Doctors, patients turn to telemedicine.
Dr. Andrew Brookens started his practice, Altitude Kidney Health, with plans to focus on telemedicine, but uptake was slow: after about eight months, maybe 10% of his patients were using virtual visits.
Then came COVID-19.
Now, Brookens only does online visits. Most patients have gotten on board, he said, though some said they’d rather put off their visits for a few weeks in the hope that things will go back to normal. Patients still have to visit a lab periodically for blood draws, but they can monitor their blood pressure from home and watch for weight fluctuations that could be a sign their kidneys aren’t removing enough fluid from their bodies.
“Kidney care lends exceedingly well to telehealth,” he said. “It’s a numbers-based thing.”
The new coronavirus has forced Colorado medical practices to rethink how they offer routine care. While Gov. Jared Polis’ order banning elective procedures doesn’t include office-based visits, some doctors have canceled appointments or switched to phone calls to reduce the number of people who could catch or spread COVID19, the respiratory disease caused by the new virus, in their waiting rooms.
Dr. Michael Stein, a licensed clinical psychologist at Anxiety Solutions of Denver, said his practice also switched to all online appointments. Before COVID-19, only about 5% of patients had virtual visits, and those were typically people who lived far away or whose symptoms were severe enough that they couldn’t leave their homes, he said.
Most clients made the change easily, Stein said. A few decided to pause therapy, usually because they didn’t have a private space at home where they felt comfortable talking, he said.
“We were lucky in that we were well prepared to make the shift easily and quickly,” he said. “I know some other therapists who have had to very quickly choose a platform and learn about all the ins and outs, legal issues, and ethical concerns in conducting online therapy.”
Telemedicine has become more attractive not only because of the need to prevent contagion, but also because many insurance companies now pay for virtual visits at the same rate as in-person ones, according to Kaiser Health News. Previously, insurance companies often paid only about half as much for online or phone visits.
Colorado took it a step further, ordering private insurers to waive co-pays and other outof-pocket costs for telemedicine visits, and requiring Medicaid to pay for phone- and online chat-based services, rather than just video visits, in most cases. Physical therapy, hospice and mental health care for children are only covered for video-based visits, though.
Dr. Ateev Mehrotra, an associate professor of health care policy at Harvard Medical School, said Americans make an average of 1 billion visits to doctor’s offices each year, so telemedicine has the potential to eliminate quite a few potential exposures to COVID-19. When people think of telemedicine, they typically picture a video call, but often there’s a low-tech option that will work as well, such as a phone call, secure messaging through a patient portal or online screening tools, he said.
“Everybody’s familiar with (a phone call), whether 85-yearolds or 25-year-olds,” he said.
Medicare has given doctors more flexibility to use common video chat tools like Skype or FaceTime and loosened its payment rules, but it’s still not easy to move into telemedicine, Mehrotra said. For example, it can be difficult to know how to bill for virtual visits, creating hassles if an insurance company rejects the paperwork, he said.
“Everyone’s sort of learning on the fly,” he said.
Dr. Eric Harker, a geriatrician with Iora Primary Care, which has several locations in the Denver region, said he’s trying to manage patients at home as much as possible, but some Medicare rules are making it more difficult. For example, some patients who need oxygen because of COVID-19 or another respiratory disease could manage at home, but Medicare
doesn’t cover short-term home oxygen use, he said.
Medicare also requires an inperson visit before it will pay for patients to receive certain services, such as home health care, Harker said.
“In a pandemic, the problem is you have to bring sick, older people in to do the paperwork,” he said. “It’s a whole set of barriers that make it more difficult to manage folks at home.”
Much of the research on telemedicine has focused on whether it’s equivalent to an in-person visit, with almost no difference detected in mental health care and increased odds of getting antibiotics for certain common conditions. In ordinary times, it might make sense to weigh slight differences carefully, Mehrotra said, but now the advantage of keeping patients away from possible exposure to a deadly virus outweighs other considerations.
“The risk-benefit (calculation) is quite clear to me,” he said.
Dr. Bethany Doran, who does research on using data to assess patients’ cardiovascular risk at University of Colorado, said she was “moonlighting” at Denver-area hospitals, but decided to switch to telemedicine as the scale of the COVID-19 outbreak became clear. She recently started a virtual practice at CoronavirusMedVisit.com, so people who think they might have the disease can avoid in-person care.
Patients can monitor their own vital signs with relatively cheap equipment such as a pulse oximeter, which checks a person’s heart rate and how much oxygen is in their blood, Doran said. She can then ask them about their symptoms and review the data for signs of trouble, such as falling oxygen levels that could point to lung damage. If done well, telemedicine can help people who might have the new virus to decide when they need to seek in-person care, as well as making it easier for people to manage their long-term conditions, Doran said.
“It’s trying to keep people out of the hospitals or ERs,” she said.