On March 11, 2020, the World Health Organization declared the novel coronavirus disease (COVID-19) to be a global pandemic. Shortly after, federal regulators temporarily relaxed restrictions, raised Medicare payment for telemedicine visits to the same level as in-person visits, and waived or reduced cost sharing for patients. As pandemic-related regulations expire, policymakers are debating the need to address insurance coverage of telemedicine services going forward. Congress should consider the lessons learned over the past 20 months to ensure that health care providers have the flexibility to meet the needs of patients.
Dr. Naresh Gunaratnam
One of my early telehealth visits was with a patient in his 80s who spent nearly a month in the hospital after complex abdominal surgery. While at home with his daughter, it was the first visit to assess his progress after discharge from the hospital. We were able to address his concerns, assess his wounds using the video on his computer, and formulate a plan so he could continue to improve. At the end of the call, his daughter mentioned in passing, “Thank God we did not have to go to the office ... that would have been a nightmare.”
The nightmare would have consisted of driving her frail father 45 minutes to our office, spending 15 minutes to park, waiting for 30 minutes to be seen, and finally speaking with the physician for 30 minutes face-to-face. Following the appointment, my patient and his daughter would spend another 10 minutes checking out before the 45-minute drive home. Instead, they spent a few minutes logging on through a computer prior to the 30-minute visit from the comfort of their couch.
The COVID-19 pandemic has resulted in millions of deaths and trillions of dollars in economic loss, as well as changed the norms of social interaction. One of the many ways it impacted our health care system is through the exponential growth of telehealth – the use of telecommunication modalities, such as telephone and real-time video – to connect patients with clinicians for the purpose of providing health care.
Prior to the pandemic, telehealth was limited to populations with limited access to health care. Our practice had never performed telehealth, yet converted nearly exclusively to telehealth at the height of the pandemic. My colleagues and I were concerned about how patients and physicians would respond to the sudden disruption of norms of patient engagement.
To measure the response, we conducted an online survey of over 500 gastroenterologists and nearly 1,500 patients from March to May 2020 to assess their satisfaction with telehealth. Our published results demonstrated that more than 80% of patients and 90% of physicians surveyed were either satisfied or highly satisfied with telehealth. Surprisingly, these trends were true irrespective of age or the reason for a visit. Greater than 80% of patients also indicated that the provider addressed their concerns and that they were willing to participate in telehealth visits in the future.
In a subsequent survey of nearly 3,000 patients who had experience with telehealth and in-person visits, 73% of respondents indicated that they received a similar quality of care through telehealth as compared to in-person visits and 61% stated that the interaction with their physician was also similar. More than half of the patients (54%) were likely to continue using telehealth services after the pandemic mainly because of shorter wait and travel times (75%), flexibility with personal schedule (56%), and ease of scheduling appointments on a desired date (47%).
During the COVID-19 pandemic, access to health care has been limited for a great number of patients, and telehealth has been a useful and necessary tool in overcoming this challenge. Telehealth also promotes the triple aim of improving health care by improving the care experience, reducing cost, and improving patient and population health outcomes. Our findings showed a high level of overall patient and provider satisfaction following telehealth appointments. Telehealth increases access to care by decreasing travel time and cost, limiting missed workdays, and reducing the need to find alternative caregivers, especially among rural communities and people facing financial hardship. For a small subset of people who lack the resources, access to technology, or ability to do video visits, telephone-only visits are an appropriate option and should be preserved and reimbursed in some capacity.
From a patient perspective, convenience and decreased cost are often cited as major reasons for satisfaction with telehealth. This is of particular importance to people with limited mobility, nontraditional work hours, and lower socioeconomic status. For patients who use public transportation or caregivers to travel to appointments, a short appointment may require hours of logistical planning and may come at significant financial cost. Enabling these patients to interact with their providers from home would make accessing the health care system both less expensive and logistically less challenging.
One unexpected benefit of telehealth that I have experienced is the ability to “visit” the patients in their own surroundings. Many telehealth visits have allowed the doctor to make a “house call” and see the patients in their homes, cars, and break rooms. Observing the chaos in a home or an extremely quiet and dark space has given me insight into the role anxiety and depression might play in health conditions – which may have not been appreciated in a visit to my office.
The most memorable meeting was a man who was sitting in his kitchen while smoking a cigarette and drinking a beer for breakfast whose main complaint was heartburn. His life habits were obviously contributing to his heartburn, and this degree of insight would not have been appreciated during a traditional in-person office visit.
Congress is now contemplating the role telehealth will play in health care once the pandemic is over. The main concerns are abuse of telehealth by providers, leading to a dramatic rise in visits due to the ease of care delivery. This in turn can dramatically increase health care costs. The long-term health outcomes of patients seen through telehealth are also unknown and must be studied.
All these concerns are valid and must be addressed in future studies, but it would be a mistake for Congress to revert telehealth back to prepandemic regulations. We must move forward with this important innovation in care delivery.
The adoption of telehealth is one of few silver linings of the COVID-19 pandemic. It will never replace in-person visits but should be preserved as an additional tool we can use when in-person visits are not the best option. The future of U.S. health care must allow for a hybrid model so that patients and providers can continue to benefit from this valuable innovation. Patients, providers, and families will be forever grateful.
Naresh Gunaratnam MD, AGAF is a practicing gastroenterologist with Huron Gastroenterology in Ann Arbor, Mich. He also serves as the chair of data analytics as a member of the Digestive Health Physicians Association executive committee. Dr. Gunaratnam has no conflicts in telehealth. He is the founder of and CMO of a weight loss device company and service.
