Covid-19: Telemedicine key to US health care even after pandemic ends


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  • Monday, 04 May 2020

A patient sits in the living room of her apartment in the Brooklyn borough of New York during a telemedicine video conference with a doctor. Doctors and advocates of telemedicine say that the administration should restore patient privacy protections by ensuring that once the pandemic has passed, only those telemedicine platforms that encrypt information and are safe from hacking are used. — AP

WASHINGTON: As thousands of patients struck by Covid-19 rushed to seek treatment in overcrowded New York City hospitals, intensive care specialists more than 350 miles away at the University of Pittsburgh Medical Center stepped up to provide remote assistance to beleaguered colleagues in New York.

Specialists in Pittsburgh can read the electronic medical records of Covid-19 patients at the New York-Presbyterian Weill Cornell Medical Center in Lower Manhattan and use telemedicine platforms to provide advice, for example, on how to care for patients on ventilators.

“There are more patients than ICUs or trained physicians can take care of” in New York, said Robert Bart, the chief medical information officer for the Pittsburgh Medical Center. To bridge the gap, New York asked nonintensive care specialists or so-called hospitalists to “manage the less acute patients on ventilators”.

Although hospitalists can manage patients who are not on ventilators, they need the assistance of intensive care specialists to guide them on how to manage settings on ventilators to match the needs of patients, said Bart, who's also a pediatric intensive care physician.

The electronic as well as audio-video interactions between physicians in New York and intensive care doctors 370 miles away in Pittsburgh, either through FaceTime or a dedicated telemedicine platform such as Vidyo, are possible because US federal and state governments have eased restrictions on sharing patient data as well as lowering barriers that prevented widespread use of telemedicine.

The Centers for Medicare & Medicaid Services on March 17 said it was waiving restrictions on telehealth services “so that beneficiaries can receive a wider range of services from their doctors without having to travel to a health care facility”. Before that waiver, Medicare would only pay for telehealth when the person receiving the service was in a designated rural area and went to a designated location to get a telehealth consultation.

CMS also said the waiver would remain in place for the duration of the coronavirus health emergency, and the agency would pay doctors and hospitals for telehealth services at the same rate as in-person services. CMS said the Department of Health and Human Services also would ease back on enforcement of patient privacy requirements under the federal law restricting release of medical information, so that doctors can use FaceTime, Skype, WhatsApp and other video platforms to consult with patients.

Those waivers came after Congress passed legislation providing economic relief to address the Covid-19 crisis and gave the HHS secretary the authority to waive restrictions on telehealth. The legislation also provided US$200mil (RM859.50mil) to be administered by the Federal Communications Commission that would fully fund health care providers for their telecommunication and information technology requirements, and for devices they buy and use for remote consultations.

Since the public health emergency and the relaxation of rules, the use of telehealth services has exploded across the country, according to the American Telemedicine Association, which represents hospitals, technology companies and others. The Moffitt Cancer Center in Tampa, Florida, has seen a 5,000% increase in virtual visits in the past few weeks, and the University of Pittsburgh Medical Center also has seen telehealth encounters increase from approximately 200 in early March to more than 7,500 in early April, a roughly 35-fold increase in just over 30 days.

Doctors, advocacy groups and some lawmakers say that restrictions on widespread use of telemedicine should be lifted permanently once the Covid-19 crisis eases, and are calling on Congress to change laws so they would allow its more unrestricted use.

"Many of the things that CMS has moved forward for compensation for telehealth and telemedicine... a lot of that needs to continue," Bart said. And Medicare should also continue paying for telehealth at the same rates as face-to-face care, whether such visits are for diagnostic or therapeutic reasons, he said.

Patients who have got used to the convenience of a telehealth consultation during the crisis are unlikely to want to go back to face-to-face interactions with doctors for routine purposes, said Mike King, director of network and telecommunication operations at the University of Texas Medical Branch at Galveston.

"Why should I go into a doctor's office for a face-to-face consultation and waste half a day when I can do it from my office" using a telehealth platform, King said, speaking of patients' mindset during a recent roundtable discussion organized by Cisco.

“Moving forward we will see much broader interest from patients and providers in using technology to meet a lot of needs that previously would have required an in-person visit,” said Kevin Harper, director of public policy at the American Telemedicine Association. “Congress will need to carefully consider the implications on both patients and providers in shifting back to the pre-Covid restrictions, especially as providers and delivery systems continue to heavily invest in telehealth to meet patient demand.”

But doctors and advocates of telemedicine also say that the administration should restore patient privacy protections by ensuring that once the pandemic has passed, only those telemedicine platforms that encrypt information and are safe from hacking are used.

In Congress, lawmakers who have been pushing to expand the use of telemedicine are reviewing how the widespread use of technologies to obtain health care can be sustained once the Covid-19 emergency eases.

Sen. Brian Schatz, author of a bipartisan proposal backed by 15 Democrats and 17 Republicans to expand the use of telehealth, continues to be interested in widespread use of technologies to provide health care, a spokesman for the Hawaii Democrat said.

Sen. Cindy Hyde-Smith, a Mississippi Republican who has backed the Schatz bill, also is seeking to sustain the expanded use of telehealth, an aide said.

The Congressional Budget Office has consistently estimated that expanding telehealth services would cost the taxpayers more through higher Medicare payments. The CBO, for example, estimated that the current set of waivers allowing physicians to provide more telehealth services during the pandemic would cost taxpayers US$500mil (RM2.14bil) more.

At a March 11 hearing of the Senate Appropriations subcommittee on the legislative branch, Hyde-Smith pressed CBO Director Philip Swagel to explain whether the agency's analysis considered possible savings that could result from expanded telehealth use.

“If seniors avoid the necessary care because of fears of getting the virus at the doctor's office, this could lead to higher costs down the road if the virus is not caught earlier and chronic disease is not managed,” Hyde-Smith said, explaining the potential savings.

Swagel said his office had considered the savings that could result from earlier detection and management of care but added that not all increased usage of telehealth services would result in such savings.

On the House side, Oregon Rep. Greg Walden, the top Republican on the Energy and Commerce panel, “thinks regulations that have been waived need a high bar to come back,” a committee aide said. “We are going to examine what worked, what did not, and what policy changes should be kept on a permanent basis.”

Meanwhile, a bipartisan group of lawmakers has a new bill that would expand telehealth options for senior citizens who live in nursing facilities during the Covid-19 pandemic.

Democratic Sens. Amy Klobuchar of Minnesota and Bob Casey of Pennsylvania have been joined by GOP Sen. Shelley Moore Capito of West Virginia on their bill. A companion bill in the House by Illinois Democrat Jan Schakowsky and New York Republican Peter T. King has won endorsements from the AARP and a slew of other organisations that advocate for the sick and elderly.

The bills would authorise an emergency appropriation of US$50mil (RM214.87mil) for the Health and Human Services Department to help nursing facilities that receive Medicare or Medicaid funding so they can expand telehealth services.

Expansion of telehealth services often has been accompanied by worries that patients would overuse it by checking with doctors too frequently about minor symptoms, and therefore increase costs, said Joel White, executive director of Health Innovation Alliance, a coalition that represents patients, doctors and insurance companies.

For that reason, most Americans who get their health care through their employers, and already have access to telehealth services provided by their insurance companies, usually are asked to pay a higher share of costs for telehealth consultations, White said. But insurance companies also weigh the costs of having a parent take a sick child into an emergency room versus having them do a telehealth consultation, which is usually a lot cheaper, he said.

Typically, private insurers have a roster of physicians and nurse practitioners who provide remote consultations instead of the usual doctors patients might see in person.

Bobby Mukkamala, a head and neck surgeon in Flint, Michigan, and a member of the board at the American Medical Association, said he hadn't done telehealth consultations until a few weeks ago when patients were reluctant to visit in person.

Mukkamala said he had heard and seen billboards from hospitals advertising telehealth services and had been skeptical, but after doing a handful of consultations using WhatsApp, he said, “my mind has shifted.”

Instead of having patients connect with a general physician for an ear, nose or throat problem, "who best to diagnose an ENT problem than an ENT doctor," he said.

"Fast forward six months, we don't want to go back to the old way of seeing 30 to 40 patients a day in the office," Mukkamala said. "Everyone I know is trying to incorporate telemedicine into their regular practice." – CQ-Roll Call/Tribune News Service

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