How to Stay Up to Date on Telehealth Guidelines

How to Stay Up to Date on Telehealth Guidelines from Patient Empowerment Network on Vimeo.

 Joe Kvedar, MD from the American Telemedicine Association shares how patients can stay aware of current telehealth guidelines at their specific health centers and gives insight into how access to telemedicine will be in a post-pandemic society.  

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Transcript

Mary Leer:  

How can patients find state guidelines about telehealth options? Can I see a Telehealth provider outside of my state?  

Joe Kvedar:  

In some states, you can. There is something called the Licensure Compact that I think 23 states have signed on to. During the beginning of the pandemic, it was, you could do anything now it’s much less wild, wild west, if I can use that term. So, in certain states, in some states, for instance, the four corner states, Colorado, Utah, and Wyoming, and I forget the forth, they all have a relationship with one another, so that it’s easy for doctors to get licensed in the other states. So, where there’s a lot of rurality and less doctors, these things tend to happen more often, whereas in a place like New York city or Boston, where you have a lot of physicians, there’s less interest in opening it up. So, it’s a complicated answer. I wish we could do better on licensure. I think it’s a very outmoded concept, but there’s so many entrenched interests that want to keep it going, I don’t think any time soon we’re going to see the state licensure paradigm change for physicians.  

Mary Leer:  

How can patients identify if their health centers have telehealth options? 

Joe Kvedar:  

Well, these days, everyone, almost everyone does, but everyone has a website, everyone has a patient onboards-man, a patient intake, a patient portal, and any of those resources typically will have…And it used to be prior to the pandemic that you… Those services were often available, but you really had to dig to find them, whereas now it’s pretty much on the front page of again, every hospital website or their portal, or you can call a phone number and get scheduled for someone, it is important for folks to realize that not every problem is suited to telehealth. So, if you ask for a telehealth visit and you get told the doctor would rather see you in person, it may be for a very good reason, it may be that there’s some aspect to that evaluation that really does need to happen in the office. So just to keep that in mind. 

Mary Leer: 

What will telemedicine look like in a post-pandemic society? That is, is my medical team likely to continue with virtual visits? 

Joe Kvedar:

Well, I wish I had a clear answer to that, I can speculate, and a lot of it has to do with this idea of reimbursement. If reimbursement continues to be reasonable from the doctor’s perspective, then you’ll likely see them doing this. And I want to just add that doesn’t mean that doctors are greedy or, but generally people like to get paid for the work that they do. That’s just a general thing. And so, if they have two channels to deliver your service in-person or virtual, and someone says, we can do either, but we’re not going to pay you to do virtual, the chances are they’re going to suggest that you come in for the in-person service. It’s just human nature. And anyway, so I think that’s the big one and how we integrate them. Hospitals are still ambivalent about this, they actually, hospitals do better if you come into the facility for a lot of reasons, so there are a few kinks to work out, but I actually think that the last CMS administrator in the Trump administration, a woman named Seema Verma said it best when she said, “The genie’s out of the bottle and we’re not putting it back.” And I think that’s really how we want to view this; it’s going to happen. We still have a little bit of an uphill battle policy-wise to make it happen, but it will and it’ll be better for our patients as a result.  

How Can the Future of Telemedicine Impact Survivorship?

How Can the Future of Telemedicine Impact Survivorship? from Patient Empowerment Network on Vimeo.

Joe Kvedar, MD from the American Telemedicine Association explains how the future of telehealth technologies can impact the survivorship of patients with chronic illnesses.

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Transcript

Mary Leer:  

How might the future of telemedicine impact survivorship, especially for people living with cancer or anyone with a chronic condition?  

Joe Kvedar:

Well, some of us feel that telehealth is ideally suited to care for folks with chronic conditions. think cancer is a special case, but one of the fundamental things about telehealth, if you do it right, and I’m not just talking about video now, but audio, what we call asynchronous, which is more like a text exchange, remote patient monitoring, where you’re monitoring people in the home with various technologies, etcetera. If you use the right tool to solve the problem, what you get is more continuous care. So, for our cancer patients, that is more touches to the system, more inputs that they can give, more fine-tuning of how they feel, what their regimen is, how comfortable they feel when they’re on treatment, all can be done better because you’re obviating the need to physically get up, travel somewhere, set in a waiting room, you’re doing it much more rapid fire. And for chronic conditions, I think it’s just a match being in heaven because once you find out, for instance, you have, I would say type 2 diabetes, then it’s not about the diagnosis it’s about management and management again, is lots of little feedback with lots of conversations, you measure your glucose three times a day, that data goes into a cloud and then software will tell you maybe you should eat a little bit less of this or that, these days, we have tools that match a smart glucometer to an insulin pump to create almost what’s like an artificial pancreas, those are all a form of telehealth, and it enables us to manage those conditions much more effectively. 

Again, conditions like high blood pressure, congestive heart failure, and diabetes are all perfect candidates to be managed in this, what I call  little bite way of doing it, as opposed to once every three months, whether you need it or not.

How Can Telehealth Broaden Access to Quality Care?

How Can Telehealth Broaden Access to Quality Care? from Patient Empowerment Network on Vimeo.

Joe Kvedar, MD from the American Telemedicine Association discusses how telehealth technologies can broaden access to quality care for vulnerable populations.  

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Transcript

Mary Leer:  

How does telehealth broaden access to quality care for various populations?  

Joe Kvedar:  

You know, I’m so glad you asked that because people… One of the things that we’ve also worked on at the ATA is this idea of bridging the digital divide and tackling disparities, I think we now all know that the pandemic did a lot to highlight inequity and disparities in health care delivery across the country in so many ways, and we really wanted telehealth to be viewed as a solution and not part of the problem. But as it stands, if we’re, for instance, doing most of this care through video visits, and you don’t have access to broadband or a computer or a smart device, you’re locked out and so that’s a problem, which is something that I want to emphasize, which is audio only telehealth that is doing what we can with a phone call that was never paid for prior to the pandemic, and it has been. And that’s another thing that we’re urging the Government to continue to pay for his audio only because it helps us cross the digital divide. I mean, there are many other aspects to it, it’s not a straightforward, simple solution, we want to have broadband penetration, we want to have more smart device availability, more health literacy, etcetera, there’s a lot of aspects to it, but if you take that one exception, and it is a big one, but if you take that away and just look at the idea of time and place independent care, which is what telehealth is, then it gives access to so many people. I do my sessions on Tuesday afternoon every week, and at least once a week, a patient will say to me, You mean that’s it? I don’t have to travel? I don’t have to do anything? I get to get this care service right where I am. 

I mean, I have people who are shut-ins who can’t get out of their apartments, I have patients who are, it takes this one particular patient who is a special needs child, he’s 20-something years old, it takes literally an army of people to get him into the office. So that access is amazing, and of course, we wany to see that continue as well, but we have to talk… I’m sorry, we have to address the inequity part very much as well. So, it’s a two-part answer, I guess.

Does the CARES Act Impact Telehealth Technologies?

 

Does the CARES Act Impact Telehealth Technologies? from Patient Empowerment Network on Vimeo.

Joe Kvedar, MD from the American Telemedicine Association shares how the CARES Act has impacted telehealth technologies and what the expiration of the CARES Act means for patients.

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Transcript

Mary Leer:  

How does the CARES Act impact telehealth technologies?  

Joe Kvedar:  

Well, so this gets back to whether we can do these sort of, any software story now, and it’s really, I think it officially still says in the law that you can use, again, Google Meets, you can use FaceTime, you can use whatever you want. But in practicality, the good news is that the industry has really responded in a way that allows us as clinicians to offer our patients a secure solution almost always, and so most of the medical record vendors have integrated a video conferencing tool into their suite. We use Epic where I work, and ZOOM is integrated into Epic, so that I can launch a call from Epic, the patient can request a video call from our patient portal, and it’s all done securely, but even for those doctors who don’t have that kind of fancy software, there’s a tool called Doximity, which is a social network fundamentally for doctors, and it’s free and Doximity has something within it called a dialer function, and what it allows you to do is place a video call. It’s very patient-friendly and it is secure. So really the need for us to use some of these other tools that are less secure has gone away now, and I think anyone that’s doing this kind of work should be using tools that are secure, of course, for the good of our patients as well. 

 Mary Leer:  

Wow, that’s very reassuring. Did the CARES Act expire? If so, when and why? 

Joe Kvedar:  

Well, a lot of the provisions went away last December, the CARES Act was a broad set of policy changes having to do with the virus, but the good news… We’re talking about telehealth. The good news is that all of the telehealth provisions are still in place, and the government just passed a few weeks ago, an omnibus spending bill, and within that omnibus spending bill was a large section of legislation around how we’re handling telehealth, at least in the first few months, after the public health emergency expires. So, the reason for the CARES Act was because there was a public health emergency and right now, we’re still in the public health emergency and it gets renewed every 90 days. The government has said to us that they’ll give us a 60-day notice if they’re not going to remit, they just renewed April 1st through April, May and June. So, the next time it comes up will be July 1, so in early May, if they’re not going to renew it, we will know, and the rule or the law that just was passed in the omnibus spending bill extends all of those telehealth regulations that we talked about earlier. 

Extends the reimbursement, extends the technology provisions through 100, it’s a weird thing, but 150 days after the public health emergency is lifted. So, we think optimistically that gives us to at least the end of this calendar year to figure out and convince Congress to do something that has more longevity to it. Their two main concerns are number one, cost, they feel like possibly telehealth is going to add so much to Medicare that it will be a drain on the trust fund, I’m being a little bit hyperbolic, but there is worry, and I think as providers we need to reassure them that we’re not adding services, but substituting for in-office services. In fact, it should be cheaper, but anyway, they’re worried about cost. The second thing though that is even harder to convince them is not a problem, is fraud and abuse, somehow people have this sense that because it’s electronic, it’s easier for people to commit fraud, it’s no easier than… And there’s a lot of, unfortunately, fraud that  goes on in Medicare and office-based practices as well, so we’re battling them on that one, but that’s what they want to do, steady for five months after the public health emergency is lifted and come up with a longer-term solution. 

So we consider that a victory. As I said, the public health emergency may not be lifted in July, we don’t know yet, but if it is, we still have a good six months to figure out how to extend as much of this relaxed regulatory environment run telehealth as we can.  

If we do in fact run out of runway to do this, it will be like going back into the ice age right now, are patients… I have to say this is, I’ve been at this almost 30 years, and when I go to the physical office and see patients, and I had mentioned to them, we could do your follow-up by telehealth, and they nod their head, they know what I’m talking about. That’s an amazing thing for me. I used to have to explain what it was, how to do it, etcetera. There’s like, no problem, we get it. So patients are now used to this and it’s a good thing, and we as I think somewhere… I don’t know whether it’s 5% of claims now, but I don’t know how much of healthcare is delivered this way, but a substantial amount, and so we risk that going away is the big risk, why is that? Because if Medicare does not get… Well, it’s called the Originating Site Rule Change, and that was given up during the pandemic, it was part of the care regulations that Medicare, as a Medicare recipient, you can be in your home and receive telehealth, you can be in an urban environment and receive telehealth. Before the pandemic, you had to live in a rural area, a very, very tight geographic restriction, and you had to go to a facility, so it was much more regulated and therefore there was much less activity. 

That’s the big one for us. There’s a few other things like federally qualified health centers, being able to use telehealth, very important, but the big one for us is this idea that if we don’t change the law to allow what’s called the originating site to be the patient’s home, then it could very well be in high siege, unfortunately, because the other thing that we should probably note is that if Medicare makes a payment decision, this is just generally, doesn’t have to be telehealth, but if Medicare makes a payment decision, most private payers will follow suit. So if Medicare makes a decision to continue to reimburse telehealth, you’ll find most private payers will feel compelled to do that if Medicare makes a decision. Well, and again, it’s Congress because it’s a law. So, if Congress doesn’t pass a new law, then we’ll find that Medicare has to go back to that very restrictive, geographic limited way and the private payers will say, oh great, we don’t have to pay for this. We’ll go back to our old ways. So that’s why I call an ice age, and where I am Chairman of the Board at the ATA, we’re working very hard to make sure that doesn’t happen.

How Have Telehealth Regulations Changed?

How Have Telehealth Regulations Changed? from Patient Empowerment Network on Vimeo.

Joe Kvedar, MD from the American Telemedicine Association discusses how telehealth regulations have changed since the start of the COVID-19 pandemic.  

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Transcript

Mary Leer:  

Can you briefly describe how telehealth regulations changed during the beginning of the pandemic? 

 Joe Kvedar:  

Yes, so as part of the original CARES Act, there were several things that happened. Some had to do with technology, some had to do with reimbursement, some had to do with privacy. And the whole idea was telehealth had to happen overnight, as you know, we sort of went into locked down them immediately in the middle of the month of March of 2020, and the government had the forthrightness to do some of these things. So, I’ll just tick them off at a high level, number one was Medicare and really all private payers began to pay for video visits with your doctor at the same rate they pay for an office visit. So that was a big one. The second one was that the doctor could use and the patient could use any technology, whether it be FaceTime, Google Meets, etcetera, Skype, to do those visits at the time, knowing full well that not all of those were HIPAA-compliant or exceptional privacy, but in order to get that going. That by the way, has since changed, perhaps we’ll come back to that later. And the third big one had to do with licensure and states, and so at the time, you could, as a doctor, I could practice across state lines. Again, that’s been whittled back subsequently as well, but the big one that stood the test of time has been about reimbursement, and that one has really led to about a 24-fold increase in the amount of telehealth that’s going on since if you compare April of 2022 with April of 2019, it’s about a 24-fold increase, extraordinary. And it’s been quite consistent over the last year or so, that we continue to see that, so it’s what we call two-channel healthcare delivery, and it’s been a wonderful thing to see happen.

There’s an App for That…Or There Should Be: Utilizing Technology for Better Health Outcomes

Health literacy has always been a passion project of mine ever since I was diagnosed with cancer. I stand by the notion that plain language and clear communication leads to better health outcomes. However, communicating with our care team isn’t always easy. How many of us have gone into an appointment only to leave the office 10 minutes later, wondering what happened and what our copay went to? Were all of our issues and questions addressed? 

This is where we have to come in as advocates for our own health, and below are a few ways to do this: 

  • Try and focus on one ailment per appointment 
  • Write down a list of questions you want addressed prior to the appointment 
  • Ask questions during the appointment – you are the expert of your body and health 
  • If something doesn’t make sense, ask for the information to be explained in another way. Patients are found to be more compliant if they know: 
    • How to take their medications properly 
    • Why specific blood tests and imaging are ordered (i.e. if they’re necessary) 

How do we keep track of all of this information, though? There are patient portals that keep track of our appointments and records, but those can often be hard to navigate, and they lack the capability of being able to enter our own information (i.e. about how we’re feeling). Additionally, different health systems have different portals, leading not only to lost passwords, but a missed opportunity for integrated healthcare. This is essentially senseless for cancer patients who have to keep track of multiple appointments and medications, all while trying to keep afloat in a system that wasn’t built for patients and their caregivers. 

However, there’s a role technology can play here. I’ve heard of patients carrying around large binders of their records from appointment to appointment, but if we’re being honest, I don’t believe a physician or other member of a patient’s care team is going to take the time to go through it. Instead, utilizing the power of the device that we’re constantly carrying around and looking at may be the way to go (in addition to a smaller folder or journal for those that are comfortable with paper). 

If we think about it, there’s an app for everything, and having an app to keep track of our cancer journey should be no different. What should this app be able to do? Here are a few things that I think are especially important: 

  • Keep track of: 
    • Medications (dosage, picture of what it looks like, how to take it and what to do if you accidentally miss a dose or take more than what is prescribed, ability to refill) 
    • Blood work (results and what they mean [featuring a scale of what’s low vs. normal vs. high], what to ask your doctor about in terms of next steps) 
    • Imaging (results and what they mean, what to ask your doctor in terms of next steps) 
  • Ability to connect with all members of your care team (primary care doctor, oncologist, nurse navigator even if they work in different health systems) 
  • Ability to connect with caregivers and share information with them 
  • A diary to describe daily thoughts, symptoms, and side effects, flagging specific keywords that can alert a member of your care team 
  • A calendar with appointments (date/time, office location, directions) 
  • Tips to assist with mental health (i.e. offering local or national support groups [both virtual and in-person], counseling that accepts insurance and/or is offered on a sliding scale) 
  • Exercise routines featuring different forms of exercise (yoga, pilates, HIIT, weightlifting, playing a sport, walking and running, etc.) based on you’re feeling side effect- and energy-wise 
  • Information about nutrition through the different phases of a cancer journey (pre-treatment vs. in-treatment vs. post-treatment) that includes recipes 
  • Most importantly, all of this information should be in plain language that’s easy to understand in whatever language the patient is most comfortable reading 

Having an app that features all of these capabilities, I believe, would push the needle forward in patient care, not only creating better health outcomes, but a more satisfied patient. What would you add to the list?