The pandemic has opened the doors for a long-awaited boom in remote care
By Jon Bell
Think back, way back, to February of this year, a time when the initial rumblings of a novel strain of coronavirus spreading across the globe were just beginning to amplify. It was a time before masks, stay-at-home orders and social distancing, a time when hospitals and clinics were still seeing patients almost entirely in person and telehealth services were but a blip, albeit a brightening one, on the radar.
Six months ago Oregon Health and Science University logged just 300 virtual visits through its online patient portal known as MyChart, a system that lets patients connect with providers via a two-way video connection. In March, after the World Health Organization declared COVID-19 a global pandemic and Oregon Gov. Kate Brown issued sweeping policies to tamp down the spread – including banning nonessential surgeries and elective medical procedures – OHSU saw its MyChart visits jump to 3,700, with upwards of 10,000 in April. In roughly the same timeframe, the hospital also saw all digital visits rocket from 1,100 in February to nearly 13,000 in March.
And there appears to be no slowing down. Though telehealth – the delivery of health care services remotely through the use of audio and video platforms – had been slowly gaining steam in recent years, state and federal regulations limited the practice. But when COVID-19 showed up and people were no longer able to go see their doctors or visit the hospital unless they really needed to, telehealth jumped into the spotlight.
Its newfound prominence and widespread adoption by providers and patients alike is just one of the more positive impacts that COVID-19 has had on hospitals and health systems in Oregon and around the country. From new ways of delivering care to shifts in how health care will be paid for, the pandemic is changing the health care world – and in many cases, for the better.
“I think the doors have really been blown open on telehealth,” said Katie Harris, director of rural health and federal policy for the Oregon Association of Hospitals and Health Systems. “This is the push we needed to really move forward. It’s one of the really good things that will come out of this public health emergency.”
A history of being hamstrung
Prior to COVID-19, telehealth had been emerging and evolving, but its use was far from widespread. Advances in technology had been helpful in improving how providers could connect with patients remotely, but federal and state regulations made it challenging for telehealth to really take off.
Those regulations limited what kinds of providers could use telehealth, what types of services could be offered and which patients were eligible. For example, regulations limited which facilities could provide telehealth services; some practitioners, such as physical and occupational therapists, speech language pathologists and others, were not allowed to offer telehealth either.
Payment for telehealth had also been an issue. According to Harris, the federal office that scores medical bills always treated Medicare telehealth visits as duplicative visits, not replacement ones, as patients would regularly have a telehealth consultation followed by an in-person visit. That led to those bills being scored as much more expensive. In addition, hospital clinical staff had simply not been able to bill for telehealth in a very widespread or efficient way.
“All of that has sort of hamstrung telehealth for a while,” Harris said.
She also noted that insurance providers have also been reluctant to pay for telehealth services at the same rate as in-person visits.
“They say a telehealth visit is not as expensive, so insurance wants to pay less,” Harris said. “A lot of times they’re paying $15 or $20 for a telehealth visit. You can barely make up your expenses at that rate.”
Throw in the lack of reliable broadband internet connections in rural and underserved parts of the country, and the result has been that telehealth has never been able to take off. According to the Department of Human and Health Services, before the pandemic only an average of 14,000 Medicare beneficiaries in the entire country received a telehealth service each week. This February in Oregon, of the 210,183 primary care visits just .1% were telehealth.
The pandemic play
But then came the pandemic and the orders to stay at home and avoid clinics and hospitals unless absolutely necessary. And with it came a temporary loosening of the restrictions that had been hobbling telehealth. HHS relaxed rules with a waiver, allowing more providers to offer telehealth to more patients from more facilities. They added 135 services, including emergency department visits, initial patient and nursing facility visits and discharge day management services that could be delivered via telehealth.
Additionally, Oregon's department of Consumer and Business Services directed commercial health insurance plans to cover telehealth services at the same rates as in-person ones. Platforms that had before not been permitted for telehealth, such as Zoom and Facetime, were now allowed, at least during the pandemic.
The result? Nationally, while telehealth accounted for just .1% of Medicare primary care visits in February were telehealth, by April it was more than 43%. In Oregon, telehealth made up 46% of total visits in April.
“With regulations being lessened, it really opened it up,” said Michelle Gardner, clinic director at Wallowa Memorial Medical Clinic in Enterprise, which is affiliated with Wallowa Memorial Hospital (WMH). She said prior to the pandemic, the clinic had not been able to offer much telehealth, but since the waiver patients have received virtual office visits, physical therapy and some other services. Despite a few bumps over reimbursement at the start of the pandemic, Gardner said the expanded telehealth services have been going well.
Joe Wanner, Chief Financial Officer for WMH, said the hospital hasn’t expanded its telehealth offerings markedly, but it has been offering more home visits and curbside services to meet demand in ways that are convenient and accessible to those who may still be reluctant to travel to the facility.
“The census on the floor in the hospital was lower, so we wanted to offer home visits and curbside because patients were staying home,” he said. “We wanted to make sure we could get them the care they needed.”
Providence Health & Services has seen virtual visits at its medical groups soar to more than 25% of the total. Its emergency room visits were down in July 2020 about 13% from the year before, which Chief Financial Officer Melissa Damm said is a concern but also an incentive to continue pushing the telehealth option.
“We remain concerned that patients are avoiding necessary care out of fear and continue to encourage them to get care, whether emergent through an ER or virtually with their provider,” she said.
Expanding telehealth has also helped hospitals and clinics from a financial standpoint. With fewer people leaving their homes for treatment, hospitals in Oregon were losing money. Estimates suggest Oregon hospitals lost $200 million in March alone and likely lost about $13 million per day in April.
‘It’s what patients want’
As of late August, the COVID-19 pandemic was still in full force across the United States and in Oregon. And, as they’d been doing since the start of the outbreak, hospitals and clinics around the country were offering telehealth services to help people get the care they need.
While that’s largely gone well for most providers, there is one area of concern that has people uncertain about the future: Most of the flexibilities that have been allowed for telehealth as a result of the pandemic are temporary. They have been extended each time the public health emergency declaration has, but there’s no guarantee that they will become permanent. If the temporary waivers expire, the growth of telehealth would likely suffer.
“It has really changed everything, but we don’t know to what extent permanently,” Harris said. “A lot of what’s happening right now is happening under waivers from the federal government. Congress and CMS have expressed interest in making them permanent, but not yet.”
Whether those waivers become permanent or not remains to be seen, but there’s one thing that is certain: Telehealth is likely here to stay, thanks in part to COVID-19. Harris said “the genie’s out of the bottle now,” and Wanner, from WMH, said it would be wise to keep telehealth a regular option for people everywhere.
“Hopefully they’ll allow us to continue this into the future,” he said, “because it’s what patients want.”