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The Great Telemedicine Experiment
Among other things, 2020 might go down in history as the year of the Great Telemedicine Experiment. After decades of being largely ignored or relegated to a few subspecialty areas, telemedicine has burst onto the healthcare scene as a force to be reckoned with. Not surprisingly, the sharp rise in its use raises issues around access, efficacy, privacy, costs, and more—as medical systems, care providers, and patients grapple with how best to use this new tool of modern medicine. (What is telemedicine? See 3 examples below)
Data are pouring in from multiple fields, parsing the huge natural experiment that saw a sudden, unprecedented pivot to virtual medicine in all its forms when Covid hit. As in healthcare generally, many factors contribute to the uneven use of telemedicine for psychological and neurological treatment within certain populations and geographical areas, including disparities in access.
A report released in December from the US Department of Health and Human Services (HHS) confirmed massive increases in the use of telehealth in 2020 compared to 2019, with behavioral health providers seeing the highest telehealth utilization relative to other providers. Telehealth comprised a third of all visits to behavioral health specialists, a much larger share than for primary care physicians or other medical specialists. The report, produced by researchers in HHS’s Office of the Assistant Secretary for Planning and Evaluation, analyzed data from 34.9 million Medicare beneficiaries, making it the largest telemedicine dataset so far. Medicare’s relaxed rules around reimbursing healthcare providers for digitally delivered care were crucial to the 63-fold increase in telehealth visits during this period.
It is perhaps unsurprising that behavioral health was the top user of the modality, as these clinicians were early adopters of telemedicine well before Covid made it a necessity. Individual mental health care in the form of counseling or talk therapy is particularly amenable to this format. Psychological care providers across the country have come up with innovative ways of using technology to stay in touch with their patients, many of whom are struggling with pandemic-fueled stressors and increased anxiety or depression.
Like many others, Tufts child psychiatrist John Sargent pivoted to telemedicine when Covid hit. His patients, who generally have to travel an hour or more for care and deal with traffic and parking in downtown Boston, cancelled fewer appointments. “It was incredibly freeing to all of us and turned out to be amazingly do-able—as long as we weren’t thinking about the people who don’t have internet access.”
Paradigm Shift In Neurologic Care?
Neurology, for its part, has incorporated forms of telemedicine for 25 years or more, typically to facilitate subspeciality care. Barbara Giesser, a multiple sclerosis (MS) specialist now with Pacific Neuroscience Institute in Santa Monica, California, was part of the MS telehealth program established at the University of Arizona in the 1990s to increase access to specialized care in the rural Southwest. “Neurological therapeutics can be very complicated, especially in areas like MS, Parkinson’s disease, epilepsy, and headache,” Giesser says. “People with these disorders may be better served by subspecialists, and there may not be any in their area.”
Stroke is the classic application of telehealth in neurology. “Telestroke” grew out of an effort to bring people having a possible stroke to the attention of a stroke specialist quickly, in order to enable appropriate treatment with the clot-busting drug tPA within its short therapeutic window. The program became a model for using technology to link patients to the specialists who can best help them. Perhaps because of this history, the neurological exam by video has been fine-tuned to the degree that one can have a near-complete workup entirely virtually, excluding certain sensory, vestibular, and neuromuscular tests.
That history served neurology well when Covid hit, and the proportion of neurologists using telemedicine jumped from 1 percent to 56 percent. The transition to telemedicine drove “a paradigm shift in the delivery of neurologic care in 2020,” Giesser said in a commentary in JAMA Neurology.
Who’s Using Telemedicine, and Who’s Not?
One big question has emerged prominently from the telemedicine data: Are virtual visits reaching the people who need them most? Several recent studies—along with observations from experts in fields as diverse as psychiatry, dermatology, family medicine, and OB/GYN—raise troubling doubts.
For example, the HHS report found that telehealth services were accessed more in urban areas than rural communities (55 percent vs. 44 percent), and Black Medicare beneficiaries were less likely than white beneficiaries to utilize telehealth, according to a press release. In both urban and rural areas, the data suggest evidence of racial and ethnic disparities in uptake of telehealth, especially when comparing the number of Black patients to white, regardless of location.
In an earlier study that analyzed data on 16.7 million private-insurance and Medicare enrollees, Michael Lawrence Barnett and colleagues at Harvard T.H. Chan School of Public Health found a distinct inverse relationship between poverty and telemedicine, with the lowest telemedicine use in counties with the highest poverty rates. They also found age differences, with older people ages 65 and up accounting for a quarter of telehealth visits compared to nearly 40 percent of visits among people aged 30-39. Geographically, 30 percent of visits originated in urban areas compared to 24 percent rural. Overall, the data suggest a skew toward younger, wealthier urban dwellers.
A separate analysis of data on 6.8 and 6.4 million employer-based health plan beneficiaries in 2020 and 2019 found similar results: disproportionately higher use by younger age groups, in counties with lower poverty rates, and in urban vs. rural areas. A third study, a random survey of telehealth use and satisfaction in 3,454 US households published in October, also found lower use in rural areas and highest use in households earning $100,000 or more. The authors say the results suggest that uneven access and equity remain potential threats to effective implementation of telemedicine going forward.
Of course, none of these data prove that the people who need telehealth the most aren’t getting it. “I think the jury is still out on who needs it most,” says Barnett. “I could argue that it may be more important to see those folks who are on the other side of the digital divide in person. There’s no clear answer.”
Richard Restak, a professor of neurology at George Washington University School of Medicine and a practicing neurologist and neuropsychiatrist, sees this disparity play out in his own older patients. Many have some form of sensory impairment that makes digital communication challenging or are simply not comfortable with or equipped for it. They may consider a visit to their doctor a social occasion, and person-to-person interaction may be a critical piece of their healthcare in such instances.
“Invariably, when I do a teleconference with anyone over 50 or so, their son or daughter is there in the background doing all the tech work,” Restak says. “We should keep these factors in mind before blaming everything on inequities.”
Health Disparities and the Digital Divide
To some degree, the issue boils down to a new iteration of an old problem, the so-called digital divide. The term refers to the fact that technological innovations generally reach certain segments of the population sooner than others, driving inequities in healthcare and other areas. Those left behind are often impoverished, elderly (as in Restak’s patients), disabled, BIPOC, or otherwise marginalized communities.
“Anyone with limited digital literacy to engage in the health system is going to lose out,” Barnett says. “Telemedicine is most likely going to follow the pattern of almost every new healthcare delivery change, which are primarily taken up by populations that have the resources and the money to use them, and the rest will fall behind. I’d love to be proven wrong,” he adds.
The problem is less about telemedicine, per se, than it is about how the healthcare system works, Barnett points out. “There are many important structural factors that limit health care access in ways that telemedicine won’t fix all on its own. It’s only one piece of what is needed to reform healthcare to address the long-standing disparities we have.”
Access to broadband is the most solvable part of the problem. According to the Federal Trade Commission, some 46 million Americans don’t have high-speed wireless internet. That makes video visits a lot more challenging. Cell phone wireless signals might suffice but doing a visit on a smartphone is less than ideal. A hot spot, then? Maybe, but video calls eat up data. Not everyone has unlimited data. These kinds of technological barriers may seem minimal if you’re tech savvy—but seniors who weren’t raised in the digital age may have difficulty trying to figure it all out.
“The whole device thing is a barrier,” says Tanner Nissly, a family practitioner at a Minneapolis clinic run by the University of Minnesota, where he is an assistant professor. The clinic serves a population of predominantly Black and Asian immigrants, the majority of whom are “under-resourced” and receive federal or state-aided health insurance. When Covid hit, he could only connect with patients remotely. Since many lacked either a proper device or access to internet, telephone visits became the norm even before government insurers paid for them.
Nissly, who co-authored a commentary on achieving equity in telehealth based on his practice’s experiences, believes that “if you really care about equity, then you need to start with groups that have traditionally been marginalized and let it trickle out to the people who are less vulnerable.”
Camille Clare is an obstetrician/gynecologist at SUNY Downstate in Brooklyn, NY. Her patients, who have government-based health insurance, often lack access to broadband or wifi, making virtual visits logistically challenging if not impossible. In the last year, access to high-speed internet has thus become an aspect of “social determinants of health”—the circumstances in which we are born, live, age, and die, that impact the kind of care we receive and, in turn, our health and well-being.
“Telehealth is a social determinant of health,” Clare argues, just like food security, housing stability, transportation, and other situations that pose day-to-day difficulties in marginalized communities.
Telemedicine in All its Variants
The popular image of telemedicine is a doctor on a big screen chatting with the patient in real-time interactive audio and video. But the reality encompasses other, simpler modalities. The Centers for Medicare and Medicaid Services (CMS), which sets payment guidelines for federal healthcare programs (and are usually followed by private insurance payers), acknowledges and pays for a suite of services under the umbrella of telemedicine. These include “telehealth visits,” “virtual visits” and “e-visits,” each with its own tightly defined parameters.
There’s a battle afoot surrounding the recognition of the simple, old-fashioned telephone call as a form of telemedicine and make it subject to “parity”—insurance reimbursement equal to that for a video call. Neil Busis, a neurologist at NYU Langone Medical Center, says telephone visit payment policies have to change if we are to make telehealth—in its broadest definition—truly accessible to all. Busis is the founding chair of the American Academy of Neurology’s new subcommittee on telemedicine, formed in April.
The phone call is arguably the most accessible healthcare tool of all, he says. While a phone call can’t replace an office visit and is inferior to an interactive video visit, he contends that in some instances it is both necessary and sufficient and should be reimbursed as such. Nissly of Minnesota agrees: “Telephone communication is an effective means to get care to a lot of people.” His group’s practice relied heavily on telephone visits to maintain connections with the community it serves during the lockdown, even when they weren’t getting reimbursed for them.
Even in the new era of unleashed telemedicine, doctors don’t generally get paid for phone calls. Only recently did CMS agree to pay for phone visits in behavioral health, such as a psychotherapy session, outside of the Public Health Emergency that was declared when Covid hit. “That’s a start,” Busis says hopefully. Outside of that specialty, phone calls can’t be billed as visits unless specific conditions are met, one of which is that an attempt at a video visit failed.
The myriad rules around how telemedicine services are reimbursed are just one of the barriers to greater use, and a primary reason it was so underused pre-pandemic. In a nutshell, if health insurers don’t pay doctors for televisits, then televisits won’t happen. Telemedicine became the new norm almost overnight only because state and federal restrictions to reimbursement for telemedicine were suspended when the Public Health Emergency began. These restrictions excluded visits originating from the patient’s home, for example. Also suspended were malpractice insurance and state licensing rules governing cross-state practice.
While some of those measures have been extended—in November, CMS announced it would continue telemedicine reimbursement through at least 2023—others, like interstate rules on insurance “portability” and licensure, have not. This leaves the future of telemedicine in limbo. No less than 23 bills currently before Congress address telemedicine issues in one way or another, from building broadband infrastructure to making permanent changes to how telemedicine is paid for.
Silver Lining of Covid?
“Covid is here to stay and hopefully, so is telemedicine,” Geisser says. “I think it’s been one of the silver linings of the pandemic. It’s forced us to be creative, to think outside of the box, and to develop new resources. And it’s showed us how effective telemedicine can be.”
“We found out that telemedicine could potentially bring great benefit,” adds Nissly. “But the question is: Is it just for those who already have access?”
Sidebar: What is Telemedicine? 3 examples
Telemedicine has emerged as an important tool for tracking progressive neurologic diseases such as Parkinson’s. In one initiative, a collaboration of researchers is using smartphones to collect real-world data on symptom progression and treatment response in people with Parkinson’s disease (PD). Within the first six months of the study, 960 participants had performed at least five self-administered active PD symptom assessments. The authors concluded: “Although remote assessment requires careful consideration for accurate interpretation of real-world data, our results support the use of smartphones and wearables in objective and personalized disease assessments.”
A 93-year-old male suffered a six-inch laceration when a tree he cut down grazed his head. He refused to go to the E.R., so his daughter emailed a photograph of the injury to his doctor. Within five minutes, the doctor called and strongly urged the patient to get to the E.R. immediately. The patient complied, and received stitches and a CT scan before being released. A week later, the doctor removed the stitches in a “curbside” appointment in the parking lot of his clinic.
A therapeutic case manager at United Counseling Services, a community-based mental health agency in Bennington, VT, created “Flat Becky” to connect with the children she could no longer see in person. She sent all her program participants a paper doll lookalike of herself wearing her usual scrubs and asked them to bring Flat Becky along on their adventures and snap pictures to send back to her and talk about in their video calls.
This article first appeared in the Winter 2022 issue of our Cerebrum magazine. Click the cover for the full e-magazine.