President Donald Trump’s administration took the unprecedented step on Monday to temporarily waive rules for the nation's largest insurer -- Centers for Medicare & Medicaid Services (CMS) -- giving some healthcare providers the ability to have phone-only visits with their patients as the coronavirus crisis rages on.
CMS covers at least 140 million Americans through Medicare, Medicaid, the Children’s Health Insurance Program, and Federal Exchanges – typically covering a constituency of people with disabilities, the elderly, and those with low incomes, many of whom may be unable to access the advanced technologies required for telehealth -- seen as an important emerging tool in maintaining people's health amid the fight against the virus.
“During the public health emergencies, individuals can use interactive apps with audio and video capabilities to visit with their clinician for an even broader range of services,” CMS said in a statement. “Providers also can evaluate beneficiaries who have audio phones only.”
Up until this announcement, CMS had not allowed its beneficiaries to use the easiest method to communicate with their doctor: phone calls. While it had loosened its regulations to allow the use of FaceTime and Skype, patients still needed both “audio and video capabilities.” But nearly 35 million Americans do not use the internet, according to Pew Research Center, leaving some of the nation’s poorest unable to take advantage of telemedicine.
“Access to phone-only services is a health equity and social justice issue,” said Dr. Jared Skillings, the Chief of Professional Practice for the American Psychological Association. “Many patients and some providers do not have access or capability to use cellphones with video chat. They may also not have internet service or broadband speed.”
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As the novel coronavirus continues to spread across the country, infecting more than 160,000 people in the United States alone – the most confirmed cases of any country in the world – Americans continue to try to “flatten the curve” by self-quarantining inside their homes and physically distancing themselves from others.
So medical leaders from across the country pushed for regulations surrounding telehealth – health services through telecommunication technology – to change, trying to ensure healthcare providers could properly take care of their patients, as well as get paid for the work they do.
“One of the ways, and in a critical way, that we can continue to offer health services – where appropriate – is the use of telehealth,” said Dr. Patrice Harris, the President of the American Medical Association, recommending medical practices of all specialties should look into telehealth to keep providing services to their patients.
That’s why Skillings, Harris, and other leaders in the medical field pushed – and are continuing to advocate for – CMS, state regulators, and private insurance companies to expand their policies to accommodate situations where simultaneous two-way audio and video capabilities are impossible.
But challenges still remain.
While CMS expanded access to neuropsychological and psychological testing by allowing telehealth for the first time, it still does not cover typical therapy services by phone, according to Dr. Stephen Gillaspy, APA’s director of health care financing.
This temporary deregulation – that ignored therapy sessions – came just a day after President Trump suggested that there will be a rise in depression, saying "You're going to have mental depression for people. You're going to have large numbers of suicides.” And yet, access to phone-only therapy for Americans covered by CMS is unavailable.
“Now, that makes no sense for all kinds of vulnerable populations, older adults, people with lower-income, folks with disabilities," said Skillings. "I'll give you the best example I have heard from one of my best friend colleagues -- she said, ‘Why should people who are visually impaired have to do a video chat?’ That makes no sense.”
Additionally, the regulatory waiver is only temporary.
CMS is federally run, but insurance – including telehealth policies – is regulated at the state level. Every state and every private health insurance company has different policies. To add to the complexity, tens of millions of Americans are not insured, and tens of millions more are on self-insured plans, which have different policies than those who are fully insured.
Because there isn’t a one-answer-fits-all policy nationwide, patients can have a hard time recognizing which policy applies to them, furthering the difficulty of finding the proper care they need.
And because it is fundamentally up to the states to adopt these new rules and regulations, this will result in a fragmented adoption of policies and make it more difficult for multi-state providers according to Dr. Bill Mills, Chief Medical Officer at BrightSpring Health Services, a large, multi-state provider of intellectual or developmental disability and behavioral health services.
“As this goes forward, the people who are the most vulnerable already are also going to be the people who are the most impacted by this crisis,” said Skillings. “And so therefore, we need to make sure we take the most care -- we need to take care of everybody -- but we need to make especially sure we take care of them too.”
The business of telehealth
While emergency rooms scramble to address the influx of potential COVID-19 patients, many non-emergency doctors and health care providers are seeing a significant decrease in the number of patients they see, leading some to develop concerns about making ends meet. Providers such as gynecologists and pediatricians have said the number of patients they see has dropped significantly. Some have reduced their patient load from 40 a day to five.
Harris says, “the pandemic is impacting practices all across the board, impacting outpatient practices all across the board, diversity of specialties and a diversity of settings, from the larger practices to the small one.”
From a public health perspective, Harris believes this is in the best interest of the patients in many cases, saying “we are urging everyone to stay home unless they have an urgent or emergent need.” She says not going into a doctor's office limits the risk of infection for both the patient and the provider, and it saves necessary medical equipment – like masks – for providers directly dealing with the coronavirus.
While Harris says postponing a yearly physical check-up is okay, she said that many patients should be able to get the care they need through telehealth.
According to the AMA, physician use of virtual visits doubled from 14% in 2016 to 28% in 2019. While data has not yet been released on the increase of tele-visits since the coronavirus outbreak, the AMA has said it is expecting a significant increase and reliance on telehealth during the pandemic.
In the past, healthcare providers could only use HIPAA-compliant telecommunication services, which would protect both the patient and the provider through advanced encryption technology.
But on March 17, Trump relaxed the rules, allowing FaceTime and Skype.
“The crisis is going to go longer,” said Skillings. “And so because that's the case, we're not just looking at emergency conditions. At this point, we're trying to look at how can we provide care potentially for several weeks or even a few months.”
It's still complicated
Understanding health insurance is notoriously difficult and Skillings warns there is a risk of relying on the rules and regulations set forth by the federal government.
“One of the things that providers also need to know is that even if the federal government waves some of their own regulations, states still have privacy restrictions, some of which are in place,” said Skillings.
States have taken a variety of approaches in dealing with the coronavirus – whether that means issuing stay-at-home orders or limiting gatherings to no more than 10 people. Telehealth is no different. Some states have championed the use of telehealth, like Ohio, where Gov. Mike DeWine allowed Medicaid to cover mental health service visits through video or phone-only sessions. States like Maryland, New Mexico, North Dakota, and Rhode Island have similar policies.
Governors from California, Illinois, and Massachusetts have taken executive action to address the payment discrepancies between tele-visits and in-person visits, now requiring tele-visits to pay providers the same as in-person visits.
But several states, including Alabama, Idaho, and Wyoming have not taken steps to facilitate broad telehealth access according to medical leaders.
Insurance companies, just like the states, have issued different guidance regarding telehealth. Scott Serota, CEO of Blue Cross Blue Shield (BCBS), which provides coverage to more than 106 million Americans, said in an online statement that BCBS is “also advocating for physician and health system adoption of ... video, chat and/or e-visits.”
“A member can have any of those functions and be able to utilize ‘alternative’ visits,” Dr. Vincent Nelson, vice president of medical affairs and interim Chief Medical Officer at Blue Cross Blue Shield Association told ABC News. “However, their provider will also need to have the capability and will vary based on the individual Blue Cross and Blue Shield company.”
Since insurance is state-regulated, what is considered appropriate telehealth engagements will vary on a state-by-state basis, meaning BCBS has different policies based on each state. The BCBS Texas policy allows for "2-way, live interactive telephone or digital video consultations," while the Illinois policy is stricter, not allowing for phone-only visits, saying it allows for "2-way, live interactive telephone communication and digital video consultations” – meaning the video and audio need to be simultaneous.
Coping with the help of telemedicine
The busier the day, the better. That’s how Nina Tang – a varsity athlete, an undergrad researcher at a Columbia University science lab, a pre-med senior at Barnard College – enjoyed spending her time.
But as Americans try to mitigate the risk of infection by staying at home, they need to find ways to cope with the isolation of the pandemic.
Tang said she’s been isolating in her apartment in New York City for over two weeks, only getting a breath of fresh air if she sits on her windowsill. She hasn’t seen anyone – outside of FaceTime – since March 21, the day her second roommate left the city. She said it's been "difficult at times."
She said she has had issues with her mental health in the past – last spring, she had a hard time dealing with anxiety and depression. Since then, she’s been seeing a therapist weekly, where she felt comfortable “talking about anything that I was experiencing.”
Now, during this crisis, her therapy sessions have moved to video chat.
“We try to do video sessions,” Tang, who has private health insurance, told ABC News. “And we did that for our last meeting. There were a couple of meetings where either I wasn't in great internet connection, or I just couldn't get to great internet connection, so we would just have phone calls.”
But telehealth isn’t perfect for Tang, saying the sessions have felt "very different." She finds herself "not wanting to talk about how this whole situation with coronavirus, like self-quarantining, has affected" her.
Tang said her anxiety stems from the fear of being asymptomatic and then passing the coronavirus onto someone else.
“I don’t want to be a carrier,” she said. “And be responsible for someone else’s sickness or potential death.”
Mental health experts suggest feelings of anxiety, fear and depression are normal.
“It's no wonder that anxiety is going up right now,” said Skillings of the APA.
Skillings says to keep a regular schedule by waking up, eating, and sleeping at the same time each day. He recommends exercising daily and finding time to socially engage with people – whether that means having a virtual happy hour, calling a friend or a family member, or sending an old-fashioned note in the mail.Nina Tang has come to a similar solution as well.
“I try and have a very structured day, where I can at least point to different things that I accomplished that I can feel proud of later,” she said.
“There are people who have it worse than me,” Tang added. “And so I think there's been a strange balance between trying to validate the way that I'm feeling, but then also trying to keep in mind that I am probably on the more fortunate end of some people who are also going through the same things.”