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.
