Dan Gorenstein: If you had to pick one word to sum up how COVID-19 has changed health care in the U.S., telehealth would be a pretty safe pick.

News clip: Well let’s start with telehealth.
News clip: Telehealth
News clip: Virtual visits by video or phone.
News clip: Telehealth
News clip: Telehealth

Private and public insurers relaxed long-standing rules to make virtual care cheaper and easier to access. 

But now, that could be starting to change.

Today, from the Annenberg Studio at the University of Pennsylvania, what we’ve learned about telehealth and how many of these pandemic policies are here to stay.

I’m Dan Gorenstein, and this is Tradeoffs.

Chad Ellimoottil: To be clear, when we think about what telehealth is, it includes video visits, using the telephone, using email, and all of these were used before. But the paradigm shift is actually putting a reimbursement model around it and recognizing it as formal health care.

DG: Chad Ellimoottil is a urologist and the director of the Telehealth Research Incubator at the University of Michigan.

He says when people stopped going to doctors’ offices at the beginning of the pandemic, commercial insurers, states and the federal government loosened a lot of regulations that had historically limited the use of telehealth. 

CE: Probably the biggest change was that patients were allowed to do these telehealth visits from home, which they weren’t allowed to do before, and they were able to use common technologies like FaceTime. Copays were also waived for patients. And then from the doctors’ side, they were getting paid the same amount as if the patient had come into clinic.

DG: So, I mean, this was huge, right? Because all of a sudden, people who had to previously, if they were going to use telehealth, jump through all sorts of hoops, were able to meet with their doctors and nurses from the comfort of their home, not face copays, and you guys, the doctors, were getting paid the same rate.

CE: Yeah, that’s exactly right. Telehealth has existed for a long time. There were a lot of regulatory burdens that made it very hard for patients and also hard for health care providers. Effectively, all of those burdens were removed in the month of March.

DG: Without those regulations blocking the way, telehealth exploded. According to the firm Epic Health Research, virtual care accounted for 70% of all patient visits at its peak in mid-April.

Now, as people have become more comfortable getting their care in person again, Epic finds that number has settled closer to 20% — still a huge increase compared to the less than 1% of people who got their care virtually before the pandemic.

DG: Chad, as a doctor who’s been doing telehealth visits as long as you have, for several years, what kind of patient case is a poster child that shows telehealth at its most valuable?

CE: When I first became interested in virtual care, one of the earliest patients that inspired me was an elementary school teacher that comes to see me from about two hours away. So she’ll take half a day off of work to come visit me. And usually those visits are 15 minute consultations where I look at a CT scan or I look at an X-ray and I give her a plan of care for her kidney stone. And that interaction is very quick for me. It takes half a day for her, and it requires no physical exam. So that’s a great example of how virtual care can improve people’s lives by making it easier to integrate health care into their daily life.

DG: And how about the flip side? Is there a patient that has helped you understand the limitations of telehealth or when it’s just not a really good fit?

CE: One story I remember is a patient who travels over eight hours to come for a visit, and so they seem like they would be a great fit for telehealth. But actually, if you talk to the patient and understand what goes on during that day — they’re older, their kids pick them up, they drive them down to Ann Arbor for the visit. After the visit’s over, they get lunch at one of the restaurants in Ann Arbor. And so for them, that whole day is the experience. And it’s not the 15 minute consultation that they have with their doctor. So being able to give them telehealth doesn’t necessarily improve their quality of life because what they wanted to do was actually spend the day with their kids.

DG: The question of access is obviously the core of the conversation around telehealth. The goal is that this can make health care more convenient and accessible. That’s clear. But my health economist friends would be quick to warn me that making care easier can also lead to waste. Have we seen telehealth leading to unnecessary or wasteful or even harmful care during the pandemic?

CE: The time period during the pandemic is a little chaotic, so it’s really hard to really understand whether or not unnecessary care is going on. At the same time, there’s also this possibility that it could actually reduce unnecessary care. There’s diagnostic tests that are sometimes done in the office that may not necessarily be very high yield, but they’re done out of convenience. And so if you skip those because you’re doing a video visit, you may actually reduce health care spending. What we will have to do is wait 6 to 12 months or so to really understand the impact on health care spending.

DG: Your point is the pandemic isn’t the best time to really understand this question. How much research do we have from before the pandemic to understand the wasteful care?

CE: Actually, our research group has been looking at this question about unnecessary care for a while. We recently published a study where we compared 600 visits in urology that were conducted through video and compared them to 600 visits that were conducted in person. What we wanted to understand was whether or not patients that were getting the video visits were actually getting inadequate care and they still have to come in for in-person care. And when we did that study, we found no difference in the number of times people were coming back within 30 days for related care. What that’s essentially telling you is that these visits are being used as a substitute as opposed to an expansion of health care services. 

DG: And is that good?

CE: Absolutely. We do have studies in other specialties where we found that there was a higher rate of in-person care after a telehealth visit. And so you should be selecting patients for telehealth in a way that they won’t need additional in-person care. And it shouldn’t necessarily lead to additional health care spending.

DG: It’s interesting that we’ve begun to see some private insurers start to pull back, and they’re no longer waiving the cost sharing for telehealth, right? Consumers now, again, are responsible for their copays. Does this worry you that momentum could be lost?

CE: I actually have mixed thoughts about this. So on one hand, I’ve always viewed telehealth as a substitute for in-person care. So, if you’re paying a copay for in-person care, then you should pay a copay for a video visit. But on the other hand, I think what matters is the patient’s perception of the visit. So are the patients perceiving the visit as equal to an in-person care? Some of our colleagues at University of Michigan did a poll of patients aged 50 to 80, and they found that two out of three actually didn’t feel the quality of care delivered through telehealth was the same as in-person care. So if they don’t feel the quality is the same, then they may be more hesitant to pay a copay, and then there may be a decrease in the momentum to use telehealth.

DG: These are questions public programs like Medicare are looking at.

There’s bipartisan support — including from the president — to make a lot of these telehealth changes permanent.

But some of the biggest moves, like expanding telehealth beyond rural America and letting patients connect from home, will require congressional approval.

And there are some tricky policy questions to consider like should nurses and doctors get paid for plain phone calls, with no video, at the same rate as in-person visits? 

CE: I have patients that are in rural parts of Michigan that it’s not easy to do a video consultation with them because of the lack of broadband in those areas. And even if they have access to internet, a lot of times it can be slow. And so doing a telephone call with them is a good substitute. And so if that’s taken away, then the ability to do telehealth will be taken away for a lot of populations.

DG: But going back to the idea of wasteful care for a second, I could see phone calls being a driver of that easy but ultimately unnecessary care. 

CE: Yeah, that’s exactly right. There’s also a disadvantage to covering telephone calls. I make about 10 phone calls a day when I’m in my clinical practice. And some of these are just calling patients back and telling them, you know, they have normal results. They’re quick phone calls. And so I would never think about billing for those phone calls. But if the Medicare program does cover all of these phone calls, there are certainly some practices that may start charging patients for quick 5 minute phone calls and then that would lead to a lot of additional health care spending.

DG: You mentioned that these phone calls could be especially good for people without a reliable internet connection, and I know that’s one of the concerns about telehealth, that it could make it even harder for people in rural parts of the country and low-income people to access care. 

Do we have any evidence on how telehealth has impacted health disparities during the pandemic?

CE: So it may be a little too early to tell whether or not telehealth is going to impact disparities. But we do know that there was a digital divide among telehealth users. For example, higher rates of use among patients that were non-rural compared to rural patients. And we also saw higher rates of use among patients that were higher income compared to low income. But overall, for all populations that we’ve studied, we saw a dramatic increase in the use of telehealth.

DG: Chad, knowing all that you know, the expert that you are, if someone at CMS or Blue Cross Blue Shield of Michigan called you up and said, “Hey, what’s your recommendation? What should telehealth policies look like post-pandemic?” What do you say?

CE: So I think that telehealth policies post-pandemic should actually look very similar to telehealth policies during the pandemic. Let’s collect data. Let’s see the impact on health care spending. Let’s see the impact on health care access. Let’s see the impact on health care quality, and then we can make decisions down the line. I’m more concerned about having patients losing access to telehealth than I am about increases in health care spending in the short term. In the long term absolutely we need to have policy changes, tweaks to the policy so that we can account for these changes to avoid fraud and abuse, to avoid excess health care spending. But in the short term, I think what we have to do is see how telehealth plays out. 

DG: Chad, thanks for taking the time to talk to us on Tradeoffs. 

CE: Absolutely, Dan. I appreciate it. 

DG: It’s hard to imagine telehealth going back to the way it was before the pandemic.

But fears over increased health spending are real.

And Congress would have to act to make some of the biggest changes permanent, meaning Chad’s post-pandemic telehealth dream is far from guaranteed.

I’m Dan Gorenstein. This is Tradeoffs.