During the height of the coronavirus pandemic, venturing outside in New York felt like preparing for battle. Germs were invisible bullets from which we tried to shield ourselves using masks and distancing. Staying home was of course the safest course of action, but for some, going out to see a doctor was crucial to their wellbeing.
“Cancer doesn’t stop for COVID,” said Dr. Mara Weinstein, assistant professor of dermatology at the University of Rochester Medical Center. Dr. Weinstein told Engadget that she is still seeing patients every day in upstate New York. People had to come in for lumpectomies, biopsies or to receive treatment for painful, bleeding rashes. Prior to the pandemic, the clinic would see about 10 to 15 patients a day. Though that number has dropped to “maybe two to four” during the crisis, according to Dr. Weinstein, surgeons there are still seeing patients daily.
For them, telehealth served as a means to assess patients’ concerns. After pausing all in-person appointments save for essential cancer treatments, the clinic began fielding questions by phone. Additionally, the staff would ask people to send pictures of skin abnormalities. Soon, they graduated to Zoom for real-time consultations, reserving in-person visits for those who needed more attention. That required stringent procedures to keep everyone safe. “You kind of have to work as if everyone is positive until proven otherwise,” Dr. Weinstein said.
With people understandably not wanting to leave their homes, telemedicine has surged as a way for patients to seek medical advice without stepping outside. Telehealth had already been seeing growing demand, and many in the healthcare industry tell Engadget that if there's a silver lining in the coronavirus pandemic, it’s that it significantly accelerated that trend.
The rise of telemedicine has drawn the interest of tech giants like Microsoft, Alphabet and Lenovo, along with a slew of startups. Earlier this year, Microsoft announced a new industry cloud platform for the healthcare sector, while Lenovo this month launched a virtual care kit that chronically ill patients can use to track their vitals. Zocdoc added video conferencing support back in May, while Verily, a subsidiary of Alphabet, launched a COVID-19 screening website in April.
Against the backdrop of a global pandemic, regulators have also had to adapt to the crisis. Since March, the FDA has loosened its rules around the use of certain medical devices like blood glucose monitors to complement virtual visits, and has generally made it easier to see a doctor or veterinarian from home. The US government also expanded Medicare coverage for telehealth nationwide. When Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act in March, it provided $200 million in funding to the FCC for a COVID-19 telehealth program that is helping eligible healthcare providers pay for telecommunications and information services, along with devices they need to provide connected care.
”Those policy changes and that flexibility with Medicare [have] been integral, allowing for the huge acceleration and use of telehealth across the industry,” according to former chair of the American Medical Association (AMA) Board of Trustees Dr. Jesse Ehrenfeld. But it’s not yet clear which, if any, of these changes will be lasting. “It's really hard to understand what the future holds for telemedicine once the pandemic is over,” Dr. Ehrenfeld told Engadget.
Last month, the Senate Health, Education, Labor and Pensions (HELP) committee held a hearing to examine if these changes should be modified. Committee chairman Lamar Alexander (R-TN) said in his opening remarks, “The expansion of covered telehealth services should be made permanent," while representatives from the medical community also gave testimonies in favor. But aside from a bill published on the day of the hearing about amending the Public Health Service Act with respect to telehealth for emergency response, no formal legislation has been drawn up. Meanwhile, since it opened submissions in April, the FCC has distributed all $200 million of the CARES Act funding to 539 applicants in 47 states, Washington D.C. and Guam.
The University of Pittsburgh Medical Center Children’s Hospital was one of the recipients of this money, and chief of pediatric transplantation Dr. George Mazariegos told Engadget that it has been instrumental in enabling his team to offer better care to patients. The hospital was able to provide the parents of an infant organ recipient with a tablet that not only contained aftercare resources, but also came with cellular data, a mic and camera for remote follow-ups. “There was no cost to the family,” he added.
According to the data analysis firm CB Insights, telehealth technology was estimated to be a $43 billion industry in 2019, while the AMA expects that figure to hit $250 billion after COVID-19. That’s just a slice of the $3.6 trillion that the US spent on healthcare in 2018, according to data from the Centers for Medicare and Medicaid Services. Even prior to the pandemic, the industry was growing by an impressive amount, with the AMA noting that insurance claims filed for telehealth rose 53 percent between 2016 and 2017. Still, there was a huge jump in the last few months alone.
Those operating in the telehealth industry believe that the rise in adoption will help America’s healthcare system overall. Zocdoc founder and CEO Oliver Kharraz told Engadget that telehealth visits can reduce unnecessary trips to urgent care, which are generally more expensive than seeing a doctor. He also argues this would unburden the system and reduce waiting times for those who need immediate attention. Virtual visits also limit the spread of infections inside facilities, too, he added.
Perhaps the most obvious benefit of telehealth is that it could simply make it easier to see a doctor. There are plenty of inconveniences and obstacles alike that can become excuses for not seeking a doctor, like having to travel or not being able to take time off from work. When it comes to scheduling annual physical exams or checking on milder conditions, “lots of people drop out from the hassle of it all,” Kharraz said.
Executives from other telehealth businesses agree. Zachariah Reitano, CEO and co-founder of the digital health startup Ro, said, “If all [telehealth] ever did was eliminate unnecessary in-person visits, then it saves lives.” He believes there’s another benefit in making it easier to talk to doctors. “I think what you'll see is what people have in their minds as warranting a doctor's visit will come down,” he explained. He hopes that if people develop friendlier relationships with their medical providers, they’ll learn to open up and discuss symptoms earlier, which could mean catching diseases sooner, and, eventually, lead to lower healthcare costs across the system.
Another benefit the pandemic brought about, Reitano pointed out, was New York state removing some restrictions in March, allowing physicians in good standing from other states to remotely help patients in New York. During the worst of the pandemic, the area was hit so hard that there was a serious shortage of medical practitioners to administer to non-COVID-19 patients. Telehealth allowed those in need to still see doctors, sometimes from other states, without having to leave their homes.
People with chronic conditions like diabetes are among those who could most benefit from telehealth, especially when they also have access to devices like thermometers, Bluetooth scales, blood pressure cuffs and glucose monitors. The FDA in April approved the use of at-home monitors like the Abbott Freestyle Libre and Dexcom’s G6 in hospitals, meaning nurses no longer have to visit diabetic patients multiple times a day to prick their fingers for a blood test, each time donning fresh protective gear.
Cynthia Fisher, founder of PatientRightsAdvocate.org, agrees telehealth has benefits for those staying home or patients with chronic conditions, but she cautions that some providers have been “gaming telemedicine as a revenue producer.” Fisher says a major hospital system in Boston billed a woman $110 each for calls they made to her in the guise of outpatient follow-ups.
In documents provided to Engadget, there were charges for what the bill called two “Outpatient Clinic visit -- Hospital” on April 3rd and April 9th of this year. According to Fisher, the woman had made a phone call to her primary care doctor at that hospital to see if she should get tested for COVID-19, which prompted the subsequent follow-up calls from the hospital. Though there’s little data on how common practices like this are, Fisher claims it’s fairly widespread. “So many patients come to us and tell us about being egregiously charged, price gouged,” she said.
That’s far from the only issue the medical community is raising. Dr. Mahmoud Kazemi, chief medical officer of diabetes care at Abbott, pointed to an obvious obstacle: “Accessibility, accessibility, accessibility.”
Whether it’s the cost of devices, sluggish internet speeds, insurance program restrictions or a lack of coverage in rural areas and schools, there can be many hindrances to using telehealth services. “It's really hard if you don't have broadband, or a way to do video to have the kind of virtual care that you might have in a different part of the country,” Dr. Ehrenfeld said. He appreciates that the authorities and insurance companies decided to cover audio-only interactions, since many people don’t have access to the infrastructure required for video visits. But there is more to be done. “Making sure that we expand and improve broadband service is a piece of the policy puzzle,” he added.
Indeed, the challenges of rural access to doctors is something FCC Chairman Ajit Pai has experienced first-hand. Pai grew up in rural Kansas, where his parents were physicians. He said during Axios’ “The future of telehealth” event this week: “I very visibly remember my parents leaving early in the morning to go to a distant town to try to provide care because there wasn't a specialist who might live in those neighboring towns that were even smaller than ours.”
When it comes to caring for children with life-threatening diseases, parents in rural parts of the country also need access to good healthcare. Dr. Mazariegos said 80 percent of his pediatric hospital’s patients come from outside Pittsburgh, with many making the trip from rural areas of Alabama, Missouri, Texas and Kentucky.
Pai added during his interview with Axios on Tuesday that he sees telehealth as a means to bring more access to underserved parts of the country. “We’ve made it a priority,” he said. “Coming down the pike on October 29th, we're starting a $20 billion rural digital opportunity fund to get high-quality broadband up to 6 million locations in rural America.” He also pointed to 5G investment and spectrum access for smaller carriers to extend wireless access to unserved parts of the country as some plans the FCC has. “For the first time in 22 years, we increased the budget for a rural health care program that provides broadband connectivity to hospitals across the country,” he added, saying the fund is now up to more than $600 million compared to the $400 million it’s been capped at since 1997.
The problem with accessibility isn’t just about broadband coverage, though. Other resources like time and availability can also be hard to come by, especially for those juggling full-time jobs with parenthood. Some schools offer telehealth programs that allow children to see a doctor without waiting for their parents to pick them up and bring them to one. According to a report published in October 2019 in Global Pediatric Health, “Over 1 million students in over 1,800 public schools have access to a school-based health center using telehealth, which represents 2 percent of students and nearly 2 percent of public schools in the United States.” The report also notes that these schools are “primarily in rural communities and sponsored by hospitals.” For families without access to such school programs, it can be hard to take time off for childcare and their own health.
There are also some potentially helpful devices, but they might be too costly. Wireless sensors could track diabetes patients “and other recent post operative patients” in real time, according to Pai, “so that they didn't have to wait for things to become emergencies.” These types of devices are “one of the things we're looking to subsidize as well,” he added.
With the tablets they were able to finance through the FCC’s COVID-19 fund, Dr. Mazariegos says his team was “able to do follow up care and keep the care and continuity” for patients and their families “just as if they were here with us.” And, he added, it was important to his team that they were able to provide these services at low or no cost to patients, with or without WiFi connectivity.
Accessibility is a major issue that can cause healthcare disparities to be exacerbated by telehealth. “We know about the racial inequity that exists in healthcare and COVID has shined a light on that,“ Dr. Ehrenfeld said. “We don't want access to telemedicine to make the problem even worse."
Part of the issue around cost of services in general comes down to an opaque billing system. Fisher’s organization has been advocating for price transparency in healthcare for years. “We have seen so many patients pay egregious bills that have come after the fact that were totally unexpected,” she said. Carberry Campbell said she returned from her teaching job in Spain with COVID-19 symptoms and went to AdventHealth for tests in Deland, FL. She was shocked to receive four bills for a total of $6,545 despite not being admitted to the hospital.
Dr. Ehrenfeld agrees. “Patients need better information about anticipated out of pocket costs,” he said. It’s still not entirely clear how insurance providers cover all the different forms of telemedicine -- would you have to pay for every text you send to your doctor and how much will it cost to have a voice call versus a video conference? Whether they’ll continue to cover telehealth also remains uncertain. “It is concerning to us that some insurance companies are now putting an end date on their expansion of coverage for telehealth services,” he added.
Reitano believes insurance companies currently hold too much power, and that more of it should be handed over to the patients and providers. He argues that if patients had the power to fully decide which doctors they were able to see or what clinics they wanted to visit, the overall quality of services would improve. “The reason that doesn't exist now is because the person paying doesn't care, and the patient, the person who does care isn't paying,” he said. “Unfortunately, for better or worse, the people and businesses follow the money.” While we do spend money out of our pockets on premiums and copays, by and large the insurance companies still decide where our dollars go. A majority of Americans are also reliant on employment-based insurance for healthcare finances, which whittles down the available choices for consumers even further.
More digital health startups have emerged in the past few years offering healthcare to the uninsured, while digital pharmacies like Ro and Nurx continue to push down the prices of some medications. But by and large, America’s healthcare infrastructure is still heavily reliant on insurance providers, and they continue to make crucial decisions on where the money goes.
Telehealth could make it easier to see a doctor and alleviate burdens on the system overall, but without the right policies we risk alienating people who don’t have access to technology. The hype over telemedicine is not unwarranted, but “we do need to have a solid plan for how we best support these services going forward,” Dr. Ehrenfeld said. “The time to plan for that future is now.”