Back 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 with a provider. However, many health care providers continued to rely on in-person visits for nearly all of their patients, with occasional phone follow-up. When the pandemic hit, it gave birth to telemedicine as a pervasive practice.
When I spoke with doctors and other healthcare providers about the change, I mainly heard two interactions: 1) some degree of surprise that telemedicine was working well for patients; and 2) a comment along the lines of: “We’ve always been willing to do this, but what has changed is that insurance has been willing to make up for it.” It is not surprising, of course, that insurance reimbursement rules will drive the style and type of healthcare provided, but it is always worth remembering.
Evidence for telemedicine is now available. Kathleen Fair, Carly Hochreiter, and Abdul Michael J. Haselberg Some Findings from the University of Rochester Medical Center in “Shattering the Three Myths About Equalizing Effect of Telemedicine” (NEJM stimulantsR., October 2022, Vol. 3, #10, you need a subscription or library to access it). The U-Rochester med center is well-sized: six full-service hospitals and nine urgent care centers, along with several specialty care hospitals and a network of primary care providers. Before the pandemic, they were serving about two million outpatient visits annually.
During the pandemic, U Rochester’s telemedicine rate went from nothing to 80% of patient contacts, and now appears to have leveled off again to about 20%.
Here’s how the authors summarize the experience:
Three beliefs – that telemedicine will reduce access for the most vulnerable patients; that reimbursement parity will encourage overuse of telemedicine; This telemedicine is an ineffective method of patient care – for years it has formed the backbone of opposition to the widespread adoption of telemedicine. However, during the Covid-19 pandemic, institutions quickly turned to telemedicine on a large scale. Given this rapid move, the University of Rochester Medical Center (URMC) had a natural opportunity to test the assumptions that shaped previous discussions. Using data collected from this top academic medical center, UR Health Lab explored whether at-risk patients were less likely to access care via telemedicine than other patients; whether the service providers have increased the volume of virtual visits at the expense of personal visits; and whether telemedicine care is of low quality or has unintended negative costs or consequences for patients. The analysis showed that there is no support for these three common concepts about telemedicine.
At URMC, the most vulnerable patients had the highest incidence of telemedicine use; Not only did they complete a disproportionate share of telemedicine visits, but they also did so with lower no-shows and cancellations. It is clear that at URMC, telemedicine makes medical care more accessible to patients who previously experienced significant barriers to care. Most importantly, this reach does not come at the expense of effectiveness. Providers do not require excessive amounts of additional tests to compensate for the limitations of virtual visits. Patients do not end up in the emergency room or hospital because their needs are not met during a telemedicine visit, nor do they end up needing additional in-person follow-up visits to supplement their telemedicine visit. As the pandemic continues to slow, payers may begin to resist long-term telemedicine coverage based on previous assumptions. However, the experience at URMC shows that telemedicine is a critical tool for bridging care gaps for the most vulnerable patient population without lowering the quality of care provided or increasing short-term or long-term costs.
The authors are careful to point out that a significant portion of health care needs to be provided in person—a point that is hard to disagree with. But this evidence also strongly suggests that telemedicine was significantly underutilized before the pandemic. It raises broader questions about whether there are other ways in which health care provision gets stuck in its ways, unwilling or unable to embrace promising innovations in a timely manner.