Healthcare providers have aggressively climbed onto the virtual care bandwagon since last March, conducting half or more of their patient visits by phone or computer. From mid-March to mid-October, nearly 40% of Medicare beneficiaries received a covered telemedicine service.
Now, with barely a year’s worth of experience and few studies to rate outcomes, researchers are asking if virtual care standards — whatever they are — and patient access to telehealth platforms are good enough. The question will be particularly relevant if payers continue reimbursing at in-person visit rates after the pandemic subsides, as the Centers for Medicare & Medicaid Services (CMS) said it was considering in August.
In addition, it is of concern that overuse, waste and, yes, perhaps fraud, as well as poor computer access and low rates of Zoom-savvy patients, may lead to inaccurate or missed diagnoses, and ultimately, much poorer care.
These are topics addressed in four articles published in JAMA, whose authors wonder if and how parity payment policies should continue in the absence of comparative effectiveness studies that confirm virtual care benefits outweigh its harms, and in which settings.
Yes, there are obvious efficiencies, especially in behavioral health or in refilling prescriptions.
But “there is limited high-quality evidence that virtual primary care does not harm patients, such as through misdiagnosis, and achieves the same or better clinical outcomes as traditional care,” wrote Kurt R. Herzer, MD, PhD, of Johns Hopkins School of Medicine in Baltimore, and Peter Pronovost, MD, PhD, of Case Western University School of Medicine in Cleveland, in a JAMA Viewpoint.
And what about checking blood pressure or cholesterol? It’s much tougher in a virtual encounter, they noted. Could a lot of dangerous hypertension conditions get missed?
There also has been limited discussion dealing with “the principles that should inform its [virtual care] development and assimilation into the U.S. health care system,” Herzer and Pronovost wrote.
There could be overuse as well, with unnecessary ordering of tests among providers concerned they might miss something because they can’t see or examine the patient’s full body. Ordering tests might “mitigate liability concerns around misdiagnosis given the lack of established practice norms and standards of care in the virtual setting,” they noted.
Cheap ‘Virtual Only’ Plans
There is reason to be wary of market evolution, as now some health insurers “are selling plans in 2021 offering lower premiums and minimal or no cost sharing for virtual primary care compared with traditional care.” Is it possible that patients who are lured to these plans by lower costs get inappropriate care? There’s no opportunity for them to evaluate that before signing up, Herzer and Pronovost said.
In a JAMA research letter, investigators funded by the California Health Care Foundation found a different issue. After the pandemic subsides, payment policies may revert to reimbursement for video visits only, disqualifying audio-only visits, the sole way many low-income and senior patients have been able to access telehealth.
That would be cause for concern, said Lori Uscher-Pines, PhD, of the RAND Corporation in Arlington, Virginia, and colleagues, who studied access to care in 41 federally qualified health centers at 534 locations in California. Her group compared the year before the pandemic to the period from March to August 2020.
While there was minimal telehealth use prior to COVID-19, during the pandemic period studied, a worrisome 48.5% of primary care visits were by phone alone, 48.1% were in person, and only 3.4% were by video. If reimbursement for audio-only care were to be cut off — as CMS has said it may do when the public health emergency ends — many patients would be left stranded, Uscher-Pines said.
Low Computer Literacy
“Right now, our data show that many patients aren’t ready for video telehealth. So limiting telehealth to only video telehealth would leave certain patients behind,” Uscher-Pines told MedPage Today in an interview.
“Our goal should be to get all patients prepared for video telehealth visits and narrow the digital divide as best we can with the intention of moving exclusively to video visits in the future,” she added.
How to pay for telemedicine after the pandemic was the topic of a second JAMA Viewpoint by Ateev Mehrotra, MD, of Harvard Medical School in Boston, and colleagues, who looked at international implications.
While there are clear benefits with improved access for patients in rural or underserved areas, by reducing no-show rates, travel time, or need to take off time from work, there could be underlying incentives for overuse. “Clinicians may schedule frequent but shorter phone visits that may not improve outcomes, but do increase government spending,” they wrote.
They suggest limiting telehealth coverage to certain populations, certain conditions, and certain telehealth modalities. And many questions remain unanswered. For example, in December 2020, Congress expanded telemedicine coverage for mental health conditions based on “the assumption” that the result would be of higher value. “However, in many cases there is no evidence, which means the decision may be based on estimated clinical use,” Mehrotra’s group wrote.
The authors also note the concern “that clinicians will choose between a telemedicine and in-person visit based on their relative reimbursement.” If telehealth is reimbursed at a lower rate, clinicians may choose an in-person visit over a telehealth one.
“The counterargument is that governments should pay less for telemedicine visits to deter overuse,” they added.
The Need for Virtual Empathy
In an accompanying editorial, Donna Zulman, MD, and Abraham Verghese, MD, both of Stanford University School of Medicine in California, noted a third element that policy makers should take into account: how to reinforce the human connection in a virtual visit.
“The shift in care from in-person to virtual encounters risks jeopardizing the human interaction that is pivotal to effective clinical care and is deeply meaningful to both patients and clinicians,” they wrote. Little is known about what happens when physical presence is removed from the clinical encounter.
What’s needed are non-verbal communication tools clinicians can use, “such as sitting up and leaning forward, using heightened facial expressions and head gestures, and optimizing eye contact by gazing into the web camera.”
In the absence of visually noting “emotional cues such as a patient’s closed body posture, nervous toe-tapping, or wringing hands,” clinicians need to pay attention to a patient’s tone and volume, and use gestures, such as putting a hand over the heart to convey emotion and empathy.