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Caswell County, where William Crumpton works, runs along the northern edge of North Carolina and is a rural landscape made up mostly of old tobacco farms and a few fast food outlets.
“There are large areas where cell phone signals are just simply nonexistent,” says Crumpton. “Things like satellite radio are even a challenge.”
Crumpton, who grew up in this region, is CEO of Compassion Health, a federally funded community health center. The county has no hospital or emergency room. And during much of the pandemic, about half of the centre’s patients were only reachable in the old fashioned way: a basic voice call on a landline.
“We have people who live in houses who wouldn’t be able to make a phone call if they wanted to,” he says. “High speed internet is not available to them; furthermore, the only connection they had with the outside world in some cases was a rotary telephone. “
So when state and federal governments temporarily relaxed privacy and security restrictions on telehealth at the start of the pandemic, many patients across the country were able to be diagnosed and treated by doctors on phones that do not have video or camera functions. This, in turn, has allowed healthcare workers to connect with hard-to-reach patients – people who are poor, elderly or living in remote areas.
But today, the rules that temporarily relax licensing and reimbursement restrictions to expand the use of this type of telehealth service are changing rapidly.
There are approximately 1,000 proposals pending before state and federal legislatures that deal with extending or extending telehealth beyond the public health emergency of the pandemic. To date, about half of all US states have adopted audio-only telehealth measures in place. In the other states, in the absence of legislation, the old restrictions governing telehealth are or will be reinstated; some will end when the federal public health emergency ends sometime after the end of the year, while others have set their own deadlines.
Meanwhile, insurance policies are also changing. Medicare, for example, says it will cover audio-only visits for mental and behavioral health treatments until 2023. But some private insurers have already stopped reimbursing coverage for audio-only care.
Taken together, the changes mean that patients could face a sharp break from the care they have become accustomed to accessing remotely and easily.
Without telehealth, she “could be dead by now”.
This kind of return to normal is not what Gail Grinius wants to see. Grinius, a Compassion Health patient, says accessing medical care has always been a challenge in her community.
“There are a lot of people who don’t have transportation,” she says. So when they run out of medication or need a test, they often turn to 9-1-1. Being able to see the doctor by phone, she said, would be a “blessing” for many people, as it was for her during the pandemic.
Grinius is 71 years old and suffers from diabetes and skin and vascular problems that prevent him from walking. She also relies on 15 different medications, so being able to meet her doctor by phone has been essential. “Otherwise, I don’t know,” she jokes, “I might be already dead.”
As lawmakers and insurers question whether to continue to allow this kind of audio-only care, the crux of the debate is whether this low-tech way to reach more people is also safe and effective.
The pandemic has changed Krista Drobac’s opinion on this compromise.
“Before the pandemic, I saw audio only as a quality issue; now I see it as an equity issue,” said Drobac, executive director of the Alliance for Connected Care advocacy group. “It really expands patients’ access to providers they might not otherwise be able to see.”
What is missing when there is no physical examination
But Texan psychiatrist Nidal Moukaddam sees the problem very differently: “The phone thing was horrible. Horrible, ”she said.
Almost all of the patients at his clinic whose first appointment was by phone did not show up for follow-up care, says Moukaddam. She is Associate Professor of Psychiatry and Behavioral Sciences at Baylor College of Medicine and a member of Physicians for Patient Protection. “Audio alone did not give us [a] patient connection, ”which was often attached on a cell phone while shopping for groceries or driving or in the bathroom, she says, and therefore not fully engaged.
Moukaddam also could not assess whether they had any tremors, skin discoloration or alcohol on their breath, she said. “Problem is, it kills medicine – you can’t do things without a physical exam.”
Telehealth has increased 38-fold since the start of the pandemic, according to a study by consulting group McKinsey & Company – not only for therapy and mental health, but also for the treatment of physical conditions.
It’s a mixed bag for people like Dr Rahul Shah, an orthopedic surgeon from southern New Jersey, who says he likes the ability to call patients over by conference call with family members, but also hears about patients meeting their surgeons for the first time in the operating room. .
“It’s scary,” he says. “It’s scary. Think about the risks the doctor takes in never getting a hold of this patient – I mean, it’s mind-boggling,” and that would never have happened before the pandemic, Shah said.
There is still no substitute for in-person health care, he says. For example, he recently saw a patient in his office who had come with various medical tests and scans indicating that his pain was radiating from his lower back. But when the man tripped from his chair, Shah suspected another culprit and ordered another MRI.
“There you go, it turns out the gentleman had signs of significant neck problems,” Shah said. “If I hadn’t seen him get up from his chair, I would have missed this whole line of questioning. This kind of change in diagnosis after an in-person visit, he says, occurs every two weeks in his practice.
Towards a hybrid of remote and in-person healthcare
Like many other physicians, Shah sees medicine evolving into a hybrid of remote care – in the types of cases where that is enough – and in-person care. His home state, New Jersey, has yet to pass a bill allowing the extension of telehealth flexibilities or specifying which insurance will pay for such phone or video visits. But given the changing regulatory and insurance landscape, Shah also says it’s also unclear how much his firm should invest in new capacity to deliver telehealth appointments.
It’s a common complaint, says Courtney Joslin, resident of the R Street Institute, a free market think tank.
“There is so much uncertainty about what will become permanent and what will return to the way it was before,” she says. “Now a lot of providers and even hospitals are like, ‘Well, should we keep investing in infrastructure for this? Will our state continue to allow this or not? “”
And that leaves many patients – and their doctors – in limbo.