After having several years of slow growth, the telemedicine market has finally exploded all over the country in a matter of a few weeks.
The overall telemedicine landscape is quite complex with several different players responding to the virus. The federal government has already taken actions, especially through Medicare, to facilitate and broaden the use of telemedicine. The state government, insurance carriers, and health systems have moved at an unprecedented speed to ensure that visits that were usually done in person were shifted to a telemedicine platform. In just a couple of weeks since the pandemic hit the country, there were several policy changes made to the field of telemedicine by the health systems, commercial insurers, state governments, and the federal government. Read on to learn about how access to telemedicine has grown in the United States:
There are several, varied definitions for telehealth or telemedicine. The most common one is that it is the remote provision of medical services using technology for exchanging information required to diagnose, treat, or prevent disease. Insurers usually define telemedicine to include technologies like remote patient monitoring or videoconference while telehealth has a broad definition that includes even the basic telecommunication tools like phone calls, emails, text messages, or sophisticated online health portals. Even though there are differences between the two, the terms telemedicine and telehealth are used interchangeably by many.
With telemedicine, health care providers have the ability to provide medical services to patients living at remote locations through virtual visits conducted via phone or videoconference. During the telemedicine visit, the patient might see a provider from their usual hospital or clinic or might interact with a provider from a stand-alone telemedicine platform like Virtuwell or Amwell. In fact, telemedicine has also been used for enabling remote consultations and interactions between providers.
Use of telemedicine before coronavirus
Telemedicine use in the United States was minimal before the onset of the pandemic. The growth of this market was limited by the lack of coverage policies across states and insurers. There were also several hurdles that hindered the establishment of telemedicine in the health systems like clinician buy-in, workflow reconfiguration, patient interest, and high startup costs.
The IBM MarketScan Commercial Claims and Encounters Database sample of health benefit claims was analyzed by the Peterson-KFF Health System Tracker. The analysis showed that out of the enrollees in this large-scale employer health plan that offered an outpatient service, only 2.4% utilized at least one telemedicine service in 2018. This number was up by 0.8% in 2016. Also, the utilization of telehealth services by traditional Medicaid and Medicare and beneficiaries who were enrolled in care plans had been growing upward but had remained low.
Use of telemedicine during the pandemic
During the coronavirus pandemic, patients and providers are using telemedicine in multiple scenarios to enable remote evaluations while respecting social distancing. The use of virtual visits with the help of videoconference or phone ensures that people are able to address their non-urgent issues and get routine management of psychiatric or medical conditions. App-based on online questionnaires are also being used for facilitating COVID-screening and determining if there is a need for in-person visits.
Patients with suspected exposure to coronavirus or coronavirus symptoms have been instructed by hospitals to either turn to telemedicine first or call their doctors, before visiting an emergency room. This is in line with the guidelines provided by the Centers for Disease Control and Prevention that encourage people who are mildly ill to call their doctors first who can help them determine if they should seek in-person care. In the case of patients with complex comorbidities or with severe symptoms like difficulty breathing, evaluation from home through telemedicine might not be appropriate. Such people should get in-person intervention as soon as possible.
Measures taken for expanding access to telemedicine in the US
As a response to the coronavirus pandemic, the demand for telemedicine services has been increasing rapidly all over the country. Before this, telemedicine was considered to be a niche model of medical care. But now, in response to the global health crisis, this is becoming more mainstream. For instance, the popular telemedicine platform in China named JD Health had a tenfold increase in its services, all because of the pandemic. Currently, it is providing almost 2 million online visits every month. In the United States, telemedicine platforms like UPMC and Amwells virtual urgent care reported a rapid increase in patients utilizing their services. A poll conducted by Morning Consult showed that 23% of adults used telemedicine services during the coronavirus pandemic.
When it comes to determining who can deliver telemedicine services to whom, in what fashion, in what location, and how they will be reimbursed, there are a myriad of laws and regulations to deal with. The coverage and reimbursement of telemedicine for self-insured plans and Medicare are regulated by the Federal government, while fully insured private plans and Medicaid are mostly regulated by the state government.
The telemedicine regulatory framework is very complex which makes it challenging for patients to know what telemedicine services are covered. It is also challenging for the providers as they are unsure or unaware of the regulations they have to abide by.
However, as the pandemic evolves, emergency policies related to telemedicine have evolved as well. The federal government, some state governments, and some insurance carriers have enabled coverage and reimbursements for more telemedicine visits.
There have been a lot of changes to the telemedicine policy and implementation by the health systems, commercial insurers, state governments, and the federal government as a response to the global health emergency. Even though the federal government has announced that telemedicine restrictions are loosened, states have their own laws and regulations that shape coverage and reimbursements in Medicaid and state-regulated insurance plans.
Also, regulations that facilitate telemedicine have only been temporarily lifted. During this time, patients and health systems have to face their own challenges in accessing and implementing these services. While most of the regulations have been relaxed, in order to make telemedicine more accessible to people in the United States for the long term, the government and the health systems need to take several actions.
Telemedicine in rural areas
There are a lot of barriers faced by rural Americans that restrict their access to high-quality medical care including lack of public transportation, ire provider shortages, and geographic distances. In the past decade, over 120 rural hospitals have shut down, including 19 in 2019. Also, individuals living in a rural area are more likely to be low-income and unemployed, with about only one in four being covered by Medicaid. Apart from providing coverage for a large segment of the rural population, Medicaid also finances several safety-net providers including rural health centers and hospitals.
Telemedicine is a quite promising field, especially in rural communities. However, there are also a lot of uncertainties regarding its effectiveness. This goes for telemedicine as a response to the pandemic and a long-term solution that will increase access to care for low-income Americans. During these tough times, in some rural communities, the number of cases and deaths caused by the coronavirus has increased, it is crucial to explore all the considerations that support telemedicine in rural settings.
In the past couple of years, the use of telehealth in rural America has increased. Rural health stakeholders are seeing telehealth as the potential solution to improve access to healthcare in rural communities as it provides care in remote areas and reduces travel times. But, in order to access telemedicine services in non-metropolitan areas, reliable internet access is a must. Broadband internet is a proxy for telemedicine services in rural areas. It is estimated that about 75% of non-urban households have broadband internet access as opposed to the 87% of urban households.
Even before the coronavirus hit the United States, rural areas were losing healthcare providers which made telemedicine increasingly appealing. It was the perfect solution to augment their limited provider resources.
With so many rural hospitals at the risk of closing and difficult recruitment in these areas, more and more efforts were made to increase the provider capacity in such areas using virtual initiatives such as Project ECHO.
Moreover, providers in rural areas, just like other providers across the country, are compensated through a fee-for-service payment structure. This means that if they are unable to see patients, they lose their revenue. Also, if a clinic in a rural community is forcibly closed and is unlikely to be replaced, individuals living in that broad geographic area might lose access to essential healthcare providers.
Because of the pandemic, this potential dynamic became a reality and increased the risk of closure for a few federally qualified rural hospitals and health centers.
Medicaids approach to telemedicine during the pandemic
Before the pandemic crisis, all the state Medicaid programs offered coverage for some form of telemedicine services, but there was, and still is, variation in defining, implementing, and regulating telemedicine. As a response to the coronavirus pandemic, most Medicaid programs increased access through emergency policies to telemedicine for beneficiaries like allowing home access to telemedicine services and loosening restrictions associated with audio-only services. CMS also issued guidelines that reinforced the state Medicaid programs to increase telemedicine service. These guidelines also mentioned that states will no longer need federal approval to reimburse telemedicine services at the face-to-face services rate. With states relaxing their licensing requirements, providers will be able to see patients from all over the country.
Medicaid is crucial for the benefit of rural health care systems. That is why rural stakeholders have to consider the potential impacts of the telehealth policy changes made in the last year. First, these policy changes might reduce the access barriers by easing the rules of out-of-state provider licensing and increasing telehealth opportunities. With these changes, individuals living in rural areas will be able to access complex health care. For instance, substance use disorder treatment providers will be able to offer virtual support services and start buprenorphine treatment without having an in-person visit; something that was historically challenging.
Loosening restrictions on what is qualified as a reimbursable service like allowing for text-based or audio-only services and implementing payment parity to provide a revenue stream to providers who were hit hard by the global health crisis. However, given the decreasing tax revenues and impending state budget deficits, it is possible that payment parity will be added to the budgetary woes.
Also, there are some concerns among stakeholders regarding the lack of familiarity with the technology or internet access gaps that will limit the growth of telemedicine services in rural areas.
When it comes to the telemedicine policy changes in rural areas, it is still early to make an assessment. However, anecdotal data suggests that there will be a significant uptake increase by providers. Most of the states have already implemented policies increasing payment and access to telemedicine services. Healthcare providers are seeing a decrease in no-show rates. But, there are a lot of challenges to deal with. Broadband access is and will be an issue for people living in rural areas, regardless of the changes made to reimbursable services, licensing, or payment parity. The CARES Act includes a budget of $200 million for increasing telemedicine access. Before coronavirus, over $20 billion were announced to fund broadband access to the rural areas by the Federal Communications Commission. In order to sustain changes, federal funding has to continue.