WASHINGTON STATE — Emily Groff had never considered telehealth until her abdomen started hurting. Even then, she wasn’t convinced it would help.
It was late March, at the start of the COVID-19 pandemic and shortly after Gov. Jay Inslee ordered the state’s health care providers to stop all in-person non-emergency medical and dental treatment to conserve meager supplies of personal protective equipment – a moratorium that would last for two months.
To Groff’s surprise, the doctors did not need to examine her in person to correctly diagnose the problem: Gallstones.
“It was a little awkward at first, but I got used to it pretty quickly,” said Groff, 44. “I don’t have any reservations about doing it anymore.”
Neither does Tammy Kesler, who like Groff, lives on Bainbridge Island across the Puget Sound from Seattle, where hospitals and most specialists are a 30-minute drive or ferry ride away. In fact, during her two recent televisits the doctors spent more time with her than in any in-person visit she can remember, Kesler said.
“I would do it before ever going to the doctor in person again.”
Across the country, the use of telemedicine has skyrocketed during the coronavirus pandemic. This came as federal and state policymakers eased restrictions on this once-niche method of care delivery and providers and patients discovered new motivation to try it.
The long-term impact of this broad experiment is still unknown but could have enormous implications for the future of rural care.
Before March, during the average week about 13,000 Medicare beneficiaries received telemedicine services nationally, Centers for Medicare & Medicaid Services Administrator Seema Verma recently wrote in an analysis of claims data published by the Health Affairs blog. During the last week of April, that number rocketed to nearly 1.7 million. In rural areas, 22 percent of Medicare beneficiaries used telemedicine services from mid-March through mid-June.
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In Washington, telehealth-friendly Medicaid policies and new payment-parity rules for private insurers helped health care providers keep revenues trickling in during the governor’s moratorium.
“It saved their bacon,” said retiring state Sen. Randi Becker, R-Olympia, who championed the parity bill.
Becker has worked for years to expand telemedicine in the state. The former health care administrator grew up on a dairy farm outside of Enumclaw, a town of around 12,000 people in the Cascade foothills. She knew what it was like to have to drive a half-hour or more to see a specialist.
But before COVID-19, fewer than half her constituents even knew about telemedicine, according to survey responses. Fewer still indicated they might try it. That all changed with this spring she said, adding that she’s since heard several positive comments from constituents who had their first virtual doctor visits.
“They felt they had equal, or in some cases better care, because of the fact that they didn’t have to drive and wait.”
Becker’s bill, SB 5385, was signed on March 19 and fast-tracked by executive order, making Washington one of only a handful of states with laws requiring private insurers to pay the same rates for telemedicine and in-person patient visits.
Dr. Geoff Jones, a primary care physician at the Newport Community Hospital in Pend Oreille County in far northeastern Washington, knows firsthand the concerns that had previously dogged providers considering offering virtual patient visits.
Jones, who is also assistant clinical dean for the University of Washington School of Medicine in Eastern and Central Washington, has been part of the Project ECHO telementoring program for several years. The program connects doctors by videoconference to present their cases to a panel of experts, which help them diagnose and treat complex health problems like Hepatitis C, opioid addiction and chronic pain.
When he floated the idea of using telemedicine for patient care before COVID-19, he said he encountered several barriers. Administrators worried about repayment. There were logistical and scheduling challenges. Doctors were concerned about care quality. There was no real agreement about which technology to use.
With the pandemic, “all those barriers just went away,” Jones said.
He said it took less than a week to agree on a platform, develop protocols and get the new system running. And while there are obvious limitations — “it’s impossible to open up an abscess over the phone,” Jones said — he’s finding surprising benefits to having a new window into patients’ home environments.
“It’s almost like a home visit,” he said.
To protect patient confidentiality, Jones offered a hypothetical example: A patient who says they live in a trailer 5 miles out of town.
That “trailer” could be a leaky, run-down hulk or a modern Airstream – a distinction that can have implications for diagnoses and treatment, but which would be hard to figure out in an office visit, he said.
Jones’ hospital is staffed by a general surgeon and a handful of primary care physicians. It does host some visiting specialists, but patients routinely have to drive an hour to Spokane or Coeur d’Alene, Idaho, for care.
Like many rural areas around the country, Pend Oreille County’s population is older and poorer than average. Jones’ patients are more likely to have chronic medical conditions like diabetes and heart disease. Over the long term, Jones sees particular usefulness in helping patients manage those conditions through a mix of in-person and virtual appointments.
He would like the hospital to offer telemedicine rooms to facilitate visits with out-of-town specialists and keep offering remote consultations to patients in their homes, when it makes sense.
Although much of the sudden interest in telemedicine was a response to a temporary crisis, there are efforts to cement recent policy changes. Thirty-eight U.S. senators have signed on to a July 2 letter asking CMS officials to submit a plan and timeline for making federal telehealth-related changes permanent, as well as a list of those that would require congressional action.
Experts say telemedicine is still a work in progress. Important questions remain about best practices, reimbursement and the balance of patient privacy with user-friendly technology. Especially in remote rural areas, a lack of broadband infrastructure continues to be an impediment.
Notable telehealth changes include:
- In early March, The Centers for Medicare and Medicaid Services dramatically expanded telehealth coverage for its 44 million beneficiaries during the public health emergency. One critical change allowed patients to consult with providers from their home.
- Later that month, the Department of Health and Human Services relaxed enforcement of patient privacy laws for telehealth consultations using popular but less-secure video communication tools like Skype, Facebook Messenger or Zoom.
- CMS later expanded approved telehealth providers to include physical therapists, occupational therapists and speech language pathologists, and allowed audio-only visits for many behavioral health and patient education services.
- The CARES Act directed CMS to pay for telehealth provided by rural health clinics. It included $11.5 million in new funding for the National Consortium of Telehealth Resource Centers – a network of 14 centers administered through the Federal Office of Rural Health Policy to provide providers with technical support. The legislation included $200 million in funding to help providers offer teleservices to patients at home or in mobile locations, and up to $100 million over three years to study ways to use the Universal Service Fund to connect low-income patients and veterans.
Jennifer Hemmingsen is a journalist in Washington state who contributes occasionally to IowaWatch.