Curbside Consult with Dr. Jayne 5/24/21

I experienced firsthand the confusion caused by the Centers for Disease Control and Prevention’s abrupt change in masking recommendations. Although it essentially stated that fully vaccinated individuals can go about their activities maskless, it completely failed to understand the dynamics of multi-age gatherings.

I was at a local park in an area where masks are required for groups that are outdoors, and it’s fair to say that the 11-and-under crowd isn’t going to self-select to wear masks when they see their parents and other adults kicking back with a cold drink and being maskless. Kids also aren’t going to stay three feet apart, let alone six, without someone giving them reminders. What I observed was similar to a rugby scrum made of unmasked 8- to 10-year-olds, so we can only hope that none of them were carrying COVID. Being outdoors doesn’t eliminate the risk if people are on top of each other. For the sake of all the healthcare providers who are having post-traumatic stress disorder symptoms, I hope we don’t get ourselves in trouble before vaccines are available for younger age groups.

As a primary care physician at heart, I hope that this push to get back to normal also involves patients being able to schedule appointments for needed healthcare. In my area, some primary care physicians are still limiting their schedules due to COVID-19 concerns. I’m curious how long their employers are going to be on board with it before there are repercussions. I’m sure those providers with RVU-based compensation plans are feeling the impact of limited schedules on their paychecks, but others on guarantees might just be in for a surprise when their next contract period comes around.

Third-party telehealth companies are still seeing plenty of patients asking for medication refills, often saying they can’t get an appointment with their primary physician or can’t get the office staff to contact them back. If access issues are real, you would think that practices would be eager to bring in part-time or contract physicians to help fill the gap and work through the backlog. None of the health systems in my area want to hire part-time physicians, which I find shocking. I’d love to see acute urgent patients one day a week somewhere, even just on an hourly or temporary contract, but everyone I’ve talked to would rather be backlogged than have part-time physicians on the books. It seems penny-wise but pound-foolish, but nothing is surprising any more when it comes to the people managing medical practices.

From the payer viewpoint, however, patients are getting back into the swing of things with preventive care services. Cigna CEO David Cordani said that in the first quarter of 2021, his company saw levels of mammograms, colonoscopies, pap tests, and childhood vaccine visits at levels not seen since the COVID-19 pandemic started. In an analyst call earlier this month, Cordani stated that Cigna has been focused on steering patients toward preventive services especially for services like cancer screenings. Cigna is my health insurance provider and I haven’t seen any outreach regarding services, so I’m curious what kind of programs they have in place.

Despite significant spending on COVID-19, Cigna seems to be holding its own financially. It’s Evernorth division, which includes pharmacy benefits management services, is growing, with total pharmacy prescriptions increasing by nine percent. I wonder what portion of those medications are prescribed to treat anxiety, depression, insomnia, and other conditions related to the stresses of the pandemic, distance learning, and altered family dynamics? Even in my limited time as a telehealth provider, I’m still seeing a fair number of those diagnoses. Patients are much more eager to just take a pill than to want to accept my recommendations for counseling or therapy. Although many think the pandemic is behind us, healthcare providers in the trenches know that there will likely be complications for years to come.

Speaking of telehealth, I was glad to see Arizona move to the front of the class with HB 2454, which supports telehealth policy. It allows for audio-only telehealth visits in some circumstances and also allows providers from other states to treat Arizona residents without having an Arizona-issued medical license. Essentially it makes emergency pandemic-driven measures permanent, identifying Arizona as one of the more progressive states in its treatment of the issue. Everyone talks about access to medical services for rural residents or those who struggle to get to appointments, but the press release from Governor Doug Ducey’s office also made note that the bill “allows snowbirds visiting our state to receive telemedicine from their home state.”

For those hoping to press forward with asynchronous care options, the bill does exclude emails, voice mails, and instant messages from the definition of telehealth. There are also some hitches in the way it manages license portability. Those licensed in other states who want to care for Arizona residents must register with the state board, register with the controlled substances prescription monitoring program, pay a registration fee, and agree not to have a physical office in Arizona. How arduous that process truly is will define how many telehealth providers want to reach their practices into Arizona.

The one thing I was surprised by in the bill was that medical examinations for worker’s compensation matters can be conducted via telehealth if all the parties involved are in agreement. Dealing with worker’s comp cases is one thing I will not miss from my brick-and-mortar practice, and personally I’d be surprised if there’s much uptake on telehealth delivery of those services.

I’m continuing to play the back-and-forth phone call and email game with some of my state regulatory folks, who can’t quite understand the idea that a physician has a “telehealth only” practice and doesn’t have a physical space where she treats patients. I’ve had several people tell me “you can’t do that” and I try to better explain it to them by saying it’s like a house-call only practice, but they still don’t get it. I’m going to try to make additional phone calls this week to get it sorted out, but until then, I’m running slightly afoul of a couple of regulations, but it’s a risk I’m willing to take.

Are you willing to give up your in-person primary care physician in favor of virtual visits? Leave a comment or email me.

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