Guest Editorial: Telehealth Visits in the Real World: How Best to Use Them, for Whom, and in What Payment Models?

Throughout history, the field of medicine has been innovative in the evaluation, management, and treatment of healthrelated problems, as well as in embracing transformational technologies. One realm of medical innovation that has been brought to the forefront recently is telehealth. The Coronavirus Disease-2019 (COVID-19) pandemic has impacted the economic landscape, altered the way we carry out daily activities, and put an immensurate strain on our healthcare system. During this time, to limit the spread of COVID-19 particularly to those most vulnerable, sheltering in place and social distancing was recommended, which has resulted in a rapid adaptation from office-based outpatient visits to virtual visits. In this way, the global pandemic has allowed for the large-scale implementation of telehealth as a public health safety measure to prevent the spread of the virus between patients and healthcare personnel.

Whereas previously telehealth was predominately used in the care of military personnel, inmates, and patients in remote rural areas, there has been an accelerated adoption of telehealth to treat patients with a variety of medical conditions and in multiple settings. Federal and local legislation passed by policy makers and alterations in guidelines for coverage and reimbursement by insurers has created the flexibility needed for more widespread implementation of telehealth by clinicians. As evidence of this, in March 2020, telehealth visits surged by 50% amid the coronavirus pandemic, according to research from Frost and Sullivan consultants.(1) Furthermore, analysts at Forrester Research anticipate virtual health care interactions in the U.S. to top 1 billion by the end of 2020.(1) Telehealth is the use of digital information and communication technologies, such as computers and mobile devices, to access health care services remotely to improve a patient’s health.(2) Two main categories of telehealth platforms exist: clinician-topatient and clinician-to-clinician (Figure 1).(3)

These platforms employ several modalities and delivery mechanisms to provide care. The clinician-to-patient platform includes modalities such as synchronous (realtime) visits, remote patient monitoring, and secure electronic messaging.(4) The synchronous modality involves using audiovisual telecommunication such as video conferencing technology or audio-only through the telephone to provide a two-way interaction between the patient and the clinician. Remote patient monitoring involves using digital technologies like mobile devices and smartphone applications to collect, transmit, and evaluate health data such as vital signs, weight, blood pressure, and blood sugar.(5)

Clinician-to-clinician platforms include asynchronous (“store and forward”) data transmission, remote clinicians providing intensive care unit (ICU) or inpatient care at a distance, and electronic consultations from clinicians with distant specialists.(4) The modality “store and forward” refers to the electronic transmission of medical information and patient data such as diagnostic images, videos, lab reports, and other documents to additional members of the care team such as a specialist who can evaluate and assist in treatment.(6)

Although there will be some instances when remote care through telehealth will not be applicable (a detailed physical examination is required or an emergent procedure needs to be performed), there are many types of patient visits where telehealth can be efficiently used to meet the standard of care and provide quality outcomes.(7) If a patient has been previously seen for an acute injury or illness, many times the follow-up visits can be done via telehealth to monitor the patient’s progress and provide recommendations. Further, if a patient is on medications that need frequent monitoring or modifications, these changes can be easily managed without the patient having to come to the office. Similarly, if a patient requires frequent medical visits for care of multiple chronic conditions, a virtual visit will allow those involved in the patient’s care at home to be more engaged in the medical decision process when they may not be able to be in the office physically. Additionally, initial triaging of patients who may have contagious illnesses can be done virtually without risk of exposure to others. Other visits where telehealth can provide utility include mental health counseling, dermatologic disease evaluations, lifestyle management, sharing of test results, and minor injuries. 

Of particular importance during this COVID-19 pandemic, medically fragile and immunocompromised individuals who often require more frequent care and monitoring should be preferentially screened to evaluate if a telehealth visit can be used in place of an in-person clinic visit. Such persons include those with cancer, chronic kidney disease, chronic obstructive pulmonary disease (COPD), immunocompromised state from solid organ transplant, obesity (body mass index [BMI] of 30 kg/m2 or higher), serious heart conditions such as heart failure, coronary artery disease, or cardiomyopathies, sickle cell disease, and type 2 diabetes mellitus.(8)

Before the pandemic, approximately 14,000 Medicare beneficiaries received telehealth services each week. More recently, over 10.1 million beneficiaries have received telehealth services between mid-March and early July 2020.(9) A survey compiled by the Alliance for Connected Care of more than 800 physicians conducted in April 2020 found that close to half (48%) are treating patients via telemedicine, up from 18% in 2018.(10) Furthermore, a GlobalData survey found 79% of specialists increased their use of telehealth as a result of the pandemic.(11)

Federal and state laws and regulations govern reimbursement for telehealth by Medicare, Medicaid, and private insurers. In response to the COVID-19 pandemic and the need to rapidly accelerate the use of telehealth to prevent further spread of the virus, the federal government introduced legislation through the Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020 to provide more flexibility in coverage for Medicare patients. As part of this act, the Department of Health and Human Services (HHS) Office of Civil Rights (OCR) allows clinicians in good faith to offer telehealth services to patients using remote communication technologies even if they do not comply with the Health Insurance Portability and Accountability Act (HIPAA). (12) Furthermore, clinicians can conduct telehealth visits with patients located in their homes and outside of designated rural areas, practice telehealth across state lines, deliver care to both established and new patients, and bill for audiovisual and audio-only visits as if they were provided in person. State laws have control over which telehealth services are covered and reimbursed by Medicaid and private insurers along with the level of parity provided for these services vs. in-person visits.(13)

There has been a trend to move from a feefor-service payment model toward a valuebased model where healthcare delivery will focus on achieving higher quality care, improving access, and lower costs.(14) In 2015, the Medicare Access and Children’s Health Insurance Program [CHIP] Reauthorization Act (MACRA) introduced a quality payment program (QPP) that rewards clinicians who use Medicare for delivering high value, high-quality efficient care. There are two tracks to choose from: Advanced Alternative Payment Models and Merit-Based Incentive Payment System (MIPS). Although telehealth is not directly reimbursed in these models, the use of telehealth services can be integrated to help achieve quality measures and performance standards.

One of the main goals of telehealth is to increase access to care. A key barrier to this is accessibility to broadband; i.e., reliable high-speed internet connections. Internet access is far from universal, with approximately 24 million people in the United States without broadband access in 2019.(15) To help achieve this goal, the Federal Communications Commission (FCC) COVID-19 Telehealth Program received funding to increase telehealth access for low-income Americans.(16) Additionally, the FCC is funding the Rural Health Care Program to make telehealth services available to geographically remote patients. Also in development, the Space Exploration Technologies Company (SpaceX) is launching a satellite internet project plan called Starlink with the goal of building an interconnected network of about 12,000 small satellites in space to beam high-speed internet to anywhere in the world by 2021.(17) This along with high-speed 5G internet connections can help make telehealth more reliable and accessible.

 The increased utilization of telehealth during the pandemic was largely due to more flexibility in coverage and reimbursement provided by legislation and insurers. Whether these temporary measures are continued after the COVID19 pandemic will likely significantly impact whether telehealth use will regress or if it will remain part of the ‘new normal’ of medical care.

Disclosure statement: Dr. Varughese has no financial disclosures to report. Dr. Patel has no financial disclosures to report. Dr. Dhindsa has no financial disclosures to report. Dr. Eapen has no financial disclosures to report. Dr. Sperling has no financial disclosures to report.

References: 

1. Telehealth Visits Could Top 1 Billion in 2020 Amid the Coronavirus Crisis. https://www.cnbc.com/2020/04/03/telehealth-visits-couldtop-1-billion-in-2020-amid-the-coronavirus-crisis.html. Accessed September 14, 2020.
2. Telehealth: Technology Meets Health Care - Mayo Clinic. https:// www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/ telehealth/art-20044878. Accessed September 14, 2020.
3. What is Telehealth? | Mid-Atlantic Telehealth Resource Center. https://www.matrc.org/what-is-telehealth/. Accessed October 30, 2020.
4. Telehealth Primer For Cardiology Fellows - American College of Cardiology. https://www.acc.org/membership/sections-and-councils/ fellows-in-training-section/section-updates/2019/08/20/14/42/ telehealth-primer-for-cardiology-fellows. Accessed September 14, 2020.
5. About Telehealth | CCHP Website. https://www.cchpca.org/about/ about-telehealth. Accessed September 14, 2020.
6. TSA. What is Telehealth? What is Telehealth?. 2014:1. doi:10.1056/ CAT.18.0268
7. Which Types of Visits Are Perfect for Virtual Care? | Chiron Health. https://chironhealth.com/blog/which-types-of-visits-are-perfect-forvirtual-care/. Accessed September 14, 2020.
8. Certain Medical Conditions and Risk for Severe COVID-19 Illness | CDC.https://www.cdc.gov/coronavirus/2019-ncov/need-extraprecautions/people-with-medical-conditions.html. Accessed September 14, 2020.
9. Trump Administration Proposes to Expand Telehealth Benefits Permanently for Medicare Beneficiaries Beyond the COVID-19 Public Health Emergency and Advances Access to Care in Rural Areas | CMS. https://www.cms.gov/newsroom/press-releases/ trumpadministration-proposes-expand-telehealth-benefitspermanently-medicare-beneficiaries-beyond. Accessed September 14, 2020.
10. COVID-19 Telehealth Polling | Alliance For Connected Care. http:// connectwithcare.org/covid-19-telehealth-polls/. Accessed September 14, 2020.
11. Over Three-Quarters of US Specialists Increased Use of Telemedicine During the COVID-19 Pandemic, Says GlobalData | GlobalData. https://www.globaldata.com/three-quarters-usspecialists-increased-use-telemedicinecovid-19-pandemic-saysglobaldata/. Accessed September 14, 2020.
12. Telehealth: Delivering Care Safely During COVID-19 | HHS.gov. https://www.hhs.gov/coronavirus/telehealth/index.html. Accessed September 14, 2020.
13. Telehealth Parity Laws | Health Affairs. https://www-healthaffairsorg.proxy.library.emory.edu/do/10.1377/hpb20160815.244795/ full/. Accessed September 14, 2020.
14. Quality Payment Program | CMS. https://qpp.cms.gov/about/qppoverview. Accessed September 14, 2020.
15. Bauerly BC, McCord RF, Hulkower R, Pepin D. Broadband Access as a Public Health Issue: The Role of Law in Expanding Broadband Access and Connecting Underserved Communities for Better Health Outcomes. J Law, Med Ethics. 2019;47(2_suppl):39-42. doi:10.1177/1073110519857314
16. Contreras CM, Metzger GA, Beane JD, Dedhia PH, Ejaz A, Pawlik TM. Telemedicine: Patient-Provider Clinical Engagement During the COVID-19 Pandemic and Beyond. J Gastrointest Surg. 2020;24(7):1692-1697. doi:10.1007/s11605-020-04623-5
17. SpaceX Starlink Satellite Internet Service Application, Beta Test. https://www.cnbc.com/2020/06/12/spacex-starlink-satelliteinternet-service-application-beta-test.html. Accessed September 14, 2020.