St. Francis Hospital Vinita is located in Vinita, Oklahoma, an old railroad town of about 5,300 people nestled in the northeast corner of the state. All told, the hospital serves roughly 25,000 people, from residents of the town and surrounding rural communities to retirees settled along the shores of Grand Lake O’ the Cherokees to the east.

The 30-bed hospital—15 medical beds and 15 geriatric psychiatry beds—used to be a county hospital and was bankrupt when the nonprofit St. Francis Health System purchased it in December 2016. Ever since, the Vinita facility, one of six hospitals in the system, has been using telemedicine to tap into the expertise of its Tulsa-based parent.

In one program, Jacob O’Meilia, MD, a St. Francis psychiatrist in Tulsa, conducts his rounds on the Vinita psychiatric ward remotely as a cordless, WiFi-enabled cart equipped with a camera is positioned in patients’ rooms. Telemedicine allows him to limit his commute to Vinita to twice a week. The remote visits are seamless, and necessary, says Todd Schuster, the administrator of St. Francis Hospital Vinita as well as St Francis Hospital South in Tulsa.

“It’s very hard to attract specialists to Vinita on a full-time basis” or to convince them to commute on a regular basis, said Schuster.

In another program, a group of nurses at the main campus in Tulsa remotely monitor the vital signs of cardiac patients across the system, including those at Vinita. And in a developing program, physician assistants who staff Vinita’s emergency department overnight can consult remotely with physicians.

These programs were the extent of St. Francis Hospital Vinita’s use of telemedicine until the coronavirus pandemic hit the United States with full force in March 2020. Federal and state authorities began to loosen the regulations that govern remote medicine, and allowed Medicare and Medicaid to reimburse for a much wider variety of telemedicine services. (Medicare is the federal health insurance program for people age 65 or older and certain younger people with disabilities, while Medicaid is the jointly run federal and state health insurance program for low-income and needy people.) Private insurers followed suit.

Almost overnight, “every family medicine, internal medicine and even many of the specialties were doing a large percentage of their visits remotely,” said Schuster. For example, in April and May, when cases of COVID-19, the respiratory disease caused by the coronavirus, began to surge in Oklahoma, “we probably went 90 percent video visits and 10 percent in-person visits for cardiology.”

Almost overnight, “every family medicine, internal medicine and even many of the specialties were doing a large percentage of their visits remotely”

Nationwide, the increase in telemedicine services was “extraordinary,” said dermatologist Joseph Kvedar, MD, president of the American Telemedicine Association (ATA). The number of telemedicine visits increased three hundred-fold between the middle of March and early May, although the increase could not compensate completely for the dramatic drop in in-person visits, according to researchers who analyzed electronic health records from 22 health systems that span 17 states and cover 7 million patients.

But as many lockdowns across the country ended and the increase in the number of new COVID-19 cases slowed in some of the earliest hit areas of the country, such as the Northeast, in-person visits to doctors’ offices began to recover and telemedicine visits began to decline, according to an updated analysis in August by the same researchers.

Telemedicine visits reached a peak of 69% of total visits to physicians in April and then fell to 21% of total visits in July, “though this is still much higher than the rates seen before the pandemic (less than 0.01%),” the researchers wrote. The swing in telemedicine services led them to title the latest analysis, “Telehealth: Fad or the Future,” published in the journal Epic Health Research Network.

Schuster says St. Francis Hospital Vinita saw the same pattern: an initial surge in telemedicine services, followed by a drastic decline, though the number of telemedicine visits still far exceeds levels prior to the pandemic. “I think people would rather come into the office in person, or at least part of that population would rather come in,” said Schuster.

In addition, some health care providers, especially those fairly new to telemedicine, may have decided that investing in telemedicine is not worth the trouble because the regulatory and payment changes are temporary, good only as long as the Trump administration and states continue to declare a public health emergency. Health care providers have to invest in a telemedicine platform, train staff and patients to use it, and gather data from the patient that might be easier to collect in an office visit, said Hilary Hatch, vice president of clinical engagement at Phreesia, a health care software company.

To restore the momentum behind telemedicine, government payers and private health insurance plans need to clarify now their long-term plans for coverage of telemedicine, Hatch said.

SWIFT FEDERAL CHANGES

“ATA is thrilled,” said Kvedar, referring to the temporary regulatory and payment changes for telemedicine services that the Centers for Medicare & Medicaid Services (CMS) made in March and April. “What we are focused on is efforts to cement those gains so that we don’t go backwards when they lift the public health emergency.”

Some of the key Medicare changes that CMS made include:

  • More than doubling the number of allowable telemedicine services;
  • Allowing all health care providers that are eligible to bill Medicare to provide telemedicine, including first-time professionals such as physical therapists, occupational therapists and speech language pathologists;
  • Waiving geographic restrictions that limited telemedicine to Medicare beneficiaries residing in rural areas designated as professional shortage areas;
  • Permitting telemedicine to be delivered to Medicare beneficiaries in their homes rather than requiring them to come into physician offices, hospitals, and other health care facilities;
  • And allowing telemedicine to be delivered over an audio-only phone in addition to video.

Rural communities have benefited from the changes, say experts. While rural residents were the only Medicare patients allowed to receive telemedicine services before the pandemic, the definition of a rural professional shortage area was fairly narrow, said Mei Wa Kwong, executive director of the Center for Connected Health Policy. “Essentially, before COVID-19, 98 percent of the state of California was eliminated from being geographically eligible,” Kwong said. “The definition even eliminated some portions of Death Valley.” Now any Medicare patient, anywhere, can receive remote medical services and receive them at home.

In addition, for the first time, CMS has authorized rural health clinics (RHCs), which provide primary care to underserved rural populations, and federally qualified health centers (FQHCs), which provide primary and preventive care to underserved populations in all regions, to provide telemedicine services to Medicare patients.

That change had a big impact at Grande Ronde Hospital and Clinics, based in La Grande, Oregon, which runs a 25-bed critical access hospital and 10 outpatient clinics, including four rural health clinics. The RHCs went from delivering zero telemedicine services in March to providing a total of 1,633 telemedicine visits through October 27, 61 percent of which were for behavioral health, says Robert Seymour, the health care system’s chief financial officer. August was the peak month.

The number of telemedicine visits would have been even greater if the new Medicare reimbursement for telemedicine were not such an “accounting nightmare,” said Seymour. Normally, Medicare pays critical access hospitals an interim payment for patient visits, including those at their rural health clinics, and then settles up once a year, making sure that 99 percent of the costs of those visits are reimbursed. Costs include everything from heating to staffing to operating the electronic health records system. But CMS is paying RHCs $92 for a telemedicine visit and not allowing them to recoup costs.

That means Seymour has to somehow estimate telemedicine’s share of the four clinics’ overall costs and subtract it before the hospital’s annual settling up with Medicare. “It’s a mess,” said Seymour, who says he told the director of clinics and Grande Ronde’s CEO to avoid telemedicine if possible.

STATES AND PRIVATE INSURERS FOLLOW

States are responsible for setting the rules for Medicaid, and before the pandemic, most had dropped any rural geographic requirement for telemedicine. In addition, nineteen states allowed patients to participate in a telemedicine visit from home, according to the Center for Connected Health Policy. Still, there were plenty of restrictions.

Since the pandemic, states “sort of followed what Medicare did,” said Kwong of the Center for Connected Health Policy. And many have temporarily eased or waived requirements that physicians providing telemedicine to state residents must have a license in that state.

Many private insurers are also following Medicare’s lead.

Before the pandemic, Blue Cross of Idaho would reimburse its members for only basic primary care telemedicine visits conducted on a mobile phone with doctors employed by MDLIVE, a telemedicine vendor. That changed on March 19, when the insurer expanded its telemedicine access so that members could visit remotely with their own doctors and specialists. “We said that we would cover and pay for any service that could be appropriately provided in a telehealth situation,” said John Worley, vice-president for provider network management. “And we would pay for it at the same level that we would pay for that same service in an office.”

Blue Cross of Idaho’s telemedicine claims multiplied, peaking at 14,400 claims a week in May, Worley said. They have since edged off to about 10,200 telemedicine claims per week as of early October, “but that is still significantly more numbers than we saw in previous years.”

WILL TELEMEDICINE CHANGES BECOME PERMANENT?

At the end of June, nearly 400 medical societies, professional associations, consumer organizations, telemedicine advocacy groups, health care practices, hospital systems and other groups signed a letter to Republican and Democratic leaders in Congress, asking them to pass legislation giving CMS the authority to make the temporary changes it made to regulations governing telemedicine for Medicare beneficiaries permanent.

“Congress not only has the opportunity to finally bring the U.S. health care system into the 21st century, but the responsibility to ensure that billions of dollars in COVID-focused investments made during the pandemic are not wasted,” they wrote.

CMS can make some of the temporary changes, such as the types of telemedicine services Medicare will reimburse and how much it will pay, permanent through administrative action. In a mid-July article in the journal Health Affairs, Seema Verma, the administrator of CMS, seemed to be leaning in that direction when she wrote, “it’s hard to imagine merely reverting to the way things were before.”

But for most Medicare changes to become permanent, Congress will need to act. Several telemedicine bills have been introduced in Congress, but Kwong doubts they will pass as stand-alone bills. Rather, she says it is more likely that permanent changes to Medicare’s telehealth policy would be wrapped into a future COVID-19 stimulus bill. But Democrats and Republicans have been battling since August over the details of a new stimulus package with no deal struck to date.

In addition, few states have yet to take action to make their temporary changes to Medicaid telemedicine coverage permanent, said Kwong.

Worley of Blue Cross of Idaho said the private insurer is committed to its current expanded telemedicine coverage through the end of this year and will continue to provide some form of expanded telemedicine benefits in 2021 and beyond. The company is studying the massive amounts of telemedicine claims data it has collected since March to determine how it should reimburse for telemedicine in the future.

In early October, private insurers reportedly began to shift some telemedicine costs to consumers. At the start of the pandemic, many had waived patient copays for telemedicine, but some have eliminated those waivers, depending on insurance plan and type of telemedicine visit.

Even if Medicare, Medicaid and private insurers make their telemedicine reforms permanent, barriers to using telemedicine remain. For example, more than 22 percent of people living in rural areas of the country lack fixed broadband access, and nearly 17 percent lack access to high speed mobile, according to an August report from the Federal Communications Commission (FCC).

“That is why we are urging our colleagues at Medicare to continue to pay for audio only telephone virtual visits,” said Kvedar of the American Telemedicine Association, “because for certain patients, that is really the only way they can access this mode of care.”