The Effect and Future of Telehealth

One of the positive things to come out of the pandemic was the sudden rise of telehealth – providing health care services remotely over video and audio platforms. This is something I was interested in prior to the pandemic, but it was frustratingly difficult to push the ball forward. Deep regulatory barriers stood in the way. For example, Medicare would only reimburse telehealth for patients in rural areas who demonstrated a specific need. Further, patients had to travel to designated locations (hospitals or clinics) to access telehealth to remote clinicians. Barriers to telehealth included state licensure requirements, reimbursement from insurance providers, institutional support, and privacy (HIPPA) regulations. This was in addition to the technology – both the physician and the patient having access to a telehealth platform.

After being mired in this bureaucratic quagmire for years, all of the barriers simply melted away when the pandemic hit. Medicare dropped all of its requirements, and many states started passing laws to require insurance coverage of telehealth, and even providing licensure reciprocity. The early days of forced telehealth were a mixed bag, because telehealth is not optimal for every patient and every visit, but there was no choice during the shutdown. Telehealth visit went from 1% prior to the pandemic, peaked at around 32% during the shutdown, and is now settling down to about 17% of Medicare covered healthcare visits.

Now, over two years later, the situation is vastly improved. Practices have had time to update and tweak the software applications used for telehealth. Patients have had time to familiarize themselves with the technology, if they were not already. Perhaps most importantly, providers and patients are able to select which patients and which visits are optimal for telehealth. While there are still some growing pains (opportunities for optimization), it now seems that telehealth is here to stay. Now that patients have had a taste of the convenience of telehealth, it seems unlikely they will quietly surrender this option.

As an example, let me present one genericized patient from my own practice (not a specific individual, but an amalgam of my typical patients). A patient with severe back pain that limits their mobility has found it difficult to come into clinic to receive care. As a result, they miss about half their appointments, and make up for this by calling the clinic with their issues and for medication adjustments. This uses a lot of staff time and is very inefficient. Further, when they do come into the clinic they have to arrange for transportation and miss an entire day of work. They live 45 minutes away, but the travel time can be much more during rush hour if they have an early appointment. The entire saga may take 3-4 hours out of their day, be extremely uncomfortable, and cost money for transportation – all to sit in front of me for 10-15 minutes to discuss their management. In many cases an exam is not necessary (I have examined them recently enough and nothing has changed).

Compare this to signing on to an app, spending 2 minutes with a nurse to update your med list, and then going right to the 10-15 minute meeting with your physician, right from your home. I have patients who do this from their office at work, or while engaged in childcare. They can also more easily have family members present with minimal inconvenience to them. This also allows me to have more frequent visits with patients when necessary.

My experience is typical. In a recent survey of physician satisfaction with telehealth:

• 85% indicated that telehealth increased timeliness of care.
• 75% said telehealth allowed them to deliver high-quality care.
• More than 70% were motivated to increase telehealth use.

Patients have a similar positive attitude. Telehealth increases access to care. It also has reduced some measures of racial healthcare disparity, such as treatment completion. It has improved access to expert care for rural and underserved populations. Telehealth reduces overhead and is simply extremely efficient for the right visits. For big medical centers, it reduces traffic, parking, and wait times.

There are still some challenges to optimally incorporating telehealth into the health care system. Even though it improves access overall, there are concerns that it may exacerbate the digital divide – relative lack of access among some marginalized populations. This has been improving with the technology, however. Patients can complete their telehealth visit with just a smartphone – even the smartphone of a friend or family member. About 92% of households in the US have some type of computer, and 84% have a smartphone. There is still a small gap, but it is steadily shrinking. In fact, it may even be cost effective for health insurance to pay for a device to use for telehealth visits for those who do not have one, rather than pay the higher cost of face-to-face visits.

After the pandemic shutdown, the one feature that reverted to pre-pandemic rules was the need for state licensure. Most states rescinded their waiver for out-of-state providers over telehealth. For example, I have patients from Rhode Island, Massachusetts, and New York who come to my clinic in Connecticut. Some patients travel for two hours to see me. They would be ideal for telehealth visits, but this is not allowed because they are out-of-state. For telehealth, states should simply change the rules so that as long as the provider is in a state where they are licensed, they can see any patient via telehealth.

Overall it is amazing how rapidly the health care system widely adopted telehealth, and that overall it worked out extremely well (unlike, say, the educational system). Telehealth is clearly here to stay, and will improve as we learn how to optimally incorporate it into patient care. The pandemic also served to reduce the unfair stigma attached to online care and unfound concerns about the effect on patient care. Telehealth is a net positive and will continue to improve health care in the future.