The use of telehealth in the fee-for-service program surged by more than 4000% during the first 6 months of the COVID-19 pandemic.1
Pandemic-related telehealth policy changes helped to enable quick adoption of telehealth as well as voracious innovation, enabling the allocation of appropriate resources to rural and urban disadvantaged communities, said Chevon Rariy, MD, Vice President and Chair, Virtual Health, Cancer Treatment Centers of America, who moderated a panel on the impact of telehealth and digital tools on quality, access, and cost in cancer care, at the 2021 Summit of the Association for Value-Based Cancer Care.
“I do think that in the years ahead, we’re going to see a lot more individuals have access to the right type of expertise for their disease. And not allow their zip code to basically determine their medical destiny, because of the ability to access virtually the right expertise,” said Lewis Levy, MD, FACP, Chief Medical Officer, Teladoc Health.
“Further expansion requires a change in the statute for fee for service,” said Lee Fleisher, MD, Chief Medical Officer, Center for Clinical Standards & Quality at the Centers for Medicare & Medicaid Services (CMS). “We do have what’s called virtual check-ins that have been proposed, initially time codes of 1 to 10 minutes. But we propose to pay for 11 to 20 minutes.”
In addition to covering benefits in Medicare Parts A and B, Medicare Advantage can offer additional telehealth services. “We’re continuing to explore where we think this [telehealth] should go,” Dr Fleisher said.
“Our electronic health record has a telehealth system built within it,” said Melissa Dillmon, MD, FASCO, Hematologist/Oncologist, Harbin Clinic Medical Oncology Rome, GA. “It has been a monumental change in the way we think about things, but I think it has been a tremendous service.” For example, communicating an abnormal lab result or a prostate-specific antigen value does not require an in-person visit, Dr Dillmon said.
Telehealth visits at her clinic numbered approximately 7000 visits per month early in the pandemic, dipped to approximately 2000 visits over the summer of 2021, and increased again with the emergence of the Delta variant, she said.
“One of the areas that we are most excited about is around delivering a diversity of services through our platform,” said Dr Levy, emphasizing “our ability to reread the original pathology and get all relevant imaging and data regarding case reviews that can result in very significant changes in diagnoses and treatment plans for patients in the oncology space.”
Sara Dolcetti, MBA, MS, Oncology Solutions and Business Development Leader, Philips, said that her organization is focused on ensuring that telehealth services writ large are not a pandemic-only tool. The Philips company is also helping its members operationalize hybrid approaches, “because we know that telehealth is not for everyone nor for every situation,” she said. “The third thing we’re focused on is acknowledging that we had a problem with access and with disparities well before the pandemic hit. We believe there’s a unique role that telehealth has in terms of eliminating disparities. It’s not only an opportunity, but an obligation that we have as a society.”
GoMo Health integrates psychosocial support into the clinical pathway and the protocol to better engage health at home, said Bob Gold, MS, Chief Behavioral Technologist and Chief Executive Officer at GoMo Health. “Especially with oral oncolytics at home, getting real-time information from the patient and feeding it back for treatment decisions has resulted in reducing avoidable emergency department visits by over 50%, reducing avoidable re-admits by over 50%, and creating a better experience for the patient,” he said. The real-time data presentation also helps to reduce oncologist and nurse fatigue, he said.
“One of the earliest televisits I did was with an elderly woman, and she couldn’t get here. She didn’t have a smart device,” recounted Dr Dillmon. “Home health went out to her home. Took the iPad. We did a telehealth visit. I got to see her. They did her vitals right there, while I was watching her. They were able to do things for me. Otherwise, I don’t know when that woman would’ve felt safe coming back into my office. That was to me an eye-opener about what the future might hold.”
The reduction in stress for family caregivers with telehealth availability is also notable, said Mr Gold.
Dr Levy recalled his telemedicine experience with a program developed for foster children, who often bounce from pediatrician to pediatrician, by Cincinnati Kids. “Through our technology, Cincinnati Kids was able to keep a primary relationship going, even though the actual child was moving all over the state,” he said. “They no longer had to have 5 different pediatricians; they were able to stick with the same pediatrician throughout their growing up years.”
In response to the COVID-19 public health emergency, CMS allowed consultations from institutions out of state, temporarily exempting the state-based licensing requirement, said Dr Fleisher. “After the public health emergency, whether we use telehealth or not, whether we will allow practice across state lines is a major question,” he said.
The geographic and originating site limitations were put in place in 1997, which was a decade before the release of the iPhone, noted Ann Mond Johnson, Chief Executive Officer, American Telemedicine Association, Arlington, VA. The geographic waivers granted by CMS during the pandemic should be made permanent, she believes, “because otherwise we are going to go off what we call this telehealth cliff. It is going to be disastrous for Americans, both clinicians and consumers.”
The digital pathology that telehealth enables allows multidisciplinary care teams to have access to data to make clinical decisions, said Ms Dolcetti, who sees continued digital access to data as paramount. “One of the challenges might be reimbursement and how that’s treated going forward, as well as the incentive to adopt some of these solutions,” she said.
Collecting outcomes data on telehealth intervention will be important to CMS in making future reimbursement decisions, said Dr Fleisher.
Although randomized studies would be ideal, “we’re in the middle of a big experiment right now,” admitted Ms Johnson. “We have to grab the information where we can, and start laying a path forward so that that real-world data can inform the next steps.”
Although the focus has been on broadband as the key to having access to telehealth services across the country, “what we’ve found is that broadband and connectivity is really the tip of the proverbial iceberg,” said Ms Johnson. “In other words, there are much more profound issues that we have to resolve as it relates to ensuring that people get access to services where and when they need it. If you look beyond broadband and connectivity, you have affordability of the devices, of the data plan, of the services themselves, and ensuring that people can actually afford to have these things done or afford access to them.”
Creative thinking is needed in the regulatory atmosphere and in the payment structure, including incorporation of telehealth into value-based payment arrangements, to pave the way forward for virtual care, said Dr Levy.
To enhance access to telehealth, Mr Gold said that GoMo Health will inquire about patients’ digital plans to engage them in the most feasible and economical way. To further clinical trial participation by underserved populations, GoMo Health is coordinating with health systems and social service organizations.
“We’re putting physical telehealth kiosks in very underserved communities and providing a way for them to access, in a hub-and-spoke model, to participate in a clinical trial, which may be at a major hospital…but they’re not comfortable going there just yet,” he said.
“I want telehealth to bring more studies out to me,” said Dr Dillmon. “I want the big studies from Emory or Vanderbilt or University of Alabama Birmingham to be able to come to me.”
- Whaley CM, Pera MF, Cantor J, et al. Changes in health services use among commercially insured US populations during the COVID-19 pandemic. JAMA Netw Open. 2020;3:e2024984. doi: 10.1001/jamanetworkopen.2020.24984.