Telemedicine made its main-stage debut at the height of the pandemic. It’s here to stay — if insurers play along
From his desktop computer with two 27-inch monitors in his Downtown Las Vegas office, Dr. Dylan Wint recently logged onto a telemedicine visit with an elderly female patient from the Lake Tahoe area. She had asked to see Wint about her memory problems and panic attacks. She was sitting with her back to a window, her face in heavy shadow, so she carried her laptop to another spot in her home.
As she found better light, Wint noticed how slowly she moved and how her facial expressions seemed to go flat. When she confirmed that she had experienced shaking, he asked her to quickly tap her thumb and index finger onscreen to test her speed and amplitude of rhythmic movement. After the 30-minute virtual visit, Wint ordered a specific imaging test the woman was able to get in her area that confirmed she has Parkinson’s disease — something she was told had been ruled out with previous tests.
Like so many other patients, because of COVID-19 concerns and the time and expense involved in seeing a doctor in person, the woman was unlikely to travel to actually step into an examination room with Wint, a neurologist and psychiatrist who is director of the Cleveland Clinic Lou Ruvo Center for Brain Health.
“Our telemedicine program made its debut around the same time we started seeing patients in person in 2009,” Wint says. “We had a dramatic increase in virtual visits — seeing patients wherever they are, through their own online devices —during the COVID lockdown, shifting about 90 percent of our in-person volume to online platforms.”
Telemedicine use surged during the pandemic, permitting safer, more convenient, more timely access to health care. While the pandemic continues to create uncertainty, telemedicine is undoubtedly here to stay. How popular it remains, however, still depends on the vagaries of the country’s health system. But the pandemic’s effect and long-term repercussions on healthcare delivery cannot be overstated.
“The pandemic was as dramatic an impact on American society as World War II. And the telehealth change is as dramatic as World War II for the nature of healthcare delivery. It really is a major culture change,” says Dr. Jerry Reeves, a trustee and chair of the membership committee of Clark County Medical Society, and medical director of Comagine Health and the Nevada Telehealth Alliance.
Telemedicine has certainly faced hurdles: reluctance among doctors to make some diagnoses remotely; an initial shortage of webcams and video-enabled computers; inevitable forgotten or missed appointments; fragile or fussy wi-fi connections; and a learning curve for both providers and patients.
“It’s not like all of the doctors and clinics knew how to do this,” Reeves says. “Certainly the patients, especially the seniors, who don’t necessarily feel that comfortable with smartphones and computers, they didn’t get it particularly well, either. So there was a huge ramp-up in just developing the competence and the skills both as a patient and as a healthcare provider to do this well, and to do it safely.”
Forty-nine percent of Americans used telehealth during the pandemic, compared to only 25 percent pre-pandemic, according to a Time/Harris poll published in June. Older patients reported the largest increases, with those 55-64 years showing a 230 percent increase, and those 65 and older a 211 percent increase. Reeves says that surge is sustaining for nonsurgical and nonprocedural specialties in behavioral health, mental health, substance use disorders, and services for the elderly and frail with multiple, chronic conditions. “The health care professionals that deliver those health services are living a completely different life from what they were before,” he says.
Flipping the script
Telemedicine’s tentative trot became a full gallop during the pandemic for Corie Nieto, director of telehealth services for Nevada Health Centers. At the pandemic’s peak, 50 percent of all patient encounters in her 17-center nonprofit organization were virtual with the patient at home. Now it’s about 15 percent, she says. Improving the experience and sustaining the momentum of a telemedicine program that started in March 2020 are among her goals.
The script has been flipped, she says. Before the pandemic, telemedicine visits were confined to about 10 conditions that doctors felt they could effectively treat. Now it’s more like 10 conditions for which patients can’t be seen from home. Chronic conditions such as diabetes, hypertension, and skin problems that are basically under control can easily be handled remotely. In a way, Nevada’s rural character makes our state an ideal telemedicine test subject. “Rural areas often skew older and, intuitively, we thought they would not want to try telehealth,” Nieto says, “but our FB analytics show it is the older population that is utilizing telehealth.”
Insurance, as always, drives how fast healthcare delivery moves in new directions. Nevada Assembly Bill 292, signed into law in 2015, mandates that insurance companies pay for telemedicine at the same rate as they would an in-person appointment and guides Medicaid and commercial insurance payers. And on a federal level, Medicare provided waivers to pay for virtual care during the pandemic. But self-funded insurance plans don’t fall under state guidelines and can choose whether to cover telemedicine visits. And whether Medicare extends waivers, rewrites policies, or falls back to not covering telemedicine comprehensively is uncertain. “Our hope is that they all choose to cover it in the future,” Nieto says.
Also subject to the whims of insurance practices are more in-home tools such as blood-pressure cuffs, blood-glucose monitors, and more sophisticated devices that patients can use to provide real-time information to clinicians. “We’re in this weird space right now where we needed the adoption to get to that,” Nieto says, “but we are looking at home kits that have the ability to give us heart and lung sounds or look in an ear or a mouth, that are both reasonably priced and easily supported, so we can enhance our virtual visits, in the patient’s home.”
Cost is among the factors that make widespread adoption impractical in the short term, but it’s not too far down the road, says Dr. Marc Kahn, dean of the Kirk Kerkorian School of Medicine at UNLV, who anticipates more even more elaborate devices becoming routine.
“As we move forward very quickly, telehealth is going to include remote physical diagnosis with ultrasound probes and stethoscopes that are wired to transmit sounds over the internet, and even electrocardiograms and simple pathology specimens that can all be transmitted over the internet,” Kahn says. Strides in haptic technology will permit Kahn, an internist, to feel a patient’s spleen from thousands of miles away.
‘Caring for our community’
In the meantime, Kahn is working to ensure students experience telemedicine in the curriculum. Because Nevada is primarily a rural state with a chronic shortage of doctors, there is a huge need for more telemedicine, Kahn says. Nevada ranks 45th among states in active doctors per capita. Eighteen of the 50 graduates in the School of Medicine’s inaugural graduating class in May say they plan to stay in the state for their residencies. Kahn says he is also advocating for telemedicine “from a policy perspective, to make sure lawmakers realize how important telehealth is for caring for our community.”
Students will need not just technical know-how, but a shift in mindset as well. Brainstorming with colleagues over Zoom or Skype during the pandemic was one thing, but telling a doctor about a health condition in a telemedicine encounter can be more difficult. Training staff and doctors to make the healthcare experience in that realm more efficient and effective is essential.
“There’s a difference between a doctor-patient relationship in-person versus one that’s totally virtual,” Kahn says. “We don’t read emotion as well. We don’t interact with each other as well. We don’t joke around as much in the different interactions. But the combination of telemedicine and in-person medicine is really what we’re going to see.”
Depending on the specialty, telemedicine follow-ups after an initial in-person appointment can be just as good, Wint says — and a crucial tool in covering “gaps in care” that patients may experience between live appointments. Telemedicine visits can encourage a patient to better manage their medications or their blood pressure, to schedule that mammogram or colonoscopy.
“There are some subtleties about doing telemedicine that are still difficult,” Wint says. “One is just the timing. There’s a little bit of delay, and watching folks’ reactions, how quickly they can answer a question, what their reactions are to what their caregivers are saying, what their caregivers’ reaction is to what the patient is saying. That’s all information that I gather in the background. And I do feel a little bit of that void when I’m doing telemedicine appointments and the connection isn’t good and I can’t see both their faces.”
While technology always evolves, delivery of healthcare moves in fits and starts, often at the mercy of insurance imperatives. Whether there’s a regression, Reeves says, “largely depends on whether telehealth is more complicated and administratively burdensome and less compensated than in-person care delivery. … If it’s easier, faster, cheaper for the patients to get it through telehealth, that’s what they’re going to do. If it’s easier, faster, cheaper for the docs to deliver it that way, that’s what they’re going to do.”