From Pandemic Fix to Permanent Fixture: How to Ensure Telehealth Lives Up to Its Full Potential
By Barbra G. Rabson
Telehealth utilization quickly soared in Massachusetts in the early days of the pandemic, not just because it filled an obvious need as a way for providers and patients to connect when face-to-face interactions were not possible, but also because Governor Baker issued an order requiring insurers to reimburse providers for telehealth at the same rate as in-person care during the COVID-19 emergency. Easing up on payment restrictions allowed telehealth to flourish because, as we all know, payment drives delivery.
The concurrence of these two events – the need to quickly shift to telehealth and the easing of payment restrictions – created the opportunity for us to see what a broadscale commitment to telehealth would look and feel like. One silver lining that may emerge from this horrendous pandemic is that we have learned a tremendous amount about what works well in telehealth and where we need to focus our improvement efforts going forward. Yet, while telehealth has enormous potential to increase patient access, many are concerned it will not be embraced after the health crisis subsides.
Two things must happen for telehealth to live up to this potential and truly be integrated into care:
Reforming the Payment System
First, we need a flexible payment system that fully values telehealth and allows the decision of visit mode (i.e., virtual or in-person) to be based on patient/provider preferences and clinical requirements. One of the lessons of the pandemic is that the current fee-for-service construct that ties payment to visits makes practices susceptible to shocks in volume such as those experienced with the COVID-19 crisis. Instead of arguing about when, for whom, and how much telehealth visits should be reimbursed, it is time to move to a payment system where payment methods empower practices to be more creative and flexible in how they tailor services to best meet their patients’ needs.
Improving the Experience
Second, we must make significant strides to improve the telehealth experiences for all patients and providers. MHQP has much to contribute to a full understanding of how patients and providers are experiencing telehealth because we have been tracking the telehealth experiences of both patients and clinicians since the pandemic started. Since July, we have been surveying Massachusetts clinicians about telehealth through our “Together for Better Telehealth” initiative as a practical way to help clinicians learn from each other’s experiences and help them adapt to this new way of providing care.
Based on the feedback we’ve received, it is clear telehealth has the potential to offer tremendous value. Here are some revealing quotes from clinicians that make a strong case for figuring out a way to support a telehealth policy moving forward:
- “Telehealth is a blessing much needed in primary care. This way of practice is modern, fresh and needed reform in our practice. It helps to get patient care faster and more efficient. Based on my experience, at least half of the primary care visits don’t need the patient to be at the office.”
- “Many patients seem more honest and less tense when discussing stressors, anxiety, and depression from the comfort of their own homes.”
- “Stress on the entire system can be lessened when selected patients are handled by telehealth for selected visits.”
- “Our most at-risk patients are now engaged in care due to the ease of telehealth when previously they have not been able to leave work to come in for care!”
- “For the patients, a 30-minute visit takes 30 minutes. An in person visit for the patient it is more like 3 to 4 hours if you count travel time, parking time, signing in, and waiting for late staff or doctors.”
On the flip side, this enthusiasm is tempered by specific areas (in addition to payment reform) that need to be improved, which we need to pay careful attention to if we are to get the most out of telehealth to improve healthcare quality, access and equity in the post-pandemic US. These can be categorized into three themes:
- Equitable Access
- Clinician Adoption
- Technological Challenges
Telehealth appears to have made accessing care easier for many patients. In particular, we have heard that it is opening up new access opportunities for high-risk patients, patients without transportation or who have other challenges that make it hard for them to get to the doctor’s office, and patients who are hesitant to come into the office due to psychological sensitivities.
Yet, as groundbreaking as telehealth has been for many patients and providers, it currently doesn’t work for ALL patients and providers and may be exacerbating longstanding health inequities. This is not acceptable. Here are some of these concerns as expressed by clinicians who responded to our surveys:
- “[I’m] seeing huge disparity in English speaking and non-English speaking access to telehealth at the outset. Not technology based, rather the outreach has been in English and not hit the communities of other languages.”
- “[The] biggest barriers [to patient access to telehealth] are general fluency with technology and reliable broadband access. [It’s] hard to solve at [the] individual level.”
- “Patients with language, literacy, cognitive issues and low socioeconomic backgrounds have difficult access.”
- “Elderly, underserved and immigrant patients are suffering. We need to bridge the gap urgently.”
22.5% of respondents said they “Completely Disagree” or “Somewhat Disagree” with the following statement: “With my existing patient population, I have been able to use telehealth to reach patients across diverse (socio)economic circumstances.” This is very concerning. We must have a policy that works for ALL patients who can benefit from telehealth and does not leave populations behind.
Clinicians are accustomed to seeing patients in person and needed to adjust to interacting with patients primarily through computers and telephones. We know from our pilot survey, which we fielded in July, that many clinicians adapted to telehealth better than they thought they would, as illustrated by these responses:
- “I/we are an incredibly versatile lot. Our commitment to lifelong learning and constant change in our profession has trained us well for meeting this moment successfully.”
- “I am surprised by how diagnostically comfortable I am when not in the exam room with a patient I am evaluating.”
- “I am so old school! But [I’m] certainly adaptable to new school!”
Yet, despite this good news, there is no doubt that telehealth continues to present many challenges for clinicians. While many clinicians appreciate that telehealth has given them an opportunity to get to know their patients in new ways and find patients are more comfortable, at-ease, and open in their own homes, many also report that interacting with patients virtually is more tiresome than seeing patients in person. 47% of respondents agreed that they find it harder to keep their energy and focus at a high level in virtual visits.
Another issue is that many clinicians feel their practice is not providing adequate support to make telehealth run smoothly. Only about 50% of respondents said their practice is “Well Organized” or “Extremely Organized” to support virtual care visits. Some find it challenging to integrate medical assistants and support staff into telehealth visits because everyone is in a different location. And many providers feel very much on their own with setting up virtual calls and troubleshooting technological challenges.
Clinicians have also been significantly hampered by technological challenges (outlined below). These potential barriers must be systematically and consistently addressed for providers to fully support the opportunity to improve patient access and care via telehealth.
Lastly, there’s the newness of the technology. 70% of respondents reported that they “Sometimes,” “Frequently” or “Very Frequently” experience technical problems that interfere with a telehealth visit. Most point to the patient’s technology as the source of the problem – e.g., slow WIFI, cell service dropping, limited data, old equipment, etc. Others point to technical issues on their side, mostly related to situations where the provider is working from home on their own equipment. Many of these clinicians lament the fact that they are “on their own” without IT support. Here are some of the voices expressing these concerns:
- “Patients are really struggling with the technology. The email option is cumbersome and delayed. Elderly patients really struggle.”
- “Usually issues with family ability to log in to the system. Sometimes poor connection quality – audio or video or both.”
- “There is such a wide range of devices that it’s hard to help sometimes when things go wrong.”
- “Video glitches are fine, but audio issues are so annoying as I am worried about missing important things my clients might be saying.”
- “Zoom freezes or connection is unstable. Occasionally sound does not work.”
- “When working from home we get kicked off the server, sometimes losing notes and causing delay and frustration. It has been frustrating to feel like we are on our own for technology at home.”
These challenges are not unique to healthcare. We have all experienced both the wonders of and frustrations with virtual technologies over the past several months. But perhaps healthcare can find some unique solutions to address these issues for patients going forward.
In addition to clinician surveys, MHQP is conducting a statewide survey about patient experiences with telehealth, in partnership with BCBSMA. This will give us a more rounded understanding of the telehealth experience.
If we are to reap the full benefits that virtual technologies like telehealth have to offer, we must pay attention to what we are hearing about provider and patient experiences in these early stages so that we can implement meaningful and long-lasting improvements. Only then will telehealth become an integral tool that helps ensure all patients get the care they need when they need it.