Is Telemedicine The Future Of Health Care?

The novel coronavirus pandemic has stretched health care systems to the brink. Covid-19, might be getting all the headlines, but patients are still getting sick from other diseases and injuries. And that's left doctors looking for other ways to treat them while minimizing contact. Enter telemedicine. Telemedicine is broadly defined as the use of electronic communications and software to monitor and treat patients in lieu of an inpatient visit. Over the past decade, telehealth, a broader term used to define all medical services and health education delivered digitally, has grown steadily as an industry. According to IBISWorld, the industry's revenue has grown 34.7 percent from 2014 to 2019. The market size in 2019 was around 45 billion dollars, but it's projected to grow to more than 175 billion dollars by 2026. Despite the increase in revenue, Americans have been slow to adopt the practice. According to a 2017 study, 82 percent of U.S. consumers don't use it. Like all of American life, that changed with the novel coronavirus.

The number of Medicare patients using telehealth has increased from roughly 11,000 a week to more than 650,000 people a week. It's led to a surge in usage for telemedicine companies such as Teladoc and American Well. And video conferencing company Zoom, whose stock is up more than 150 percent since the start of 2020. Shares of Microsoft, which owns video conferencing software Skype and its teams platform, are up more than 14 percent since the start of 2020. Telemedicine visits surged to 50 percent in March and are on pace to reach 200 million by the end of 2020. That's up from earlier predictions of 36 million America's health care system has skipped the test run and jumped to using telemedicine as a primary means of care during the coronavirus pandemic. Here's how coronavirus could change the future of U.S. health care. Telemedicine dates back to the mid 20th century when radios were used to provide medical advice on ships. In hospitals, the first usage was in the 1950s through a closed circuit

television link for psychiatric consultations. In the last 30 years, telemedicine treatment has expanded to mental health, stroke and patients with chronic diseases like asthma, diabetes or heart failure. A number of research studies have found it to be an effective alternative and satisfying for both the patient and provider. Telehealth proponents have sold it as a solution for patients in rural areas. Now they advocate it as a low cost and convenient option for tech savvy millennials and busy parents as well. A 2019 American Well study found that 66 percent of Americans are willing to use telehealth, but only eight percent had already tried it. Dr. Michael Barnett is an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health and a primary care physician at the Brigham and Women's Hospital in Boston. He's published papers about telemedicine adoption in the U.S. There are many different reasons why the use been so low. The first is that insurers are very worried that people would use too much telemedicine if they covered it too easily.

And so there are lots of restrictions on the kind of telemedicine visit that insurers will pay for. So, for example, Medicare, which is the big federal government payer that covers older adults and the disabled, they only pay for telemedicine if somebody is a rural resident. And you also have to go to a specific kind of facility with a specific kind of equipment and has to be a doctor that you've already seen. In addition to that, in the U.S., I think people are really quite attached to seeing their doctors in person. Doctors or, also, their business model is very much tied to seeing patients in the office. So they don't have a lot of incentive to offer telemedicine because there isn't really a whole lot of patient demand. So when the government announced that they would lift telehealth restrictions for Medicare, it was a big deal. Today, we're also announcing a dramatic expansion of our Medicare telehealth services. Medicare patients can now visit any doctor by phone or video conference at no additional cost, including with commonly used services like FaceTime and Skype. The move paved the way for private insurers and others to waive

their restrictions. However, the new exceptions didn't void requirements states might have for telehealth. Telemedicine has been cast as a tool to protect medical professionals from exposure to Covid-19, to help reduce reliance on personal protective equipment and keep the vulnerable and healthy at home. Now, coronavirus could boost telehealth interactions to one billion by the end of 2020. Telemedicine companies like Teladoc and American Well have seen a big boost in users during the coronavirus pandemic. They've been able to meet demand thanks to most states temporarily modifying their license requirements for doctors, meaning a doctor in one state can diagnose a patient in another state. That's led Credit Suisse listing Teladoc as one of their top 10 investment ideas amid Covid-19. Berenberg Capital Markets predicts the company's market opportunity can only head upwards. And William Blair has called it the only clear beneficiary of the Covid-19 outbreak in our universe. Even tech companies are entering the telemedicine space. Here's CNBC reporter Cristina Farr on the growing overlap between health and tech. So all of the major tech companies out in Silicon Valley have

been interested in telemedicine now for years and have been studying ways to incorporate it into their products. Microsoft, for instance, has been developing chatbots, has collaboration software like Teams. They also have video conferencing services. Same with Apple, same Google. And increasingly, they're finding ways to point people to use these sorts of services. While telemedicine on paper looks like a near perfect solution for policymakers. It isn't always the best solution for providers or patients. Dr. Jessica Bender is a primary care doctor and a clinical instructor of medicine at the University of Washington. Telehealth is not for all issues. We want to provide the right care to the right patient at the right time. Some medical issues just cannot be resolved over the phone or over video and require an in-person visit. Doctors are not always paid the same amount for a virtual visit as they are for an inpatient visit. As of December 2019, only 10 states pay the same amount or have what they

call payment parity laws. There are a number of states that have passed so-called parity laws that basically force insurers to pay the same amount of money for a telemedicine visit as an in-person visit. And the fact that telemedicine pays less than in-person visit is another reason why it's been adopted less because not only are there all these requirements for whether you get paid or not, but also in many situations, doctors may not get paid as much for doing the same service. Additionally, to access telemedicine services, patients need reliable Internet access. And according to a 2020 Broadband Now study, 42 million Americans don't have access to a wired or wireless broadband connection. Telehealth has a risk of exacerbating pre-existing inequities in health care, in either access to care or in health outcomes. We talk about something called the digital divide. So large parts of the country are rural and may not have access to high speed internet, for instance. Many of my patients who I see are unhoused.

They don't have phones, they don't have Internet or they might not have a safe place or private place to be for a visit. And so if we leave those folks out of our approach to telehealth, we will just make health inequities worse. In the U.S., more than 50 health systems such as the Cleveland Clinic of Ohio and Mount Sinai in New York City have telehealth systems to conduct a virtual check-ins with patients. While most health systems have been able to quickly adapt, there are still ways to improve. We're seeing hospitals start to strike these deals with telemedicine companies. Right before the pandemic, we saw Cleveland Clinic, for instance, a big medical institution, sign a deal with American Well, one of the largest telemedicine providers. And that's true across many of these large hospitals that have gone from having some kind of telemedicine option that's available, but very few people know about it. To now pushing telemedicine front and center, marketing it, emailing it, putting it right up on their websites for people to use, really trying to make sure that they are aware that the option exists. Massachusetts General Hospital, one of the top hospitals in

the United States, has been using a mix of existing and in-house platforms to meet care. Dr. Lee Schwamm is the Director of the Center of Telehealth at Massachusetts General Hospital and the Vice President of Virtual Care at Partners HealthCare. In the beginning of March, before Covid really came to us, maybe four weeks ago, we did about somewhere between 0.7 percent and 0.8 percent of all of our ambulatory visits were over telemedicine. This week, we're doing more than 75 percent. We also created a program where we mounted an iPad on some specially configured hardware to attach it to an I.V. pole and turned it into an always on video intercom so that we could reduce the need for providers to put on protective equipment, which is in very short supply. But continue to engage with patients in a way that's much more compelling than just over the nursing call bell. The University of Washington Hospital offers a number of telemedicine services for specialties. However, like most hospitals, not every service was equipped for

telemedicine. The high demand for care has left hospitals and practices to retrain physicians on how to care for patients virtually. In our healthcare system, we have an online training that everyone who is credentialed in telehealth needs to complete, and that teaches us how, logistically, how to do telehealth. It gives us some tips about setting up a space. So I'm lucky I'm in my basement at my house. I have a separate room with a closed door. It's quiet. When I am actually interacting with patients, I make sure I wear my badge and that it's visible. Telemedicine has adapted quickly during the time of coronavirus. However, the practice hasn't been a perfect transition for all forms of care, especially for doctors who are used to seeing patients every day. It's been disorienting to see so few patients in person. For a lot of doctors, this has been a learning experience, to put it mildly, because we are so used to having our priority list and how we take

care of our patients dictated by who's on our schedule that day. And now we just don't have the same mechanism. Another thing that has become very important in this tragic crisis are serious illness conversations with patients. Talking with patients and their families about their choices and if they have chronic medical conditions, talking about whether or not they would want to be on a ventilator if their illness progressed rapidly due to Covid and they could not breathe. So, again, many of the things that we used to take for granted would happen in person. We've now been forced to reinvent in this video only environment. Telemedicine has helped maintain some business for the health care industry, but volumes of visits are still down. That could hurt the system financially over the long term. One of the primary care clinics where I work, it looks like, our in-person visits have decreased probably by 80 to 90 percent. So they're at levels of 10 to 20 percent of what they previously were.

And then our telehealth visits, make up, bring us back to our prior levels. So if we had before 100 visits a day, now we have maybe 20 in person and 50 to 60 telehealth visits. Something the federal government, I think, needs to catch up on is that the way they have relaxed telemedicine regulations. They still don't pay really nearly enough for practices to make up for the lost volume that they're experiencing right now because patients are really either staying home and visit volumes are plummeting across the country for practices everywhere, and it's especially hitting small and medium practices hard. And doctors aren't necessarily making up that volume with telemedicine. But also telemedicine visits only pay a third or even less of what a normal in-person visit would pay. So they're getting hit doubly hard. Hospitals and other health care providers are slated to receive about 175 billion dollars to make up for the increased costs and lost revenue as part of the Coronavirus Aid, Relief and Economic Security Act. However, it might not be enough to save them.

This crisis has an enormous financial impact on hospitals. We've canceled all of the elective cases that are what help support the mission of the hospital, and we are now caring for the sickest of the sick and those patients are staying in the hospital for a very long time. And so without federal and state relief, this is an impossible burden for hospitals to carry financially. And we may be very much at risk of hospital bankruptcies because of the extraordinary concentration of needing to spend more money, acquire more supplies, care for the sickest of patients and at the same time, no longer have the mainstay, the bread and butter of the procedures that largely fund the operations of the hospitals. Cleveland Clinic predicts within five years, half of the outpatient visits in the U.S. will be virtual. After this pandemic is over, telehealth will be here to stay and people w ill want, they won't want to go back to only in-person visits. I think people will want the option of telehealth visits as well.

Now, they can't replace our entire healthcare system and people still will need to come in for their pap smears and exams. But I think people will find a preference for this. They won't have to take off a day from work or take three buses to travel to the doctor's office or find childcare. The system that we were in before was not particularly efficient. There were just massive costs. And you saw just, you know, that increase every single year. It just it wasn't sustainable. Telemedicine for a long time has been a way to bring costs down. It makes sense. You should see some of these patients virtually that can be seen that way and then save the physician time for those that really need that in-person care. And I think telemedicine offers that and it's likely where medicine is going. For doctors the new rules for telemedicine and insurance means they stand to make more money from the practice, if those rules do stick around. Insurers are also going to have a very hard time clawing back this flexibility with telemedicine payments. And so it's also going to be much easier for physicians to get paid for

their time and have a viable business model providing care across the whole spectrum. The coronavirus pandemic created a clear line between the before and after for the wider health care industry. And telemedicine might be a big part of what comes after Covid-19.