In 2015, the American College of Physicians officially endorsed telemedicine — that is, providing health care services to a patient who is not in the same location as the provider. Nonetheless, many healthcare providers continued to rely on in-person visits for nearly all of their patients, with occasional phone follow-ups. When the pandemic hit, it induced the birth of telemedicine as a widespread practice.
When I spoke with doctors and other healthcare providers about the change, I heard two main reactions: 1) a degree of surprise that telemedicine was working well for patients; and 2) a comment like “we were still willing to do this, but what changed was the insurance was willing to pay it back.” It is of course not surprising that insurance reimbursement rules determine the manner and type of health care provided, but it is always worth remembering.
Evidence on telemedicine is now available. Kathleen Fear, Carly Hochreiter, abd Michael J. Hasselberg describe some findings from the University of Rochester Medical Center in “Busting Three Myths About the Impact of Telemedicine Parity” (NEJM Catalyst, October 2022, vol. 3, #10, need subscription or library to access). The U-Rochester Medical Center is a good size: six full-service hospitals and nine urgent care centers, as well as various specialty care hospitals and a network of primary care providers. Before the pandemic, they served about two million outpatient visits a year.
During the pandemic, telemedicine at U-Rochester has gone from virtually nothing to 80% of patient contact, and now appears to have stabilized at around 20%.
Here’s how the authors summarize the experience:
Three convictions — that telemedicine will reduce access for the most vulnerable patients; that reimbursement parity will encourage the overuse of telemedicine; and that telemedicine is an inefficient way to care for patients – have for years formed the backbone of opposition to the widespread adoption of telemedicine. However, during the Covid-19 pandemic, institutions quickly turned to large-scale telemedicine. Given this rapid evolution, the University of Rochester Medical Center (URMC) had a natural opportunity to test the assumptions that shaped previous discussions. Using data collected at this large academic medical center, UR Health Lab explored whether vulnerable patients were less likely to access telemedicine care than other patients; whether providers have increased virtual visit volumes at the expense of in-person visits; and whether care delivered via telemedicine was of lower quality or had unintended negative costs or consequences for patients. The analysis showed that there is no support for these three common notions on telemedicine.
At URMC, the most vulnerable patients had the greatest use of telemedicine; not only did they complete a disproportionate share of telemedicine visits, but they also did so with lower no-show and cancellation rates. It is clear that at URMC, telemedicine is making medical care more accessible to patients who have already encountered significant barriers to care. Above all, this access does not come at the expense of efficiency. Vendors do not order excessive amounts of additional tests to compensate for virtual visit limitations. Patients don’t end up in the ER or hospital because their needs aren’t met during a telemedicine visit, nor do they end up requiring additional in-person follow-up visits to complete their telemedicine visit. telemedecine. As the pandemic continues to slow, payers may begin to resist long-term telemedicine coverage based on previous assumptions. However, URMC’s experience shows that telemedicine is an essential tool to fill gaps in care for the most vulnerable patient populations without reducing the quality of care provided or increasing costs in the short or long term. .
The authors are careful to point out that a substantial part of health care must be delivered in person – a point with which it would be hard to disagree. But this evidence also strongly suggests that telemedicine was significantly underutilized before the pandemic. This raises broader questions about whether there are other reasons why healthcare delivery is stuck in its tracks, unwilling or unable to adopt promising innovations in a timely manner.