Many issues affect the delivery of care to patients who are most in need. Particularly, those who live in rural areas or those who need specialized care may not have access to the care they need. Patients whose care transitions across acute care and long-term/post-acute care (LTPAC) settings may have additional challenges in receiving coordinated care. Telehealth, using technology to provide health care at a distance, could expand capacity and connect patients with the specialists they need.
Telehealth can overcome geographical barriers, allowing use of technology for providers to connect with each other or patients to receive care from providers who are not co-located. For example, a nursing home resident with mobility challenges due to a recent fall, or a patient with diabetes who must travel over an hour to see an endocrinologist, could receive care close to them. These patients have complex conditions that would benefit from regular monitoring to avoid preventable emergency department (ED) admission; however, various barriers prevent patients from obtaining this care.
While the technology has existed for decades, widespread adoption has been slow until recent years. A recent American Hospital Association (AHA) survey [PDF] illustrates the rapid growth of telehealth. In 2017, 76% of hospitals reported using telehealth to connect patients with providers at distance sites—a jump of 41% since 2010. Although telehealth adoption has grown exponentially in hospitals, adoption in the outpatient setting has lagged. While many interactions occur in a real-time, synchronous method, providers can use asynchronous communications or consults in non-urgent situations to review images or data without the patient.
How Can Telehealth Help Patients?
Here are a few more examples of how telehealth can help patients:
- Tele-consults for Emergency Care: For some patients, such as those in LTPAC settings, staff can contact on-call emergency personnel who can triage common symptoms like dizziness. Patients would be able to remain at the facility and get help for their illness and also avoid the emergency room.
- Tele-consults with Specialists: For a chronically ill patient with no proximity to necessary specialists, care team members could schedule real-time consults with specialists to avoid delays in care. As a result, patients could have better control of their chronic conditions.
- Remote Monitoring for Chronic Care: Finally, devices and systems can collect physical and/or mental health data while outside of the medical environment. This remote monitoring can be beneficial for certain chronic diseases, such as congestive heart failure (CHF). Health professionals can then review these data for changes in health status that may prompt updates to treatment plans or visits with healthcare professionals.
How Can We Increase Telehealth Adoption?
Reimbursement Challenges
Reimbursement, which varies by payer, remains the biggest challenge to telehealth implementation. Previously, the Centers for Medicare and Medicaid Services (CMS) allowed providers and health systems to bill for telehealth in very limited instances. These instances included restricting originating sites to non-Metropolitan Statistical Areas (MSAs) or a rural Health Professional Shortage Areas (HSPAs). There are exceptions for treating acute strokes or end stage renal disease (ESRD) visits.
Starting in 2019 [PDF], Medicare patients can receive brief virtual check-ins and providers can remotely review pre-recorded patient information without the same site restrictions as other telehealth services. These changes could benefit patients in a few ways. These brief virtual check-ins will allow patients to take advantage of technology from the comfort of their own homes. Providers can use these virtual check-ins to determine if the patients should come in for further evaluation, potentially preventing patients from traveling unnecessarily.
Telehealth has been shown to reduce patients’ travel burden and time off work. Allowing patients to check in with their providers virtually without the originating site restrictions will continue the shift towards more patient-centered care.
Credentialing Challenges
Credentialing is another challenge in telehealth. When a telehealth interaction takes place, the provider at the distant site must be credentialed with the originating site. This process is very time consuming and expensive.
In 2011, CMS changed its rules to allow credentialing by proxy, whereby the distant site’s credentialing of the provider will act as the credentialing for the originating site. The Joint Commission does require both hospitals to be accredited by the Joint Commission. Despite being law for roughly 7 years, only 33% of hospitals use this type of credentialing. Education and outreach efforts should focus on this type of credentialing to ensure hospitals take advantage.
Regulatory barriers also limit providing prescriptions via telehealth, particularly when patients have not been seen by a provider face-to-face. This is of particular import for sub-specialty providers and for providers who are offering medication assistant treatment (MAT) for opioid use disorder treatment [PDF].
Workflow Challenges
Lastly, logistical and workflow challenges may also impact telehealth offerings and adoption. Providers need a space to establish a secure video connection with their patients. Patients also need to have access to high-speed internet and computing equipment and be comfortable with technology to take part in telehealth visits.
Changes on the Horizon
The Medicare physician fee schedule has expanded reimbursement for telehealth over the past few years. There will likely be additional changes over the next few years. Since the reimbursement landscape is changing across payers, we expect to see additional support for reimbursement of telehealth services. This could be in the form of loosening restrictions on services and sites that are eligible for reimbursement and expanding reimbursement.
In addition, the regulatory landscape for telehealth is inconsistent across states. We expect to see changes at both the State and Federal level. Telehealth enjoys bipartisan support, but issues of sustainability have made it difficult for a regulatory change to gain traction. The Congressional Telehealth Caucus is expected to put forth legislation about telehealth in the next Congressional session.
Saira Haque
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Shellery Ebron
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- Using Telehealth to Deliver Care to Patients When and Where They Need It - September 26, 2019