Telemedicine — the delivery of care by a clinician in one location to a patient in another — is seen as a vital component of the nation’s response to the Covid-19 pandemic. The Centers for Disease Control and Prevention and the World Health Organization have urged physicians and other health care providers to use telemedicine, and both the federal government and private health plans have implemented numerous temporary regulatory and payment changes to facilitate its use.
Physicians initially responded to these changes. Based on a sample of more than 50,000 clinicians who are clients of Phreesia, a health care technology company where two of us (D.L. and H.H.) work, we saw a sudden and dramatic rise in telemedicine (see the chart below). From almost no telemedicine visits before the pandemic struck in the U.S., by early April almost 14% of the usual weekly number of pre-pandemic visits were being conducted via telemedicine. The assumption among many was that, after witnessing the benefits of telemedicine, physicians and patients would embrace it and growth would continue.
Patrick Skerrett / STAT
Source: Phreesia, Inc. Provider organizations were broken into four groups (1-5, 6-20, 21-100, 100+) based on the number of clinicians in the organization. Percentages represent the number of telemedicine visits in a given week divided by the number of all visits (telemedicine and in-person) in the baseline week beginning March 1.
That hasn’t happened. In fact, the use of telemedicine is now steadily declining and during the week of June 14 was used for only 8% of the usual pre-pandemic number of visits.
What happened? Did telemedicine fail to deliver? Or is something else going on?
Implementing telemedicine isn’t easy. To do it well, a physician practice must buy appropriate technology and train staff and patients to use it. It takes time to help an 80-year-old unfamiliar with technology do a video visit. New workflows must be introduced. If a patient needs a laboratory test, for example, where do you send them? Clinical schedules need to be changed. Documentation protocols must be updated. And on and on.
This type of implementation takes both resources and expertise. Not surprisingly, bigger organizations with dedicated information technology, procurement, and implementation teams were able to do it more successfully. Bigger organizations (100-plus clinicians) were able to shift almost 16% of their pre-pandemic visit volume to telemedicine (see chart above). Smaller provider organizations (five or fewer clinicians) were using it at approximately half that rate.
In the midst of a lockdown and stay-at-home orders, physicians did what they could and switched to telemedicine visits as their only option. Because of technology problems with video visits, many reverted to phone calls. But as we are getting into a new normal and communities are reopening, making in-person visits an option, many physicians are deciding the investment in telemedicine is not worth it and are abandoning it.
We believe that physicians are doing this because of uncertainty regarding its financial sustainability. A physician or physician group will invest in telemedicine only if it has long-term viability. While health plans and the government gave providers more flexibility to implement telemedicine and get reimbursed for virtual visits at the beginning of the pandemic, they explicitly stated that those changes were temporary. Physicians need to know now what telemedicine payment and regulations are going to be look like in the post-pandemic world.
For example, if Medicare and private health plans announce that the expansions of telemedicine are permanent, then physicians may begin investing resources into telemedicine. But if there is continued uncertainty, then practices will decide against those investments and accelerate their switch back to in-person care.
In interviews, physicians have told us there is also uncertainty in other aspects of telemedicine. They are confused by state Medicaid programs’ coverage of telemedicine or frustrated by the low payment. Physicians who mostly care for patients with Medicaid, such as many pediatricians, are particularly leery about whether to take the plunge. This is not limited to Medicaid: physicians said that when they submit their bills to private health plans they are not paid or are being paid less than what they expected. It is easy for any insurer to say it has a “policy,” but that policy must be reflected in reality.
All of this is occurring in the context of a huge drop in revenue for physician practices. They are struggling financially, especially smaller ones. When you are struggling to keep the lights on, there is no appetite for uncertainty. You do what you know will allow you to you survive.
The virus continues to circulate in communities throughout the United States and there remains some risk to patients going to their doctors’ offices to be seen. Patients with the highest risk of dying from Covid-19 — the elderly and those with chronic illness — also account for most physician visits. So to protect patients, telemedicine should be a key component of care for months or even years to come. But momentum will be lost unless government payers and private health plans clarify their long-term plans now.
Ateev Mehrotra is a physician and an associate professor of health care policy at Harvard Medical School. David Linetsky is the senior vice president for life sciences at Phreesia, Inc., where Hilary Hatch is a clinical psychologist and vice president of clinical engagement. The statistics in this essay are based on Phreesia’s business data.
While both comments are absolutely true, let’s not discount the value of those telehealth visits that can be done. And can be done without sacrificing care. But let’s keep in mind that we have not done very well at reaching so much of our population, no matter your zip code or other disparities that are barriers to care. We can’t give up now. I believe that health providers as well as our patients, have to serve as advocates to keep the movement going in terms of access and reimbursement. We have to position ourselves for the balance of doing both face to face visits and video visits. If we ever expect to have true shared decision making and facilitate self-management skills, we must not abandon this opportunity to have options.
There is a time and a place for everything – therefore not all the time and everywhere. A doctor often sees & feels more than a patient can fully describe, notices symptoms or expressions the patient is not even aware of him/her self. There is merit to telemedicine, but it has its limits. Of course it gets stepped up in a crisis of contagioun – to keep patients, staff, and doctors safer. And once a crisis wanes, the use of telemedicine will logically subside.
You are overlooking the fact that telemedicine will never replace a real physical exam. The number of times looking carefully at what the patient was complaining about and touching and feeling and seeing their response to my touch and feel made a major difference in the diagnosis is very high. Patients don’t know what to look for or how to describe it. My tummy hurts versus peritonitis is rebound tenderness. Try and accurately asses that over the phone! It’s only one of many examples.