Should Medicare's telemedicine push continue after the pandemic subsides?
Medicare has widely broadened the use of telehealth services during the pandemic. Virtual healthcare provided by video or phone link has been a lifeline for people who mighthave otherwise gone without receiving health services at all. Some patients like the convenience of telehealth, and insurance companies see it as a way to save money (and grow profits). But now, the Trump administration is moving toward making some of these expansions permanent, and health advocates are urging caution.
They worry that widespread adoption of telehealth services could exacerbate already- existing disparities in care and leave behind under-served communities.
For starters, consider the chart above from a new article in JAMA Internal Medicine examining access to computers, mobile technology and high speed internet among Medicare enrollees. As you can see, access varies quite a bit by age and race (income too, but that’s not on the chart). Still, the basic fact that 41 percent of Medicare enrollees don’t have a computer with high speed internet access is a clear indicator that telehealth should be studied carefully before it is permanently added to Medicare’s toolbox.
This week, the Centers for Medicare & Medicaid proposed to permanently allow some services to be performed via telehealth, including home visits for the evaluation and management of a patient, and certain types of visits for patients with cognitive impairments. CMS also opened a period of public comment on whether some other telehealth services should be expanded permanently.
And NBC News reports that President Trump will sign an executive order on Monday “that serves as a call for Congress to make doctor visits via personal technology a permanent fixture of [Medicare],” but only for rural patients.
This post from the Center for Medicare Advocacy sums up the concerns about a rush to make telehealth services permanent:
[We have] concerns about the rush to make telehealth changes permanent, without addressing a range of underlying issues. In particular, we note growing concerns that current telehealth practices may increase health care and access disparities.
While we recognize that the expansion of Medicare-covered telehealth services has helped many beneficiaries reduce risk of transmission of the COVID-19 virus by receiving care while staying home, the Center for Medicare Advocacy has concerns about premature expansion of telehealth services. The Center, together with Medicare Rights Center, recently released principles to help guide policymakers when assessing Medicare coverage for telehealth.
Of particular concern is that expansions in telehealth services could exacerbate disparities in care, leaving behind underserved communities.
This concern was underscored by a July 2020 Congressional Report, Left Out: Barriers to Health Equity for Rural and Underserved Communities Report of the Committee on Ways and Means Majority U.S. House of Representatives, which examined the context for social determinants of health in order to frame policy solutions striving for health equity. The report explored the limitations of telehealth for communities with limited broadband access, “[i]n many areas, the absence of reliable broadband service makes it impossible for residents to rely on telehealth as a viable form of health care, emphasizing the interplay between health system and environmental factors in many of these communities.”
Having access to high speed internet, or broadband, is essential for telehealth expansion to be equitable, and improve outcomes for all beneficiaries. While estimates vary based on the study (a recent CBS report highlighted a Microsoft study that showed 162 million Americans do not have broadband at the speeds that the FCC defines as ‘broadband,’ meaning that about half the population of the U.S. has either very slow internet or none at all) it is clear that access to reliable internet must be factored into telehealth policy.
The JAMA analysis defined "telemedicine unreadiness" as meeting any of the following criteria:
Difficulty hearing well enough to use a telephone, even with hearing aids
Problems speaking or being understood
Possible or probable dementia
Difficulty seeing well enough to watch television or read a newspaper, even with glasses
Owning no Internet-enabled devices or being unaware of how to use them
Not using email, texting, or the Internet in the past month
Here’s a MedPage Today write-up of the study results:
Overall, 38% of Medicare beneficiaries -- representing 13 million older adults -- were unready for video visits. Even if people who provided social support could set up a video visit, 32% of older adults still were unready. An estimated 20% of older patients were unready for either telephone or video visits because they had difficulty hearing, difficulty communicating, or dementia.
"I'm very concerned we are overlooking issues of virtual access for older adults," Lam told MedPage Today. "As long as clinics remain virtual, older people can't get in."
"It's like having a clinic up a flight of stairs with no ramp or elevator," he continued. "We need to realize that providing telecommunications devices -- like smart phones and tablets, and preferably geriatric-friendly ones -- in the current environment is like building a ramp to get to a virtual clinic."
Older adults account for 25% of physician office visits and often have multiple morbidities and disabilities, Lam and co-authors noted. While HHS and other organizations have promoted video visits to reach patients at home especially during the COVID-19 pandemic, these consults require patients to be able to get online, operate and troubleshoot audiovisual equipment, and communicate without the cues available during a personal visit, they added.
Time to throw on the brakes, I’d say, and take a careful look at teleheath before we make it permanent.
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