Curbside Consult with Dr. Jayne 6/15/20

I had the chance to catch up with a good friend last week. We were talking about the odds of telehealth truly achieving payment parity and continuing into the future. We share a healthy dose of skepticism, mostly around the fact that payers (including CMS) aren’t going to want to pay the same amount for an item that they used to get for less, and in some cases, for free.

Unless they’re involved in administration or work in a multi-state organization, most physicians don’t realize that CMS has different payment rates depending on what part of the country you’re in. These rates vary due to labor and real estate costs – it’s more expensive to hire nurses in the San Francisco area than in rural areas of the Midwest, for example. There have also been special payments to certain sites of care, such as designated Rural Health Clinics.

Providers are excited about being able to see patients in their own homes from their own homes, cutting down on commuting, office costs, budgets for professional clothing, and more. The reality, though, is that CMS and other payers are going to feel like they’re subsidizing your love of fuzzy bunny slippers, and it won’t be long before there is an adjustment.

CMS leadership has stated “I can’t imagine going back” and “People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits.” I think a lot of folks in the technology space, especially those looking to get their piece of the pie with telehealth, are missing the key connection between doing the work and getting paid for it. Although equal payment drove the expansion of telehealth during the pandemic, it’s a good bet that once the payments start changing ,we start to see more visits being pushed back to the office setting unless providers are participating in programs where they’re paid on a capitated basis versus fee-for-service.

Mr. H picked up on conflicting comments that CMS has made around the long-term viability of telehealth and mentioned them earlier in the week, especially those made during announcements encouraging a return to face-to-face visits that “while telehealth has proven to be a lifeline, nothing can absolutely replace the gold standard: in-person care.” I bet it won’t be long until they begin changing the payment structure.

Another dose of reality comes in the readiness of practices to actually see patients in person. Despite the multiple announcements encouraging patients and providers to get back to business as usual, some facilities just aren’t ready. I continue to hear from colleagues who can’t get adequate supplies of personal protective equipment, and  when they find supplies, prices are exorbitant. It seems like not much has changed since the start of the pandemic as far as the availability of N95 respirators, despite our having had months to ramp up the supply chain.

My employer has provided four N95s to each employee, which we are expected to rotate indefinitely until they become soiled or the straps break, in which case we can get a new one. If I want to take advantage of the Battelle hydrogen peroxide processing unit that my state has brought in, I have to personally drive my masks to a drop point across town, wait three days for them to travel across the state and be processed, and then drive across town to pick them up. We have one option for masks and no formal fit testing (since CDC waived it due to the public health emergency), so doing your own quickie fit test every time you put it on is how we roll. If you become allergic to the foam on the office-provided masks as some of us have, you’re kind of on your own since officially the CDC says we don’t need N95s and that simple surgical masks are OK since there are shortages.

For providers, continuing or expanding telehealth necessitates understanding the reality that telehealth requires a paradigm shift, and not everyone can make the jump easily. You have to go from being able to use reliable measurements performed by your staff to trusting patient-reported data or hoping that your patient can use available technology to capture their vital signs or pictures of a rash. You have to also start trusting other indicators of a patient’s status, such as level of anxiety, tone of voice, etc. that some have tuned out during in-person visits because it seems like many patients are anxious and stressed by the entire in-office visit process, especially if it occurred at a large healthcare complex with parking challenges, wayfinding issues, etc. Additionally, some specialties aren’t amenable to telehealth visits, so brick-and-mortar offices will continue to be a must.

For patients, access can be a double-edged sword. While some rural communities have embraced telehealth as a way to avoid long and time-consuming travel, others struggle with the connectivity that is needed for successful telehealth visits. Although the majority of adults in the US have access to a smart phone, that doesn’t mean that it’s their personal phone or that the access is 24×7. Sometimes it takes patients a couple of visits to get the hang of telehealth, and even then there can be issues with dropped calls or anxiety about displaying video of their living situation.

Only time (and the will of patients and payers) will tell how this is going to play out. If payers cut back, will we reach a point where patients will be willing to pay a premium for telehealth visits? Will clinical employers use telehealth as a way to shift more burden (including scheduling, pre-visit data gathering, and more) onto providers while saving money on ancillary staff salaries? Or will they embrace using ancillary staff to continue to perform pre-visit clinical work to better support physicians? Will telehealth technology improve to a point where it’s almost like being there, perhaps with the addition of virtual reality devices? Will data from third-party tools flow seamlessly into the EHR, or will we be stuck working with multiple systems and siloed data?

I’d be interested to hear what the HIStalk community thinks. What does your crystal ball say? Leave a comment or email me.

Email Dr. Jayne.