By Deborah Borfitz
May 12, 2020 | Over the past few months, necessity has been the mother of invention for thousands of primary care physicians forced to practice medicine amidst a public health crisis. Seemingly overnight, telemedicine—a technology lightly employed for decades—became the most popular offering in healthcare. Removing the regulatory barriers and paying doctors a fair price for virtual patient visits are what made it all possible, according to Jacqueline Fincher, M.D., a private-practice internist in rural east Georgia and newly seated president of the American College of Physicians (ACP).
Telehealth, and particularly the use of video calls, was enjoying a modest gain in popularity even before the COVID-19 pandemic upended the practices of healthcare providers, Fincher says, citing results of the latest ACP member survey conducted between December 2019 and January 2020. But those telehealth statistics would likely be dwarfed by current, real-world usage among practitioners trying to keep as many patients as possible safe at home. “It’s a viable substitute” for face-to-face visits, she says, “at least for now.”
The enduring value of telehealth is between, rather than in lieu of, office visits, says Fincher, most importantly keeping patients stable and out of expensive emergency rooms [ERs] and hospitals. “You don’t want to be there unless you absolutely have to be.”
In-person visits could never be replaced by telehealth, she emphasizes, because being a physician is all about “the laying on of the hands.” The physical exam is about more than monitoring vital signs; it’s also about detecting irregular heart rhythms and listening for wheezes in patients’ lungs and bowel sounds in their gut, and discerning if their chest pain is cardiac, reflux, or musculoskeletal pain.
Moreover, a bathroom scale and a blood pressure monitor aren’t necessarily available at home, Fincher adds. When the patient complaint is a swollen leg, it can be difficult using video alone to distinguish mild edema (treatable with compression hose or a mild diuretic) from a clot in one leg or heart failure requiring multiple medication adjustments to prevent a trip to the ER.
For a patient complaint of a potential urinary tract infection, a laboratory test is the only sure-fire way to make the diagnosis, continues Fincher. Guessing wrong, based solely on symptoms, can miss a pelvic problem requiring a gynecologic exam or a diagnostic test, and lead to inappropriate prescribing of antibiotics that can contribute to antimicrobial resistance and doesn’t treat the actual medical problem.
Both are real-world examples of when it is a better bet for patients to make a planned trip to the doctor’s office during a pandemic than risk their health and finances with an emergency visit to a hospital.
As a practicing physician herself, Fincher has some firsthand experience with the telehealth transition. Before the COVID-19 outbreak hit Georgia in mid-March, few providers in the state were using the technology and a lot of that had to do with reimbursement and geographic restrictions, she says. Doctors were paid less for telehealth visits than for office visits and had to meet certain site requirements to qualify for payments. For new Medicare patients, the Centers for Medicare & Medicaid Services (CMS) recommended that telemedicine not be used at all.
Patient safety during the pandemic has been a top driver of physician and other clinician interest in telehealth, says Fincher, particularly keeping communication channels open with patients about their chronic medical problems and preventing disease exacerbation. But an equally important driver was loosening of restrictions by CMS and many private payers, allowing parity in pay for the evaluation and management codes specific to telemedicine, telehealth coverage for new-patient visits and patient copays for the virtual visits to be waived.
The pay parity provision, in addition to the Paycheck Protection Program of the Small Business Administration, has been “huge, particularly in terms of keeping our independent primary care practices open and our staff employed,” Fincher says. Many primary care physicians, especially in the Southeast and Midwest, have remained independent practitioners. The concern is that some of these practices will eventually be forced to shutter, reducing access to primary care physicians already in short supply in some regions.
The cost of the technology has not been a big issue for at least the past five years, since most physicians are now using an electronic health record with a built-in telehealth module, Fincher continues. One of the most frequently used independent platforms, Doxy.me, is available free of charge and the more robust paid version used by the 36-physician Center for Primary Care (where she practices) is a “very reasonable” $35 per physician per month.
“Our CEO had us up and running on Doxy.me in 48 hours,” she says. “We went from doing no telehealth at all to suddenly doing 50% [now 80%-90%] of visits via telehealth.” It has overall been a good experience, although not all patients find it intuitive to click through a couple of boxes to get set up for their first online visit.
Fortunately, older patients in their 80s and 90s who haven’t personally embraced a lot of technology often have children available to help them get connected to their doctor virtually. Video chats tend to work better than telephone-only visits with these patients, she notes, especially if they have difficulty hearing or get easily confused about the multiple medications they’re taking.
In rural areas, internet broadband can be a big barrier, says Fincher, who resides 40 miles outside of Augusta. Even if patients have a smartphone, they don’t have enough bandwidth to open the app her office uses for telemedicine. The only available hot spot for some people is the county library, and from their car when it is closed or has reached social distancing capacity.
The telephone remains the best telehealth option for many patients, given the fact that 90% of information exchanged between physicians and patients is verbal, Fincher says. Although CMS has been reimbursing for the audio-only visits at “less than 50%” the rate for video calls, the agency just reversed its position.
As announced April 30, CMS has increased payments for telephone visits to match that for similar office and outpatient visits. This increases reimbursement for these services from a range of about $14-$41 to about $46-$110—and the payments are retroactive to March 1, 2020.
With more than 159,000 members, the ACP is the largest physician specialty organization in the world, Fincher says. In collaboration with the American Medical Association and the American Academy of Family Physicians, the ACP has taken a leadership position in educating physicians about how to get started in telehealth as well as advocating for reasonable rules and regulations regarding its use by primary care physicians and internal medicine subspecialists, including pay parity for video and telephone-only visits.
COVID-19 educational resources are all freely available on the ACP website, including how to bill for and get paid for telehealth services.
It’s important to understand the limits of telemedicine as well as its potential, says Fincher. “Just like going to an important business or educational meeting, you can get the same information in a virtual way, but some of the most important and insightful moments are the side conversations and social interactions you have with your other colleagues.”
Frequently, only in the “sacred space” of the exam room are emotional and mental health matters allowed to be freely expressed, Fincher continues. “It can be difficult to make that important personal connection of conveying trust and empathy for patients over video, especially if it is a very sensitive problem or issue.”
Telehealth visits can “feel public, like you’re on TV,” she says. “Certainly, with brand new patients, you want to see them first face-to-face. But when you have a public health crisis situation, you just have to make do with the best substitute available.”