Curbside Consult with Dr. Jayne 8/19/24

Nearly every health system has some kind of telehealth initiative in place even though rates of growth are much slower than they were during the height of the pandemic. Many of them are cautiously watching and waiting to see if Congress will extend telehealth access provisions for Medicare patients. People in the know think it’s likely that the extension will happen, but many suspect that it won’t happen until after the upcoming US election cycle, when they are included in end-of-year legislation.

Patients have become dependent on telehealth services. It has been a huge benefit for seniors who previously had to travel large distances to see specialists at tertiary care centers, but who can now have follow up visits from the comfort of their own homes. The current provisions expire at the end of 2024, and I don’t think any health system CEOs or COOs enjoy that kind of down-to-the-wire finish.

It’s hard enough to predict your patient care volumes for January and February given the unpredictability of influenza seasons that have changed a bit since COVID has been on the scene. Those months are also challenging for elective procedure volumes because patients have yet to reach their deductibles for the year and often avoid scheduling surgeries during the first quarter of the year. What happens if you go ahead and allow scheduling of telehealth visits on your physician schedules (which sometimes are opened more than a year in advance) and changes to the rules force you to have to move or cancel all those visits? There’s not enough modeling in the world to make you feel comfortable with what might happen.

Even when looking at non-Medicare populations, health systems have gotten creative with how they deploy telehealth care. I worked with one organization that implemented telehealth in their urgent care centers, diverting patients to sign up for telehealth encounters before they had a chance to check in at the registration desk. A fair percentage of patients would return to their vehicles and access the organization’s patient portal to get in line for a virtual visit. Those who made it to the front desk were signed in for the urgent care wait list, but were also offered the option to go into the queue for a virtual visit as well. From a patient standpoint, it’s nice to have the option to hold a place on the in-person wait list in case the telehealth physician feels your condition needs in-person evaluation.

For the physicians who were working at the sites where this concept was piloted, it caused stress at the end of the shift, where they worried about a potential burst of patients deciding to go ahead and come inside before the doors closed, just in case. Policies about patient care at the end of shift vary dramatically from urgent care to urgent care, so depending on how the practice runs, I can understand their nervousness. I worked with one urgent care organization whose policy was that every patient who signed in prior to the posted closing time would be seen, which led to providers staying a couple of hours late every night. When you’re already working a 12-hour shift, that can be a significant negative. The organization that was piloting the telehealth hybrid stopped accepting registrations 30 minutes prior to closing time, which seemed to mitigate those stresses at least somewhat.

I’ve also seen a slight uptick in organizations that are implementing so-called asynchronous telehealth in states where the modality is accepted. In many states, there has to be an existing physician / patient relationship before this type of visit can be done, although some allow it for new patients. For an asynchronous visit, patients complete a symptom-based questionnaire and provide relevant medical history and then a provider — more often a nurse practitioner or physician assistant — reviews that information and determines whether the patient can be treated via a response message or whether they need to be seen for a real-time telehealth visit or referred for in-person care.

Some insurance companies don’t pay for these kinds of visits, and the situations where I’ve seen them used most are when the organization has risk-sharing contracts where they are incentivized to keep patients out of the office and manage them as cheaply as possible. That’s fine if you have a younger and healthier population, but gets trickier when you have higher-acuity patients.

Asynchronous care technically also encompasses those organizations that are billing for patient portal messages where a new condition is discussed or a new treatment is requested. It’s unclear what kind of an impact those actions will have on overall telehealth volumes. A recent study that was published in JAMA this month showed that billing for messages at UCSF Health corresponded with a slight decrease in overall message volume. Not surprisingly, in that study a significant decline was noted among self-pay patients and adult patients under the age of 50. The authors noted a study limitation in that they could not look at patient outcomes or causality, but it’s an interesting starting point. I’ll be keeping an eye out for further studies of this phenomenon as more health systems adopt the practice. If you’re doing research in this regard, feel free to drop me a line.

Thousands of leaders from Epic-using health systems are descending on Madison, Wisconsin this week for the annual Epic User Group Meeting. They’re expecting more than 7,000 attendees for sessions that range from reviews of the research and development roadmap to specialty-specific forums. The event kicks off with Sunday’s “Taste of Epic” picnic/campfire event and runs through midday Thursday. Highlights include Tuesday’s executive address and “Cool Stuff Ahead” sessions as well as that evening’s “The Very Hungry Dinner” event named to go along with this year’s “Storytime!” theme. “The Very Hungry Caterpillar” is a book that I can recite from memory, so I got a chuckle out of the agenda’s callout that attendees could “eat through one of everything until you get a stomachache.” I’m unable to make it this year due to other commitments, so if you’ve got pictures or stories to share, feel free to send them my way.

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