The events of the last few weeks are unprecedented in our lifetime and have brought into sharp focus the pricelessness of healthcare access. Even as the pandemic highlights gaps in our health care system, individuals, organizations, and governments have stepped up to deliver innovations to fill these gaps. While this change has come amidst a crisis, there are important lessons in these emergency measures that have the ability to affect our profession into the foreseeable future.
Remote Patient Care
In this age of social distancing, telemedicine has come out on top. While not a novel concept, virtual connectivity in healthcare has lagged behind other sectors as physicians struggled to implement services amidst concerns regarding reimbursement, privacy issues, and integration into the medical workflow. The emergency decision by the Center for Medicare and Medicaid Services (CMS) on March 17, 2020 (and retroactively in effect beginning March 6, 2020) to pay for telehealth visits outside of rural areas has eased physician concern. The decision allows physicians and other health care providers to charge the same rates for real time- audiovisual and in-person office appointments for new and established patients. While patients are subject to the same co-pay or deductibles as per their plan instructions, health care providers may be able to reduce or waive these fees (and all fees are waived when the visit concerns COVID-19). Established patients also have access to virtual check-ins (brief audio or audiovisual check-ins initiated by a patient concern) and e-visits (communications via established patient portals). CPT codes for billing purposes are available.
The Health Insurance Portability and Accountability Act (HIPPA) has been temporarily waived during the COVID-19 pandemic, allowing physicians and others to use any videoconferencing tool, including Facetime, Zoom* and Google Hangouts. However, these platforms typically do not utilize a business associate agreement (BAA) – which ensures protected health information is safeguarded – and their use will become illegal once the emergency declaration runs out. Luckily, there are several companies, such as Teladoc, Doxy.me and American Well that implement BAA safeguards and even provide practice management features such as scheduling and e-prescribing. The downside is that not all will incorporate into your existing EMR and patient portals, requiring the use of two devices – one for the virtual visit and the other for documentation. Several EMRs include basic videoconferencing tools, and with physician advocacy, the rise of telemedicine can encourage expansion or partnerships with telemedicine companies such as Cerner has done with American Well.
It makes sense for physicians to invest in a BAA compliant platform now to ensure continuity as telemedicine’s convenience will have patients requesting these appointments into the foreseeable future. Medicare Advantage, Medicaid, and many private insurers have already seen the writing on the wall and already have regulations regarding virtual visits in place, as do the majority of states. While previously, e-visits were not granted equity to in-person visits, physician and patient advocacy may well change these laws in the future. Taking some time now to implement a robust system allows you to continue to use this convenient, effective, and lucrative option in the future.
Additionally, remote patient monitoring (RPM) is on the uptick as mobile technologies and wearable, connected physiological measuring devices provide robust medical data to physicians from the comfort of patients’ homes. More hospitals will likely invest in telepresence robots, or computers on wheels that allow virtual communication and assessment in inpatient care areas. These “virtual” providers can limit overexposure of health care providers to the COVID-19 virus while permitting inpatient evaluation. Even following the pandemic, these virtual tools will be invaluable to care for patients in diverse settings and physician-limited areas.
Evolving from State to Nationwide Licensure
For anyone who already provides telemedicine or works in multiple states, the impracticality of individual state licensure is well recognized. On March 13, 2020, the Health and Human Services (HHS) issued an emergency declaration allowing all physicians and other health care providers with any valid state medical license to provide care to Medicare and Medicaid patients across state lines. Physicians accepting Medicare and Medicaid patients will have fees, site checks, and criminal background checks waived. While this relates to Medicare and Medicaid only, individual states have the option to waive requirement for individual state licensure.
While these emergency measures are approved for a finite time, many healthcare providers may find the post Covid-19 period to be an opportune time to advocate for a transition to a nationwide system of medical licensing. Physicians can opine that national licensure can limit the shortage of healthcare providers, especially in rural and other underserved settings. COVID-19 only magnifies the existing problem that can be reduced by allowing physicians to supplement care across state lines, whether in person or virtually.
Other Emergency Declarations
There are a host of other emergency declarations affecting inpatient, long term facilities, and home health services. Emergent declarations allowing nursing and medical trainees as well as recently retired health care providers to join the health care force will almost definitely expire following the crisis. However, this crisis has put a spotlight on short fallings of the health care system’s emergency preparedness. The shortages of personal protective equipment (PPE), medical equipment (including ventilators and other respiratory devices), and inpatient capabilities point to the inability of the health care system to support population health above and beyond provider man-power.
So far, the Federal Drug Administration (FDA) has invoked Emergency Use Authorization (EUA), expediating approval of testing kits and modified respiratory devices (including anesthesia machines, positive pressure devices, and ventilator tubing connections) in short supply. During this epidemic, we have seen that ingenuity and academic collaboration fill gaps and provide lifesaving equipment to the public. Moving forward, the FDA’s continued modification of its regulatory system can help provide improved implementation to health care innovations.
The Way Forward
Health care providers are at the front lines treating their patients and protecting the public, while advocating for the health care tools necessary to support this mission. Despite the adversity, COVID-19 has encouraged us to rethink out healthcare system’s preparedness for pandemics and other emergencies. Employed physicians and physician groups can encourage investing in telehealth solutions within their organizations. Physicians and other health care providers can petition state medical boards and their US representatives to advocate for national licensure. To survive another day, our health care system must shift from a reactionary to an anticipatory point of view. In this way, we can ensure we truly learned the lessons from the past and will not be doomed to repeat them moving forward.