Telemedicine — a boon for many in pandemic — threatened with cutbacks

When Gabi Berner stopped responding to her ulcerative colitis treatment in summer 2020, she was grateful to confer with her doctor over the telephone. Together, they made a plan for a new medication and transitioned her care to a different doctor who could coordinate transfusions.

Telehealth visits, which flourished during the pandemic, made it possible. They were popular with patients like Berner. And experts predicted they would expand in the months to come. Instead, telehealth opportunities are being steadily pared away.

For Berner, the new clinic was almost an hour away from her apartment in Cambridge, Mass., and she didn’t have a car. Working full time from home as a data scientist, she could check in easily with telemedicine visits.

“It’s usually just a short conversation between you and the doctor,” Berner said. “So unless I’m out of remission, a phone call is preferable.”

By April 2020, telehealth accounted for 32 percent of office and outpatient visits, and have stabilized at 13 percent to 17 percent across all specialties, according to a McKinsey report.

While not an absolute replacement for in-person visits, many assumed telemedicine was here to stay. When Berner’s clinic told her they would offer only in-person visits after June 15 this year, she dropped her appointment.

“I didn’t really want to pay money to Uber an hour away for a general checkup,” she said.

Beyond a pandemic necessity, telehealth held promise for the long term. Its potential to reach individuals in remote communities, nursing homes and low-income neighborhoods could mitigate barriers to care.

In turn, it gave physicians the opportunity to see patients across the country without obtaining licenses in multiple states. Telehealth also allowed providers an informative window into the actual living environments that shaped their patients’ well-being.

But as the second summer of the pandemic wanes, state emergency orders that mandate coverage of telehealth visits and waive the requirement for out-of-state medical licenses are expiring.

In their wake, more patients are discovering that telemedicine is no longer an option. With a fourth wave of coronavirus cases surging, the safety of in-person visits, especially for immunocompromised patients, remains a concern.

University of Iowa clinic finds success with telemedicine

“Even with vaccination, cancer patients don’t always mount enough of an immune response,” said Pashtoon Kasi, a medical oncologist at the University of Iowa. “So if there’s any way we can minimize their exposure to the hospital, minimize their number of visits, we want to.”

After Kasi’s clinic began offering telemedicine visits, he was thrilled by a huge uptick in out-of-state patients seeking his opinion. Because of it, he said, clinical trial enrollment in his field reached an “all-time high” in 2020 — a record that he believed would be surpassed in 2021. Such trials can offer patients new, innovative treatments that they would otherwise not have a chance to try — often the best option for patients with advanced disease.

On Aug. 22, however, the state emergency order in Iowa expired. The United States is one of the few countries in the world where physicians must apply to practice medicine separately in each state — a requirement that was waived by many emergency orders at the start of the pandemic. In several states, those waivers have already terminated.

“A lot of patients don’t have the time or the money to fly down from New York or Florida to come see me in Iowa and discuss if they are a good fit for our trials,” Kasi said. “And while they’re busy taking time off and taking two flights to get here, their cancer isn’t taking a vacation for them to figure this all out.”

Technology gap leads to inequity

Other patients are losing access to telemedicine because of a technological gulf. For in-state patients, some providers continue to reimburse video visits at comparable rates to in-person, but this has become infrequent for telephone visits. Medicare announced it will no longer offer payment parity for video and telephone visits after the federal public health emergency order expires (most recently extended until Oct. 18). As of March, only 22 states required insurers to even cover telephone visits.

This can exacerbate a troubling inequity.

“You’re basically cutting people off at the knees,” said Ji Chang, assistant professor at the NYU School of Global Public Health, recalling how one physician described the effect.

Her work found that the digital divide — the gap between people who have full access to digital technology and those who do not — affects not only patients but also providers. Practices in an area of higher social vulnerability are more likely to use telephone than video systems to provide care.

Early in the pandemic, at least 1 in 4 Americans did not have the digital literacy skills or devices to participate in video visits. At highest risk included the elderly, people on Medicaid and those whose preferred language is not English.

Patients at the intersection of all three are routine for Leah Karliner, primary care physician and professor of medicine at the University of California at San Francisco. Nonetheless, she was heartened to observe many of her patients grow comfortable with telemedicine over time, often with the help of family living together in lockdown. As care delivery patterns keep shifting, she emphasizes being “nimble” with solutions.

“With every change,” Karliner cautioned, “there is a potential for creating or worsening health care disparities.”

The deluge of cumbersome, rapidly evolving policies that differ by payer, state and type of service has sowed unease about reimbursements, sometimes deterring practices from offering telemedicine at all.

“It’s not even just about reimbursements now,” Chang said. “That perception of uncertainty poses a bigger barrier than the actual reimbursement itself.”