COVID-19 pandemic fuels telehealth expansion

It may be months yet before the COVID-19 pandemic recedes, but already it's creating lasting changes in health care, with more patients using computers, tablets and phones to talk with doctors, nurses and therapists.

The use of electronic devices in patient care, known as telehealth, has long held promise as the next big thing in the industry, but not until the coronavirus hit, raising a host of safety concerns, did it become commonplace.

Nearly 30% of health care visits are now conducted electronically, much of it made possible because federal and state regulators, as well as insurance providers, responding to the pandemic emergency, relaxed some of the rules and requirements that made it more difficult to use telehealth.

For example, under Minnesota law, some patients had to drive to a clinic or hospital to use that facility's secure telecommunications equipment if they wanted to talk with a doctor located at another site. In the past year, that rule has been waived.

As the number of COVID-19 cases begins to rise once again in Minnesota, there is bipartisan support at the Legislature to make permanent many of the changes that have driven the increase in telehealth, with both chambers advancing bills to rewrite the state's telehealth laws.

On Saturday, Minnesota reported 1,744 new infections and four more deaths, bringing the pandemic total in the state to 513,833 cases and 6,825 fatalities. Saturday's totals marked the third consecutive day that new case reports topped 1,700.

Some legislators and lobbyists have raised questions about whether insurance should pay as much for a telehealth session as an in-person visit, as well as the clinical effectiveness of telephone calls without video.

For now, the Legislature appears poised to require insurers to reimburse telehealth at the same rate as in-person visits, continuing a provision in current law, and allowing telephone calls. Those issues will be studied once a new law is implemented.

"There is no doubt that one of the silver linings of the COVID-19 pandemic, if that is possible, has been the greatly increased use of telehealth and telephone visits to provide patient care," said Rep. Kelly Morrison, DFL-Deephaven, a physician and sponsor of the bill.

Said Sen. Julie Rosen, R-Fairmont, the lead author of a telehealth bill that passed in 2015: "It is a very important option for the patient and a critical tool in delivering health care. Telehealth is here to stay and the conversation needs to continue on how we deliver that."

Before the pandemic, telehealth accounted for 3% of patient visits, according to a Minnesota Medical Association survey.

When COVID-19 arrived, many clinics stopped seeing patients altogether, not wanting to become breeding grounds for new coronavirus infections.

"I think everybody wanted to do the right thing to keep patients safer at home," said Dr. Beth Averbeck, senior medical director for primary care at HealthPartners. "We were still trying to figure out with the virus how does it spread."

At the same time, health care providers knew that delaying care, especially for patients with chronic conditions, could have dire consequences, sending some to the emergency room.

Recognizing the need, relaxed rules for telehealth were written into many pandemic emergency orders, including in Minnesota, setting up a scramble to retune health care delivery.

"We needed to go from about 1 mile per hour to over 60 miles per hour," said Dr. David Ingham, vice president of health information at Allina Health. "For decades we've been fine tuning the clinic visit, with all kinds of checks and procedures. With a video visit there was none of that stuff."

Apart from ramping up technology, part of the challenge was teaching physicians how to adjust from actual face-to-face interactions to ones broadcast on a screen.

"Teaching them how to have a screen presence and how to interact with patients was a big lift," he said.

James Hereford, chief executive at Fairview Health Services, is familiar with telehealth from a previous job at a Seattle-based health care system which made great use of what it called virtual care.

"The addition of virtual care clearly was a benefit to the patient, their satisfaction went up, quality went up and overall costs went down because we really architected our system to take advantage of virtual care," he said.

The virtual visits worked best with patients who already had an established relationship with the physician and clinic and where hands-on care, such physical exams or blood draws, were not needed.

Telehealth also has been extremely popular in mental health and substance use treatment, with many health care systems reporting high volumes of therapy visits.

Without telemedicine, therapists and patients would need to wear masks during an office visit. "Masks are an essential tool to prevent spreading of the disease but they are a serious barrier to mental health care," said psychiatrist Dr. Tom Winegarden. "With telemedicine I can see a patient's face. I can see the suffering and despair but just as importantly my patients can see my face."

Providers say it is important that they get the same insurance reimbursement payments as in-person visits because overhead costs are the same for virtual visits.

"It is not bricks and mortar costs as much as the infrastructure and all the people behind it to do that work," said Ingham. "You can't have virtual visits without those foundational costs."

But the Minnesota Council of Health Plans and employer groups say that the startup costs should decrease over time and telehealth could eventually bring down the cost of health care.

"We think we will be able to find values and efficiencies that can be passed on to consumers in the form of lower costs," said Lucas Nesse, the council's chief executive, who added that he supports "95 percent" of the legislation being considered.

Another issue has the been the question of whether an audio visit using a telephone is as effective as video. The Minnesota Department of Human Services, which recently surveyed Medicaid and MinnesotaCare enrollees and providers, said it wants to do more studies to see if telephone visits are effective.

"DHS does not oppose telephone as a mode of providing clinical or human services," said Assistant Commissioner Matt Anderson. "What we've asked for is more time ... to better understand what services have worked well and what may not be clinically effective or not safe."

A telephone may be the only option for some who lack internet access or can't stream video.

"If we are serious about addressing health disparities we think telephone needs to be covered as well as video," said Dave Renner of the Minnesota Medical Association. "You can't do the same things on telephone, that is for sure, but the things you can do can be the same standard of care and quality."

Glenn Howatt • 612-673-7192