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Is this “new normal” a false reality?

As we are now well into October, many months into COVID-19, I think we all have to look at what all the associated changes are going to mean for healthcare. I have been seeing so many telehealth advocates saying “the genie is out of the bottle” and related phrases, such as this being the “new normal” and “we can never go back,” but I think there is still a lot more to be said about the future of telehealth.

I have clients that have said they cannot get their doctors back to the office. They have found the convenience of working from home, the abundance of family/free time, and less overhead appealing, and it seems that their staff are frustrated trying to get them to realize that we are still under a “temporary” public health emergency (PHE). This is not the new normal, but necessitating circumstances due to a virus that continues to affect the country.

I have heard patients even tell their physicians that “I am not coming back into the office,” not because they can’t, but because they don’t want to. The convenience of not having to get ready to leave the house, not having to drive to the physician’s office, and not having to wait in a waiting room has become a mindset. It makes me wonder if patients can really exert that much influence over their physicians. I would hope they can’t, but when the doctors are seeing equal reimbursement to in-person visits during the PHE, why would the physicians want to return to the clinic, and why would the patients? If the old rules, prior to PHE, on telehealth were enforced, and physicians weren’t getting paid as much for telehealth as for an in-person visit, that would make for a real battle for patients to keep demanding telehealth out of convenience versus necessity, and would give the physicians an incentive to return to the office.

The reality I see is that COVID-19 has in effect created a false market for telehealth. I call it a false market because the number of telehealth visits and services we are seeing during the COVID-19 pandemic aren’t driven by natural forces that are going to persist forever. I know about these false markets. Remember when we saw the same thing happen with electronic health record (EHR) software about 10-12 years ago?

In 2009, the federal government hoped to spur adoption of EHRs and invested nearly $1.2 billion in grants to help providers computerize their records. The funding was part of the government’s $787 billion economic stimulus package. This created a false market wherein physicians and practices and hospitals went crazy chasing government money, but at some point the providers that did not apply for it still had to convert to an EHR, and had to pay for the transition on their own dime or be penalized. The same is true today with practices jumping on the proverbial bandwagon to adopt telehealth into their practices.

My concern here is over promoting the idea that telehealth, as it is reimbursed now, during the PHE, is going to last forever. I’m not sure even the most zealous telehealth supporters think that 50-60 percent of visits should be telehealth visits – like what was happening at the height of stay-at-home orders under COVID-19. In many of those cases, both patient and doctor would have rather been in the office, but COVID-19 and its rampant spread prevented that. However, the false telehealth market did expose the concept to both doctors and patients who may have previously been skeptical. I have been trying to get many providers to at least add telehealth as an option for the delivery of medicine for years, and until the pandemic, many thought it wasn’t effective. What changed their mindset? We are going to see how many have become converts and how many revert back to old habits in the coming months. 

We’ve already seen the pullback of telehealth from payors that as of September have added back in the patient shares of cost, and as we open up our states, patients who need that in-person visit are finding their way back to the provider’s office. The real question is, how far are we going to pull back? In other words, what does a rational telehealth market look like? It’s clearly far above the 0.1-percent telehealth adoption (or something close to that number) we had prior to COVID-19, but it’s also likely much less than the 50-60-percent adoption we saw as the pandemic unfolded.

My gut tells me that the real telehealth market is closer to 12-15 percent of office visits, and the best health systems will push that to 20-25 percent.

Of course, there’s one big determining factor in all of this, and that’s reimbursement. When answering any question, you have to first “follow the money.” If telehealth doesn’t continue so that the same service provided through telehealth is reimbursed at the same rate as in-person, then we could see an even bigger falloff. If reimbursement converts back to the “facility rate,” (which, if physician and practice overhead and work relative value units (RVUs) are less, would make sense), I could see telehealth falling into the low single-digits of office visits.  That would be an unfortunate reality, and would no doubt anger many patients who grew fond of telehealth during COVID. But physicians need to understand that telehealth was introduced for necessity, not convenience. So in the future, the medical necessity and the quality of care that is delivered under telehealth when there is no PHE will have to weighed against missed diagnoses and the quality of care of in-person visits. Convenience will no longer be a factor in determining reimbursement, only a talking point.

I’m sure we’ll see some direct to consumer (DTC) telehealth options that are successful as well. We already are seeing those models emerge, and they work in affluent areas, where patients can pay for those types of services and are willing to pay out of pocket. The problem I see with those is that they don’t scale to the entire health system.

We cannot foresee the future of where telehealth is going, but as one recent CMS “Office Hours Calls” pointed out, when the question was posed whether the patient’s’ home would be a valid place of service (POS) after the PHE ends, the answer was no. Only for rural HPSA (Health Professional Shortage Area) or MSA (Metropolitan Statistical Area) patients was that a possibility. That is a huge determining factor when a patient chooses to use telehealth or not. If they have to leave their house anyway to transport to an “approved” originating site, they might as well keep driving to their physician’s office, if that is an option.

Stay tuned to this ever-changing virtual delivery of medicine, and how, after the PHE, the reimbursement process will be handled – and how it will affect continued offerings in medical practices.

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