As the coronavirus pandemic continues, Bloomberg Opinion will be running a series of features by our columnists that consider the long-term consequences of the crisis. This column is part of a package on public health. For more, see Max Nisen on creating a faster vaccine, Faye Flam on a grim future for the medical profession and Joe Nocera on why federal disaster-management efforts have failed.
Under normal circumstances, internist Jenni Levy makes house calls, checking on patients with chronic conditions and serving as what she calls “rolling urgent care.” She works for Landmark Health, which offers supplemental home visits to people with Medicare Advantage plans and a high risk of hospitalization.
When she joined Landmark, Levy heard that the company was working on a telemedicine app. Two and a half years later, she still hadn’t seen anything. It turns out developing proprietary software that complies with the privacy provisions of the U.S.’s Health Insurance Portability and Accountability Act, better known as HIPAA, is a time-consuming process. So far, the company has pilot programs running in only a couple of markets.
Now, with circumstances far from normal, Levy and her colleagues are suddenly seeing patients over FaceTime and WhatsApp. In response to the Covid-19 pandemic, federal regulators last month eased the stringent interpretation of HIPAA for telemedicine. Rather than special HIPAA-compliant platforms, health-care providers operating in good faith can use everyday communications tools, so long as they aren’t open to the public. FaceTime is fine, in other words; Tik Tok is not. The changes, says Levy, a college friend of mine, “enabled us to start doing something we’d been intending to do all along.”
Until recently, telemedicine seemed like one of those technological promises that was always in the future. While it sounded good in theory, it confronted economic barriers, regulatory hurdles and resistance from doctors and patients.
Covid-19 has radically changed the environment. For all its horrors, the pandemic provides an opportunity to cut through some of the red tape that stymies medical progress.
To keep patients out of waiting rooms and limit the spread of the disease, physicians, insurers, and state and federal regulators are pushing the rapid expansion of technologies once confined to niches and optimistic press releases. In the U.S., regulatory barriers have fallen, reimbursement rates have risen and skeptical physicians are getting comfortable with video consultations. Doctors, patients and businesses are having to change the way they think about telemedicine. If we learn the right lessons and avoid reverting to the status quo ante once Covid-19 is brought under control, the result could be better care at lower costs — without eroding the already shaky finances of primary-care physicians.
Take the relaxation of those HIPAA rules. When the privacy law was passed by Congress in 1996, nobody was thinking about how it would apply to FaceTime visits. We were living in the world of fax machines, letters and phone calls — the technologies HIPAA still favors absent a crisis. The emergency response reveals just how ill-founded the restrictions are.
Letting doctors use widely available, even free, software to examine patients at a distance vastly expands the number of practices that can incorporate telemedicine. You no longer have to be a large organization capable of building or buying a specialized system. You don’t have to make telemedicine the backbone of your practice, hiring crews of nurse practitioners to take calls from around the country. You can be a small clinic that wants to offer an occasional convenience to regular patients who are too sick or located too far away to easily come to the office.
That, in turn, changes the political economy of the concept. Many primary-care physicians have resisted telemedicine, supporting state restrictions that limit its scope. They justifiably feared that virtual consultations could skim off their profitable cases and put them out of business. If even small practices can offer online visits, however, telemedicine becomes a way of expanding care and potentially increasing income. It’s cheap and convenient but no longer a substitute for an ongoing relationship with a primary-care physician.
But if regulators later demand a return to the old rules on telemedicine platforms, warns Grady Gibbs, a technology consultant who admits he’s self-interested, since his clients are primary-care practices, “that will kill telemedicine — not kill it dead, but it will make the rollout much, much more difficult because the small, especially independent, PCP office — one doc, maybe one doctor and a mid-level — is not going to be able to go out there and get access to a good platform that’s HIPAA-compliant.”
Regulation isn’t the only barrier to widespread telemedicine. “The single biggest thing that probably has held back deployment is, as is often the case, reimbursement,” says Steve Spearman, senior director with Huron Consulting Group, who specializes in health-care issues. Here, too, the current crisis has changed the status quo. Medicare, which used to pay a much lower rate for telemedicine when it reimbursed it at all, is now covering a wide range of telemedicine services at the same reimbursement rates as in-person offerings. Private insurers are following, voluntarily or by demand from state regulators.
That equal treatment likely won’t continue once the pandemic passes, but it sets a precedent for how to think about telemedicine: It doesn’t have to be a quick, cheap and transient service offered by companies without bricks-and-mortar investments in local clinics. It could also serve as an addition to primary care, especially for patients with chronic conditions — if reimbursement rates reflect clinic overhead.
Gibbs makes an analogy to how restaurants and bars are regulated differently depending on whether serving alcohol is their primary business or an adjunct to it. Doctors who offer telemedicine to existing patients as a convenience could get higher reimbursements, he suggests, while “if you operate the big call center, then maybe your reimbursement is just dirt cheap. And it becomes something that only gets used in the off-hours” or perhaps by patients without primary-care doctors. “That to me would be a great way to thread the needle, because you’ve got to protect the family practitioner.” We don’t want local doctors to disappear — or to fight the advance of new technologies.
Even before Covid-19, Medicare had changed its reimbursement policies to encourage a particularly promising form of telemedicine: regularly monitoring patients with chronic conditions, including diabetes, hypertension and congestive heart failure. In 2018, a primary-care doctor who sent a patient home with equipment to take regular readings had to personally spend 30 minutes a month going over results with the patient to receive reimbursement from Medicare, which paid nothing for the equipment. And the monthly payment was a paltry $59. “No doctor is going to do 30 minutes of their own time, plus capital equipment, to make $59,” says Gibbs. “So there was no adoption.”
In 2019, however, Medicare changed its policy. In industry jargon, it “unbundled the code,” offering a one-time setup fee and a monthly equipment-rental reimbursement averaging $66 nationally. It also allowed doctors to delegate the monthly checkups to staff and cut the time required to 20 minutes. “We go from 59 bucks for 30 minutes of the doctor’s time to $52 for 20 minutes of the staff’s time, plus the 60-something for the equipment itself,” says Gibbs. That made the idea profitable for primary-care practices.
Starting this year, the doctor can hire a third party to analyze the data and alert the practice of any warning signs. The result is significantly greater adoption of telemedicine. Instead of measuring blood pressure twice a year during in-person checkups, for instance, patients take their readings every day. Down the road, wearable technology will make it possible to continuously monitor at-risk patients. “The world that we’re headed to,” says Gibbs, “is your PCP is going to know what’s going on with your health 24/7 and will then only intervene when there’s a problem.”
Gibbs, whose firm analyzes data for doctors and makes money by renting them the monitoring equipment, recounts the recent experience of training a small practice that brought in 10 patients to set up with monitors. Three of them turned out to have such high readings that the nurse immediately walked them back to see the doctor. One man’s systolic blood pressure reading topped 200, where 120 is considered normal. “He was four months away from his next office visit,” says Gibbs. “So what happens to him in the next four months? He strokes out. He passes out, falls, breaks a hip because of the high blood pressure.” Telemonitoring allows early detection of changes that might otherwise lead to hospitalization. That saves both lives and money.
By forcing doctors to think about how to best serve patients remotely, Covid-19 has encouraged greater adoption of telemonitoring. It has also taught patients who would never have used online services, such as Dr. Levy’s elderly clientele, how to reach their doctors remotely. When the crisis is over and in-person visits are again easy to manage, these habits will remain. With the right regulation and reimbursement policies, telemedicine can become a normal part of regular health care in the United States — a complement rather than a substitute for hands-on practice.