The VCU Massey Cancer Center looked for ways to continuously care for patients while keeping them out of the hospital or clinics during the coronavirus pandemic.
Instead of setting up multiple face-to-face appointments to monitor cancer patients, VCU doctors used mobile testing services to collect blood samples at patients’ homes and video calls to discuss the results.
Richmond-area medical practices have quickly expanded telehealth services like these since March by having virtual doctor’s visits with patients via smartphones, tablets, laptops or desktop computers.
Telemedicine has been around for years. Many medical practices began developing services for patients to see their doctor virtually while companies encouraged workers to use the service as a way to improve access and to save money.
The pandemic boosted the need for more virtual care for patients. But the future of telehealth after the pandemic remains uncertain.
Strict government regulations and low demand from patients limited telehealth use for years.
“Before COVID-19, we realized that telehealth is important, but due to the requirements set by the government for licensing and infrastructure, we were in very preliminary stages,” said Dr. Wei Zhao, the vice chair of operations at the Children’s Hospital of Richmond at VCU.
Yet by the end of March, many patients felt that seeing their doctor virtually was safer than going into the office.
“The pandemic made people dip their toe in the pool and once they tried [telehealth], they liked it and have been seeking it out more,” said Eric Hays, division assistant vice president for the physician services group for HCA Healthcare, the giant hospital operator with six hospitals in the Richmond area. “I think it will be integrated into how we conduct care in the future.”
Tight regulations on telehealth were lifted in March, which allowed medical practices to quickly meet the new demand for virtual health care.
But these changes are temporary — slated to expire on Oct. 23.
Under the loosened regulations, doctor’s appointments can be held through a phone call, FaceTime, Zoom and other online videoconferencing platforms that were previously prohibited under federal privacy laws.
Doctors used to be paid less for telemedicine visits than for in-person visits, so offering virtual services was less profitable.
But since the beginning of the pandemic, Medicare, the federal government’s program for those age 65 and older, has reimbursed telehealth visits at the same rate as in-person visits.
Most private insurance companies have followed suit for all patients and reimbursed phone calls and online videoconferencing visits at the same rate as in-person visits for now. For instance, Anthem Blue Cross Blue Shield, Virginia’s largest health insurance company, will cover telehealth services until Sept. 30.
“Once the insurance companies started reimbursing at the same rate, there was no reason not to do telehealth,” said Dr. Annemarie Tull, a pediatrician at the Pediatric Center, a practice with three locations in Henrico County.
President Donald Trump signed an executive order on Monday to permanently expand Medicare coverage of telehealth for recipients in rural areas. It’s unclear whether the other temporary changes that allowed for the recent expansion of telehealth will be made permanent.
Doctors say that if the expanded policies and insurance reimbursements for remote visits continue, telehealth could transform the health care industry. If they expire, virtual offerings will dwindle.
“[The government] took such a fast response to lift certain barriers for us to see patients virtually,” said Zhao, a pediatric allergist and immunologist. “That’s why for us, 20 telehealth patients a day turned into almost 2,000 telehealth patients a day.”
The increase in telehealth visits helped local practices generate revenue when in-person visits decreased dramatically.
Being reimbursed by insurance companies at the same rate for telemedicine visits as in-person visits provided the financial incentive for practices to implement or expand virtual services.
In-person office visits to the Pediatric Center, for instance, decreased by about 60% during late March and April. The practice pivoted and implemented a telehealth system in less than two weeks.
“Telehealth is something we have been toying with for years,” Tull said. “We believe in in-person visits, but with the pandemic starting in March, the anxiety and fear for many of our patients about coming in for a visit went through the roof. So we scrambled.”
Because insurance coverage of telehealth was expanded during the pandemic, it became financially viable for practices to offer a large portion of their visits virtually. Before March, doctors were paid less for virtual visits than for in-person visits.
Telemedicine visits reached 35% of total visits to the Pediatric Center in April, but dropped to 10% since July.
“But I think that’s very specific to pediatrics,” Tull said about the reason for the drop. “Because we do so many vaccines and well checks and it’s so much harder to assess babies, our in-person visits have ramped up much quicker.”
Some patients at OrthoVirginia, which has 12 offices and three orthopedic urgent care locations in the Richmond area, have returned to in-person appointments, but many are still opting for virtual visits.
“We saw a tenfold increase, if not more,” said Dr. Steven Reece, a sports medicine and orthopedic physician at OrthoVirginia. “Now [telehealth visits are] not as low as before the pandemic, but they’re not as high as [March and April].”
VCU Health’s telemedicine visits reached 40% of all visits in May.
“Due to the change of regulations during COVID-19, we were able to implement telehealth much faster. Within days, we started seeing a lot of patients through virtual visits,” Zhao said.
Teladoc Health Inc., which makes technology to support online doctor visits, said greater awareness and acceptance of virtual health care are helping to drive growth. The publicly traded company based in Purchase, N.Y., saw its visits more than triple to 2.8 million in the second quarter compared to last year.
While Teladoc saw a surge in online visits because of the pandemic, CEO Jason Gorevic said the company continues to see higher use rates, even in markets where coronavirus cases have decreased.
“We are also seeing sustained demand in areas that are no longer considered hot spots. In some states where the curve has flattened, we are still seeing twice as many patient visits as last year,” Gorevic said in a statement.
Doctors and patients agree that convenience is one of the biggest benefits of telehealth.
“The actual visit time will be the same, but if you add the drive to get there, waiting in the waiting room, filling out forms and waiting in the exam room, you could spend more than two hours on an in-person visit,” Zhao said.
Paige Wolk of Hanover County has had several online virtual visits with OrthoVirginia over the past few months.
“I was a little nervous at first, but the technology was simple,” Wolk said. “It truly felt like I had more of the physician’s undivided time than I would have in the office. There were no distractions on either side. And I didn’t have to wait in the waiting room.”
Patients can schedule a telehealth visit during their lunch break, instead of needing to miss work to go to the doctor’s office, said Dr. Keith Fernandez, the chief clinical officer of Privia Health, which has practices across the country, including three in the Richmond area.
“For people who are chronically ill, I think this is one of the places where virtual health care becomes incredibly important, with or without [COVID-19],” Fernandez said.
Increased access to health care is the biggest upside of telemedicine, doctors said.
“I think that if we can implement this virtual platform, it can actually change the structural manifestations of the health care system that limit access,” Fernandez said. “I think that access to health care is maybe the most important thing — that people who need to see a doctor can when they want to.”
Telehealth also saves time by eliminating the need for transportation.
At VCU Health, many patients miss their scheduled appointments because they can’t arrange transportation.
“Our system has no-show rates between 10 and 20% each day. For a lot of them, it’s because they had to arrange for their transportation,” VCU’s Zhao said.
But implementing telehealth so quickly hasn’t been seamless.
“The technology platforms are sometimes a little bit clumsy,” said HCA Healthcare’s Hays. “It’s something that’s new to both the patient and the provider, and it takes getting used to.”
OrthoVirginia’s Reece expects that over time, technological issues will subside.
“Now, almost everyone is accustomed to this Zoom format, so I think it’ll be easier moving forward,” he said. “But the patients who need it arguably the most are also arguably the most technologically troubled.”
Telemedicine can emulate many aspects of a doctor’s appointment. But behind a screen, doctors can’t perform a traditional physical exam.
“The disadvantage is that you don’t get the personal touch,” Wolk said. “Having a relationship with the physician makes it smooth, and I don’t know how comfortable I would be if I didn’t already know my doctor.”
There are still ways for doctors to re-create an in-person exam on a video call, Fernandez said.
“Just seeing the patient is part of the physical exam,” he said. “Then you can ask them to do certain things that are quite possible for most patients, like check their pulse or move in certain ways to see if something causes pain.”
Some visits are less conducive to telehealth. But for follow-ups, medication checks and more, telehealth is effective and more convenient.
“I am not seeing that telehealth will replace certain in-person visits, especially when the patient needs a procedure, vaccine, imaging or testing,” Zhao said. “But I think telemedicine will last.”
Telehealth is here to stay — as long the policies and insurance coverage that expanded services during the pandemic remain in place, local doctors say.
“Right now, those waivers and changes in requirements are temporary. But I think we may embrace this new way of doing health care. Through our experience during COVID-19, we think telehealth will continue and will be used on a daily basis in our medical care,” Zhao said.
“Previously, telehealth was very poor in terms of reimbursement to the provider. This has been temporarily lifted,” he said. “If we can continue that and the policy could change long-term, it would mean that’s no longer an obstacle to providing telehealth.”
Tull hopes the policy changes will become permanent so the Pediatric Center can continue offering virtual services.
“Telemedicine is here to stay and would be hard to take back from patients,” she said. “Let’s hope that insurance companies decide that they’re going to continue to pay for these virtual visits.”
Wolk plans to continue seeing her doctors through telehealth for certain types of visits.
“I would want that physical exam and to be able to have the doctor see and experience what I’m going through for an initial injury or illness,” she said. “For any follow-up visits, I think it would be very beneficial to do those through telehealth.”
But once the pandemic ends, it’s unclear whether the temporary regulatory changes and increased reimbursements to doctors will be made permanent.
“I think it’s become such a valuable tool that I hope the insurance companies will re-evaluate their position on it,” Reece said. “My guess would be that they will continue to authorize the visits, but may adjust their reimbursement scale based on patients’ risk or age.”
Telehealth could transform the health care industry if the current policies continue, doctors say.
“We can expand this phenomenally,” said Privia Health’s Fernandez.