Telemedicine was working its way into the system but in little increments, most of which were driven by reimbursement (or should we say the lack of it- as we know physicians do not like to not get paid a reasonable fee for the provision of their services). The introduction of a pandemic virus brought fear into the minds of patients and caregivers alike starting with the notion of sitting in a crowded waiting room with “sick” people. Preventive and routine visits suddenly started getting cancelled. Sensing the need for flexibility, Health and Human Services (“HHS”) responded with a host of regulatory waivers. These included Center for Medicare and Medicaid Services (“CMS”) expansion of Medicare reimbursement, Congress giving HHS authority to waive originating site requirements for Medicare beneficiaries and states waiving licensing restrictions.
Patients being offered virtual visits initially experienced uncertainty. They were not necessarily tech savvy and may not have even been certain that their computer had a camera. Much of this uncertainty was alleviated by the use of smartphone technology and amplified by the comfort of not being exposed to any germs in the waiting room or physician offices.
As recently as last year, only 8 percent of Americans had ever used telemedicine. Overnight in the spring of 2020 that has changed to where 95 percent of patient visits are now virtual and insurance companies and health providers have begun advertising their telemedicine offerings. Telemedicine is defined as a visit between a patient and a health care provider by telephone, smartphone, tablet or computer and is just one part of telehealth which also includes programs such as at-home patient monitoring and physician-to-physician consults. (One of the most obvious examples of this is teleradiology in which CT scans and MRIs are interpreted by radiologists who can even be on a different continent than the patient’s physician.)
Innovative telehealth programs are successfully reducing the need for patients to go to the emergency room or the hospital and are proving so attractive to patients and health care providers that this is evolving into becoming mainstream. Additionally, more and more applications or instruments are being deployed that automatically transmit the captured information to the provider, thus providing an updated patient chart and treatment modifications as necessary.
If a patient has a chronic condition such as diabetes, congestive heart failure or chronic obstructive pulmonary disease, they will benefit from this type of virtual care. Atrium Health, which serves 37,800 patients across Georgia and the Carolinas, has seen this use increase 500% since the pandemic began. In fact, they have a program for heart patients who require heart surgery called Perfect Care that follows patients before, during and after surgery. When patients go home, they are equipped with a smartphone (if they do not have their own) along with a weight scale and wearable devices that monitor heart rate, the number of steps they take and their sleep patterns. This data is transmitted to a patient dashboard that enables the provider to manage care from afar and reduce emergency visits and hospitalizations.
Making Change Last
So the big question is: Will telehealth become the “new normal?” This, of course, depends on how insurers and government agencies decide to approach the complicated web of the American healthcare system.
Historical regulations have restricted access to a patient’s health records. Regulations have also required electronic communications (including virtual visits) to be encrypted in order to avoid security breaches of a patient’s personal medical record. With the onset of the pandemic, HHS relaxed its privacy rules permitting physicians to utilize previously off-limits technologies such as FaceTime, Skype and Zoom. While certain service levels provide greater access, HHS encourages providers to notify patients that these third-party applications potentially introduce privacy risks. If and when the pandemic passes, what will happen to these regulations?
Another obstacle is the digital divide. Approximately 21,000,000 Americans lack broadband internet access. This issue is especially serious in rural areas and amongst the poor. This does not include those patients who have no smartphone and those patients who have poor reception which makes even simple phone visits difficult to impossible. In consideration of this, Congress has allocated $200 million for expanded telehealth services in its current pandemic legislation but there is no assurance that this funding will reach those in need. The adequacy of the broadband infrastructure also will need to be addressed and strengthened.
A third variable in this complicated equation is the uncertainty of how insurance companies view telemedicine. To no surprise, a 2018 survey found that the leading reason physicians were reluctant to offer telemedicine services was because insurers either didn’t cover these services or reimbursed them at significantly reduced rates. While as stated earlier, CMS passed emergency legislation to raise Medicare rates to equal in-office visits as did private insurers, these increased rates are temporary.
One of the avenues to ensure that telemedicine continues to be used is to make the reimbursement adjustments permanent. CMS Administrator Seema Verma has suggested that some of the telemedicine waivers granted during the pandemic remain in place.
On the other side of the coin is the interesting anomaly that if these reimbursement and other waivers remain, we may find that total healthcare expense may go up instead of down. It may turn out that the technology and other costs (which make it convenient for the patients) actually drives total costs up. Could the increased costs be justified because of the other benefits telemedicine provides and what about the patients who have evolved to endorse telemedicine and the virtual visits? Will they still be advocates if they have to bear a portion of the increased cost?
The Road Forward
The expanded use of telemedicine during the pandemic provides a unique opportunity to study what is working, what is not and what should become permanent. Its use has exploded onto the scene by circumstances no one anticipated and we should utilize the opportunity to make it even better. We firmly believe that telemedicine is here to stay but needs to be optimized.
What Comes Next? The New Normal-How Will the Pandemic Change Our Lives?
Unlike anything we have seen in our lifetime COVID-19 will change everything in our lives from how we greet each other, how we work, how and how often we travel and what might be on our bucket list. The experiences we have had over the past several months will dramatically change how we do things for years. Let us predict what is coming, what may be on the ropes and what we may lose forever in this crisis.
1. Fixation on washing away deadly germs. Just when we thought sneezing into our elbow was difficult to learn, be prepared to brace yourself for the upcoming hygiene horizon. The older generation will be even more fixated on hand scrubbing, mask wearing, and a hyper attention to surface disinfection. The attention to details has made us evolve to where we will not be entering a supermarket or office building without a blast of Purell (or another brand) of hand sanitizer. Sales in March spiked 73 percent. Unfortunately, this will be ushering in a new realm of electrostatic sprays and ultraviolet light wands.
The wearing of masks won’t just make it harder to hear on socially distant walks. Masks will be reshaping lines politically and personally and between young and old. The mask wearing will be sending a message as to how seriously someone takes public health warnings, about views on personal liberties and even generational differences, especially since adults 70 and older rate the threat of COVID-19 as more serious than younger people; HOWEVER, the events of the past several weeks may change that perception as the 25-44 year old age bracket has been viciously attacked by the virus.
Clean will become the new green as businesses will attempt to show an increased attention to hygiene. There will plexiglass partitions between customers and sales personnel and even temperature check stations to enter a building. We will be attempting to migrate to a touchless or contactless economy. Online ordering will become the norm for millions of people and a lifeline for older adults. Downloads of shopping apps have quadrupled in one month. The use of bots is increasing and there is much experimentation in expanding their use for delivery.
2. The Knockout Punch. COVID-19 has successfully put the mall, dinner and a movie and the morning paper on an endangered species list. Retail companies that were already reeling through 8 rounds of online competition finally succumbed to filing bankruptcy. It is estimated that as many as 15,000 stores could ultimately close. One media analyst has decried the pandemic as an “extinction event” for print as newsstand sales, subscriptions and advertising dollars shrivel.
As we enter a world where no one is going out, diversions are disappearing. The restaurant industry was already challenged by low margins but now it is estimated that one in ten establishments could close for good. Restaurants and bars accounted for 60% of job losses in the month of March alone. Those jobs may never come back as well as some items such as salad bars and buffets.
People are enjoying the new abundance of streaming video which is great news for Netflix and Amazon Prime but it could put the lights out permanently at movie theaters. Staying away from theaters may become an issue of life or death for the population most at risk. On the other hand, drive-in theaters may see a resurrection with families remaining in their cars and concessions by phone.
3. Peoplephobia. Our collective mindset is shifting on everything from stadium gatherings to dream trips. The days of packed stadiums may be over and the athletes may perform to empty stadiums (or life size cut-outs).
The use of mass transit will be affected as well. Public transportation ridership demand has dropped 75 percent nationally during the crisis. The New York subway traffic is down 93 percent. There is an even more telling statistic on this—It took six years for transit ridership to return post 9/11 and people were not worried about pathogens and germs as they ride crunched in together.
Society is about to do a major rethink on commuting now that telecommuting is here and is a real option. This also has made the status around clustering in a city center less desirable. Interestingly, American cities will reassess the width of sidewalks, the access to parks and the need for cars. New York City has already made plans to close 100 miles of streets for pedestrian use. It will be extremely difficult give back all that opened space.
4. There is no place like home. The pandemic has made the line from the Wizard of Oz be more true than it ever was. The safest place in the pandemic, agoraphobic as that might be, is home. As we embrace again the joys of being at home may choose to stick around even more. As the grim news of the day resonates we as a people are looking for a respite. Games are being played again and it has been estimated that 87 percent of Americans surveyed have enjoyed catching up on TV and movies. People are trying to remember how to operate their DVD and (heaven forbid!) their VHS players for those movies recorded and not looked at for years. Home improvements and projects have been resurrected (and not all the results are what was planned). So we should not give up our day job if we still have one.
5. Oh, That sounded great at the time. In the good old days (defined as February and before) we viewed staying in a stranger’s guest unit as the smart way to avoid high-priced hotels. The pandemic has drastically changed that view. Airbnb recently laid off 25% of its workforce and is implementing new rigorous cleaning guidelines including the ability to block off 72 hours between guest visits. While 74% of people surveyed indicated a preference of staying in a home where they had more control of their surroundings as opposed to a densely populated hotel, the question to ask is “Do you really want to sleep in a room cleaned by someone who is doing this as a hobby?”
Retirees who were considering downsizing and moving to an apartment in town are rethinking that choice as well. Aging in place is going to mean aging with more space. Americans who thought the best place to retire would be somewhere dense with access to transportation, restaurants are rethinking that as cities like New York became the epicenter of the virus.
6. The Unknowns. Life as we know it is changing and there is really no way to accurately predict what all that change will be. You can pick any concern and it is punctuated by question marks. The Economy? Medicare? There is no doubt the downturn will be the worst since the Great Depression. Voting in the new era will be a learning experience that hopefully we will accomplish before the November election.
This capsule hasn’t even dealt with some very significant issues like:
- Remote Work and Work from Home Policies
- Office Building Use
- Company Travel
- Reopening the Workplace Protocols that include:
- Operating the Business Safely and Legally
- Workplace Safety Protocols
- Screening for Illness
- Compensation Reductions
- Families First Coronavirus Response Act (FFCRA)
- Qualifying Reasons for Emergency Paid Sick Leave Act (EPSLA)
- Returning Employees to the Workplace-What You Should Ask and When You Need to Ask It
- Managing Decisions About Who to Recall, Notifications and Employee Refusal to Return
- Nursing Homes in general and with COVID-19
- Many more too numerous to mention.
We have attempted to deal with the broad brush as to how the Pandemic will change our lives and there are many challenges ahead. There are more changes coming (especially with the significant increases the last two weeks). We may put out a special edition to cover the issues expressed above concerning the issues surrounding the reopening of the workplace and telecommuting. Companies should review what they are doing with independent consultants and their legal counsel. America has always demonstrated its resiliency and we have to hope that it will do so again both to deal with the current crisis and to better prepare us for the next.
To explore ways in which we can provide assistance with your strategy or decipher the changing reimbursement rules being promulgated by CMS in this evolving health care environment, please contact David H. Fater at [email protected] or Richard M. Cohen at [email protected].