When the coronavirus pandemic forced people to stay home last year, doctors and other health care providers adjusted and began to see their patients virtually, by computer or telephone.
Government and private health insurers adjusted, too, changing their policies and reimbursement rates to ensure health care providers got paid for telehealth visits. While the pandemic forced health care providers to go virtual, they say it wouldn’t have happened on a large scale without changes in insurance payments.
“The reimbursement policies from payers were huge enablers for telehealth growth in the last year,” said Simon Curtis, vice president for ambulatory services at Duke Health Private Diagnostic Clinic, with includes 1,800 doctors associated with the Duke health system.
Before the pandemic, Curtis said, Duke Health was doing 100 to 200 video visits with patients a month. This spring, long after last year’s initial spike in telehealth use, it continued to do about 1,500 each day, he said.
Like working from home and cashless transactions, telemedicine is one change brought on by the COVID-19 pandemic that won’t go away. But what form it takes in the future is still not clear, as health care providers work through when a virtual visit is appropriate and insurers decide how much and when to pay for it.
Insurers are wrestling with whether to maintain their COVID-era telehealth policies and reimbursement rates after the pandemic is over. Hospitals, doctors and other health care providers think they should, to ensure they can continue to offer it to patients, but insurers say there ought to be some savings from virtual health care that is reflected in what they pay for it.
“A telehealth visit is going to be lower cost for the consumer, because there’s not a physical location where somebody has to go,” said Garland Scott, Carolinas regional CEO for United Healthcare Corp., which insures 1.4 million people in North Carolina. “So by nature the virtual visits are less costly…, and our reimbursement will differ between a telehealth visit versus an in-person physician visit.”
Insurers say they’re still studying utilization and costs of telehealth to determine the proper rates in the future. In the meantime, many are maintaining the policies they put in place when people were ordered to stay home last year.
Blue Cross and Blue Shield of North Carolina announced in April that it will keep its pandemic telehealth policies through 2021. That means it will continue to cover doctor visits by video or phone the same as face-to-face visits, and providers will be paid the same as for in-person visits.
The use of telehealth by Blue Cross’ 3.9 million members grew by more than 7,500% in 2020, compared to the year before. The company will not roll back its policies to the way they were before the pandemic, said Von Nguyen, chief medical officer. But it’s not likely to keep its current COVID-inspired rates and policies in place either, Nguyen said.
“Exactly where those land, I think that’s going to be very much data driven,” he said. “And right now we’re still very much gathering that data.”
Restrictions on telemedicine lifted during pandemic
The technology that enables doctors and other providers to meet virtually with patients existed before the pandemic. But insurers often covered telehealth under limited circumstances, such as in rural or underserved areas and only if the patient called from another physician’s office, said Dr. Blake Cameron, a nephrologist and medical director for telehealth and access innovation at Duke.
“With the pandemic, most of those restrictions were eliminated, allowing patients to use telehealth within their own homes and with their own devices,” Cameron said.
Cameron says he went from doing no virtual visits to practicing telemedicine nearly full time in the early weeks of the pandemic. He’s gone back to seeing most of his patients in person but still has a sizable number of virtual visits each week, he said.
Ajaya Gupta of Raleigh has seen Cameron and three other doctors through Zoom calls over the last year. Gupta, a retired engineering professor at N.C. State University, is 76 and checks in with the doctors regularly to go over lab results and discuss his medications for chronic problems such as diabetes.
Gupta finds the telehealth visits much more convenient.
“Usually the doctors don’t have to look at my body,” he said. “So for me to go to their office is a lot of work. Typically you wait there in the office, and it takes a lot of time. This way I’m at home.”
Gupta had never had a telehealth visit before the pandemic and had never used Zoom, the software that lets him and the doctor see each other over the computer. He says it was clearly new to the doctors as well.
“Sometimes there would be a problem with sound, maybe a problem with the picture, because initially either I or the doctor didn’t know how to click certain switches,” he said. “It’s not a problem anymore.”
Does virtual health care have to mean video?
Cameron said telehealth works best when the point of the visit is counseling or discussing a diagnosis, prognosis or treatment options. Doctors can arrange to gather blood pressure and other vital signs from patients in advance, he said, in some cases using devices that report the results via computer.
Insurers say psychiatrists and other behavioral health care providers also relied heavily on virtual visits during the pandemic.
Scott, United Health’s regional CEO, said the pandemic created a watershed moment for health care by introducing telehealth to patients and providers alike. Through surveys, the company found that 81% of its members who accessed virtual care had their issue resolved in one call and that nearly three out of four said they were likely or very likely to use it again.
“So I think all the way around everybody involved saw this as an enhancement that we want to continue to offer going forward and to expand on,” he said.
But the value of virtual visits and what providers should be paid for them is far from settled.
For example, while insurers continue to fully cover video visits, some have stopped reimbursing physicians for virtual visits by phone, said Cameron. Video offers advantages, he said, in being able to see someone’s facial expressions and pick up on nonverbal cues. But not everyone has access to computers or adequate broadband for video visits, he said, and a phone call is often just as effective.
“We think that’s an important thing for payers to recognize, that the phone still provides the vast majority of the clinical value of the video,” he said. “And I think we’ll be missing something if coverage for phone-based care is cut off.”
Blue Cross is continuing to cover telehealth visits by phone for now, Nguyen said, in part because enough of its members don’t have internet access or simply don’t use video.
“At this point there is absolutely no distinction,” he said. “Whether there will be in the future, it gets back to that question of, Does it improve quality of the visit?”
Should virtual and in-person visits cost the same?
Blue Cross will make similar determinations about whether to continue reimbursing physicians and other providers for virtual visits on par with in-person ones. If a virtual visit is not as complete as a physical visit, Nguyen asks, should providers be paid the same?
“I don’t actually know yet,” he said. “We’re going to look at the data to find out.”
Doctors argue that what patients are mostly paying for is their time and expertise, which can be comparable in virtual and in-person visits.
The pandemic has given providers the opportunity to show that telehealth has value, said Cody Hand, vice president for government relations for the N.C. Healthcare Association, which represents hospitals. The result should be adequate and dependable reimbursement from insurers to justify offering it in the future, Hand said.
Toward that end, the association is backing a bill in the General Assembly that would require insurers to cover a consultation through telehealth if they cover it in person and with the same co-pays and deductibles. House Bill 149 overwhelmingly passed the House in early May but has yet to receive a hearing in the Senate Rules Committee.
The bill doesn’t address whether virtual visits should be covered at the same rate as in-person visits, a mandate the insurance industry would oppose.
While the details are unsettled, it’s hard to find anyone involved in health care who thinks providers and insurers will return to the pre-pandemic days when telehealth was rare.
“The genie’s out of the bottle. Now that they’ve experienced the convenience of telehealth and have gained the confidence and trust that this is a suitable way to receive medical care, I think patients will be clamoring for this,” said Cameron, the Duke nephrologist. “And I would anticipate that insurers will continue to cover it in the long term. Some of the details may change, but the overall thrust of this is that telehealth is here to stay.”