The New England Journal of Medicine recently published an article titled “Covid-19 — Implications for the Health Care System.” In it, the author team, David Blumenthal, M.D., M.P.P., Elizabeth J. Fowler, Ph.D., J.D., Melinda Abrams, M.S., and Sara R. Collins, Ph.D., discuss the four core crises that have arisen in healthcare as a direct result of COVID-19.
Blumenthal et al outline the crises and their suggested solutions under four main topics: Insurance Coverage, Financial Loss, Racial and Ethnic Disparities within the System, and the Public Health Crisis. These are not only the four main crises of healthcare, but of our nation, as we continue to struggle through the pandemic. Much of Blumenthal et al’s advice hinges on the need for drastic reform and federal oversight. While we agree, we also think that the conversation about the future of healthcare must include telehealth.
Below, we reflect on these crises, and how telehealth can help us overcome them.
“The pandemic has significantly undermined health insurance coverage in the United States...These developments will add to the 31 million persons who were uninsured and the more than 40 million estimated to be underinsured before the pandemic struck.”
Blumenthal et al discuss how the recent surge in unemployment has left more than 20 million additional Americans without employer-provided health insurance. Additionally, as employers take on the brunt of economic decline they may be tightening their belt, as it were, on employee plans.
Initially the Public Health Emergency (PHE) and CARES Act extensions afforded to healthcare helped bear the brunt of the Coronavirus on our existing systems, helping cover telehealth service charges and aid care systems as they quickly pivoted to meet the pandemic head on. Telehealth claims increased 4,000% from the previous year (Mallow). Now, insurance companies are pulling back their coverage of telehealth and patients and care systems are left in limbo, unsure of what will be reimbursed.
These instances further highlight the obvious need for healthcare reform.
“For the first time since the Great Depression, crippling financial losses threaten the viability of substantial numbers of hospitals and office practices, especially those that were already financially vulnerable, including rural and safety-net providers and primary care practices.”
Many non-essential visits have been canceled for the same reason they can be conducted virtually – they require little physical or immediate intervention. There are a host of procedures and tests that must be conducted in person, but safety precautions should not limit providers from connecting with their patients. Now more than ever we need to connect, not just as the healthcare industry, but as humans. Fear and worry over the dehumanizing features of digital interaction are old biases. In the same way we join a Zoom meeting or FaceTime with our family, connecting with a provider over video can provide reassurance, guidance, and even the joy of human interaction.
Telehealth is not complicated or difficult to obtain. While the worry of weak internet infrastructure in rural America is very real, the tools needed to conduct sound telehealth consultations are not beyond the reach of most. A smart phone is all that is needed to smoothly run simple telehealth solutions like Cloudbreak Telehealth.
For patients without access to smartphones, it is important that we apply regular pressure to our lawmakers to include phone consultations in telehealth coverage. Blumenthal et al raise valid questions about the way we pay for healthcare, suggesting that our current insurance coverage system is part of what makes healthcare so financially weak. Again, reform is undoubtedly needed.
“It creates incentives to raise prices and push up volumes, shortages of poorly compensated services such as primary care and behavioral health, and an undersupply of services in less financially attractive poor and rural communities. But in the extreme circumstances of a pandemic, a new question arises: is health care an essential national resource that warrants secure financing beyond what the current fee-for-service system offers?”
How insurance covers telehealth, how providers bill for telehealth, and how patients pay for telehealth sessions all comes down to our mindset. What is the burden and subsequent cost of a virtual versus in-person consultation? If virtual care becomes more lucrative, will it discourage providers from hosting in-person consultations when they’re more applicable?
“Upfront, global payments also offer providers the flexibility to innovate. For example, they could substitute virtual care for in-person care without worrying about how telemedicine is compensated under fee-for-service rules.”
The answer is to recognize that telehealth is healthcare, and to include it in any future payment models as an equal to in-person care. This eliminates patient worry about payment processing or confusion over co-pays and makes it easier for providers to explore mixed in-person and virtual care plans that support better connection with patients and better outcomes.
RACIAL AND ETHNIC DISPARITIES WITHIN THE SYSTEM
“Black persons constitute 13% of the U.S. population but account for 20% of Covid-19 cases and more than 22% of Covid-19 deaths, as of July 22, 2020. Hispanic persons, at 18% of the population, account for almost 33% of new cases nationwide.”
The mobility and flexibility of telehealth lends itself to overcoming healthcare disparities, from breaching healthcare deserts to providing language services to overcome linguistic barriers. Mobile units equipped with tablets and a comprehensive telehealth platform could help expand a care team’s impact on their community without displacing doctors. While current telehealth development is trending towards expanding virtual care at the bedside to help institutions weather quarantines, we should also be adapting our care to reach patients where they work and live.
“Disparities in access and health outcomes are entrenched features of the U.S. health care system. They reflect a history of racism and discrimination that permeates society generally.”
Technology is not intrinsically without bias and we must take our own biases and faults into consideration when employing technology, to ensure we are building the most equitable solutions possible. One such example is integrating language services throughout a healthsystem so that every step of care is accessible. It is important that equitable accommodations follow patients through the full care continuum, instead of focusing on the point of care alone. To build these systems, telehealth must be interoperable, easily integrating with other platforms and EHRs. Otherwise, the cost of overhauling existing digital investments, as opposed to scaling them as needed, will be too high for healthcare systems to provide necessary resources with consistency.
“Greater support for safety-net facilities and small community providers, including inner-city and rural hospitals and community health centers, could also improve access to basic and advanced services for populations of color.”
Scalable technology is key to overcoming healthcare inequities. Comprehensive systems can support multi-specialty care at the bedside, but there should also be affordable and easily employed options for small and rural clinics. It is the responsibility of telehealth innovators to build scalable solutions to carry healthcare into a more equitable future.
We must also recognize that telehealth is not only a resource for patients, but for providers as well. Important bias training, certifications, and reporting can all be delivered through telehealth platforms to users so that all staff members have access to the same tools and resources to provide equitable care.
THE PUBLIC HEALTH CRISIS
“The United States has 4% of the world’s population but, as of July 16, approximately 26% of its Covid-19 cases and 24% of its Covid-19 deaths.These startling figures reflect a deep crisis in our public health system.”
The US handling of the pandemic has been internationally regarded as a failure. Largely this has hinged on inconsistent and confusing direction from the federal level, from lack of participation to lack of regulation. As Blumenthal et al warn, this will not be the last pandemic we will have to weather, and we must use this failure as an opportunity to build a more robust response. Again, this depends on federal direction and oversight. But telehealth’s role should not be overlooked.
“Tellingly, there is no national public health information system — electronic or otherwise — that enables authorities to identify regional variation in the demand for, and supply of, resources critical to managing Covid-19”
Telehealth can be leveraged to not only connect providers with their patients, but to connect care systems across the nation, building a dependable system that would pool information and resources nationally.
Telehealth is healthcare with greater reach, built in accessibility, and more flexibility. The future of healthcare depends on integrating telehealth solutions into every level of care. For future pandemics, an investment in telehealth will enable healthcare to remain nimble and reduce future risk of lost revenue while protecting care teams from undue exposure. Telehealth is the next logical step in healthcare advancement, and as the industry struggles against the crises created by Coronavirus, telehealth is also the next necessary step.
Blumenthal, D., M.D., M.P.P., Fowler, E. J., Ph.D., J.D, Abrams, M., M.S., & Collins, S. R., Ph.D. (2020). Covid-19 — Implications for the Health Care System. New England Journal of Medicine, 383(17), 1698-1698. doi:10.1056/nejmx200018
Mallow, J. A., & Davis, S. (2020, October 27). Health insurers are starting to roll back coverage for telehealth – even though demand is way up due to COVID-19. Retrieved November 05, 2020, from https://theconversation.com/health-insurers-are-starting-to-roll-back-coverage-for-telehealth-even-though-demand-is-way-up-due-to-covid-19-147648