‘An awakening’

The headaches of getting to a doctor’s appointment in traffic on Northern Virginia roads drove the Virginia Pediatric Group to invest in telehealth capabilities years before anyone had heard of COVID-19.

“I felt it was a way to improve access and to conduct follow-up visits with adolescents who were busy with after-school activities,” says pediatrician Dr. Russell Libby, the Fairfax-based medical practice’s founder and president.

Uptake among patients was moderate. In early March 2020, Libby says, the practice was doing around 10 telemedicine visits per week. But after the pandemic forced health care providers to shutter nearly all in-person services, those numbers soared. By the end of March 2020, Libby says, the pediatric group was conducting between 250 and 300 visits per week via telemedicine.

One year after the onset of the pandemic, Libby says, between 25% and 35% of his practice’s visits are conducted virtually.

The COVID-19 pandemic gave health care providers and many patients a crash course in telemedicine.

When the public health emergency created a need to curtail face-to-face medical visits as much as possible, providers like Libby expanded their telehealth offerings, while many others had to learn how to offer this modality from scratch.

Health care systems such as VCU Health System and UVA Health, both of which started telemedicine initiatives in the 1990s, were able to open the floodgates, transforming telehealth from a limited service used to target underserved populations into a powerful tool that could allow providers to take care to patients more directly.

Many longstanding limitations on how insurers reimburse for virtual care were lifted during the pandemic. Now that patients and providers have gotten a taste of what can be accomplished through remote tools, many don’t foresee a return to business as usual.

“I believe this is the future of how we are going to be delivering care,” says Dr. Vimal Mishra, medical director of telehealth at VCU Health. Mishra is also the director of digital health at the American Medical Association. “It was an awakening for the entire world as to the delivery system and how we can improve it.”

Access for a larger group

Telehealth has long been viewed as a promising tool to expand health care access to underserved populations. Well before the pandemic, some of Virginia’s largest health care systems saw it as a way to make doctors available to patients in rural corners of the state without requiring a two- or three-hour drive.

VCU’s telehealth program started in 1995, focused primarily on providing care to individuals who were unable to receive in-person care at VCU Health Center in Richmond. The program provides access to care from specialty clinics to incarcerated patients at 30 Department of Corrections sites across Virginia.

UVA Health also started investing in telehealth in the 1990s, under the leadership of Dr. Karen Rheuban, who leads the U.Va. Karen S. Rheuban Center for Telehealth. Before the pandemic hit, this program had expanded to 150 partner sites across Virginia where patients could consult with UVA Health providers via telehealth from a virtual care center — the reimbursement model did not exist for patients to receive care in their homes.

“It was a transformation with COVID-19,” Rheuban says. “Necessity is the mother of invention, and that really drove the massive scaling of telemedicine.

Virtual care appointments within UVA Health increased more than elevenfold in the first three months of the pandemic, compared with the same period a year prior, she says.

At VCU Health, Mishra says, telehealth surpassed in-person care in April 2020,and 20% to 30% of visits were still being conducted virtually in early March 2021.

Roanoke-based Carilion Clinic established its telemedicine program in 2016 and prior to the pandemic had begun to expand telehealth offerings to pediatric specialties and a stroke program in community hospitals, according to Dr. Stephen Morgan, senior vice president and chief medical information officer at Carilion.

Before the pandemic, Carilion was logging about 100 telemedicine visits per month. That number rose to 800 visits per day in the first weeks of the pandemic, and Morgan says Carilion would like to see 10% to 15% of daily visits performed virtually going forward.

“We showed that you could still have a personal touch even through a telephone or video visit,” he says.

Dr. Andrew Rose, system medical director for patient access and regional medical director for Bon Secours Richmond, described the system’s use of telehealth as “very minimal” before the pandemic.

“We were in the double digits, less than 100 visits per day on average across the entire Bon Secours system,” he says. “Once we went live when the pandemic hit, we were in the thousands per day. It was active, live learning.”

A trial by fire

The rapid acceleration of telehealth introduced many physicians and patients to the potential for digital delivery of care.

Before the pandemic, Dr. Sterling N. Ransone Jr., a family physician in Deltaville who is president-elect of the American Academy of Physicians, says his office had only one webcam available for provider use. Now all computers are equipped with a camera and microphone, and he invested in a Zoom telemedicine platform to deliver video visits.

Adoption hasn’t been without hiccups. Ransone tells the story of one patient who thought they were on a telephone call but didn’t realize they were on a video visit — the patient broadcast a closeup image of their ear the entire time. But it has opened Ransone’s eyes to ways that virtual care could better serve his patients in the future.

As a practitioner in a rural area where access to Wi-Fi can be limited, Ransone says one of the most important developments during the pandemic health emergency was the ability to be reimbursed by Medicare and Medicaid for delivering care via a technology that’s not so new — the telephone.

“Audio-only” visits were not reimbursed by Medicare or Virginia Medicaid before the pandemic, but that restriction was waived at the beginning of the public health emergency last March. Many physicians hope this provision will remain, as telephone visits can more easily reach patients who lack computers, smartphones or reliable broadband when a visual assessment is not necessary. Phone visits also provide a way for physicians to be reimbursed for important consultations they would probably be delivering anyway and ensure good continuity of care.

Ransone and many other providers also point out that the pandemic-driven expansion of telehealth has highlighted the need for expanded broadband as a health access issue.

Expanding broadband access holds the potential for greatly improving care, he says.

“We have made a huge leap and we are hoping that after investing in the infrastructure and hardware to do that, we will be able to continue to provide this service for our patients,” Ransone says.

Eyes on insurers

Continuing telehealth care at a high level will depend on whether public and private insurers continue to reimburse for it.

Many providers are hopeful that the rapid increase in telehealth usage during the pandemic has provided the data needed to demonstrate to insurers that telehealth can help make health care delivery more efficient and cost-effective.

They foresee a future when patients with chronic conditions such as diabetes and high blood pressure can be monitored remotely. Visits to refill prescriptions or conduct a mental health assessment could happen from the comfort of a home or office, and patients could be discharged from the hospital sooner, sent home with connected devices for continued monitoring.

This kind of continuous virtual care can lead to fewer hospital readmissions and fewer emergency room visits as well as illness prevention, physicians say, all of which would lower costs.

“Virtual care can be done at lower cost with equal quality, and I think payers are starting to see that,” says Carilion’s Morgan. “We feel that the payer market for this is going to continue to be favorable. It’s a shame that it took a pandemic for our country to realize that you can do so much care and outreach to underserved areas using a virtual platform.”

The market is also being shaped by new offerings that lie outside of traditional employee health plans. Amazon.com Inc.
announced in March that it plans to expand Amazon Care — an app-based telehealth service that is not billed to health insurance, but subsidized by employers — to Amazon employees in all 50 states, as well as to non-Amazon employers.

It’s one of several virtual-care apps on the market seeking to bring urgent and primary care directly to consumers.

“I like to say the genie is out of the bottle and it is not all going back,” says UVA Health’s Rheuban. “I think there will be without question a pivot in public policy that will endure.”

The General Assembly passed legislation this year that addresses several telemedicine concerns. Signed into law by Gov. Ralph Northam in late March,  the measure includes provisions that would establish Medicaid coverage for remote patient monitoring for certain high-risk patients and would make permanent the state Medicaid program’s reimbursement for audio-only health services.

At the federal level, a bipartisan group of U.S. representatives in January introduced the Protecting Access to Post-COVID-19 Telehealth Act of 2021, which would make some of the waivers for telehealth coverage by Medicare and Medicaid permanent. It would also require a study on the use of telehealth during COVID-19, including its costs and outcomes. The bill has been referred to the House Subcommittee on Health.

At Bon Secours Richmond, Rose sees the evolution of telehealth as part of the overall evolution of primary care toward more preventive medicine. Telemedicine makes that far more effective.

“I can’t see the payers backing off on it,” he says. “I think in the long run, insurance has been evolving toward this concept of being proactive with patients, reaching out, being preventative. The idea is to prevent cancer, to prevent a heart attack. Not to treat it afterward.” ν