A Report Card for Telehealth: What’s Worked and What Hasn’t

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode above!

Dan Gorenstein (DG): The use of telehealth skyrocketed during COVID. Virtually overnight 40 percent of doctors visits for older Americans were over the phone or on video. 

One key reason for the explosion, Medicare and other insurers started paying for this service.  

There were high hopes telemedicine’s convenience would improve care and lower costs. 

But there was some real fear that extra appointments would drive costs through the roof.

Ateev Mehrotra (AM): The concern of telehealth has been that its convenience is its Achilles heel.

Today, as Congress figures out the future of telehealth, we get a reality check from a top researcher about what this care has and has not delivered. 

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, this is Tradeoffs.

*****

DG: Today 66 million older Americans who have Medicare can call or video chat with their doctors from their couch.  

But that could end by 2025 when the rules governing telehealth in Medicare are set to expire.  

That puts in jeopardy patients’ ability to see and talk to their primary care providers, cardiologists or other specialists from home.

Congress must decide whether to keep these rules in their temporary status, develop permanent telehealth rules, or wind back the clock pre-COVID era when these visits were mostly uncovered.  

To make this decision lawmakers are hungry for evidence on what’s working, what’s not, and how much telehealth costs. 

Dr. Ateev Mehrotra has been going through the data. He’s a professor at Brown University School of Public Health and has studied telehealth for a decade. As a skeptic by nature Ateev says he wants to understand whether the promised innovations are all that they’re cracked up to be.  

AM: I think there’s been a lot of excitement about telehealth. But I also  recognize that a lot of what’s out there that people are pitching is going to be a new revolutionary idea, is a bunch of crap, or is just not going to work. And so I do feel that there’s a real need for good evidence. Does it work? Does it not work? And if it does work, you know, how can we make it better?

DG: So, when Covid 19 hit, the federal government started requiring insurers to pay for phone calls, video calls with our doctors. And I remember Ateev,  in that moment – I’m sure you do, too – there was both hope and hype and some concern. I want to walk through this across a couple of different metrics. Let’s start with quality. When it comes to quality, Ateev, what was the hope? and what was the reality?

AM: Yeah, the hope is that the use of telehealth will allow more people to get care and will lead to substantial improvements in terms of chronic disease management or people accessing care that otherwise couldn’t have got treatment. The concern was that video visits and phone visits, they’re just not up to par, and actually this is going to negatively impact the quality of care Americans are going to receive. 

DG: And what has the research borne out? 

AM: So, I think the answer is somewhere in between. which is kind of frustrating. But that’s just the nature of what research is all about. In some clinical areas, we have found that it has led to substantial improvements, but across the board, the improvements are relatively small in nature. For example, in one study, we found a small improvement in medication adherence, but not the big improvements that people had hoped. But also, I don’t see any evidence that it’s negatively impacting quality. If anything it’s improving quality modestly. 

DG: So marginally improving health. And when you are talking about small improvements in ‘medication adherence’ you’re talking about people being more likely to take their meds. Ateev, that leads me to the next category which is spending. Is that marginal improvement worth it? What was the hype and what’s the reality around spending?

AM: The hope has always been that people who get more telehealth would better manage their, uh, chronic illness, for example, say, diabetes or high blood pressure. And that would decrease hospitalizations and ED visits. And therefore, the savings from those fewer hospitalizations and ED visits would save the health care system money. So that’s the kind of the general way that people have hoped that telehealth can save money. 

DG: Healthier people, fewer hospital visits fewer ED visits – which are ‘emergency department’ visits. Sounds like people thought telehealth may achieve the holy grail of health care innovations. What was the concern with spending? 

AM: Yeah, the concern of telehealth has been that making care really convenient will lead to more people getting care and the care that comes from that will increase overall health care spending substantially. 

DG: And, drum roll…the results?

AM: Somewhere in between.

DG: Ateev, this is like Groundhog Day with you, dude. You do know it, you know it’s May, man.

AM: Exactly, exactly. I have seen no evidence that telehealth is decreasing health care spending. However, the increase was not as large as I had expected. we’re seeing in my work about a 1 to 2% increase in spending.

DG: In your own mind, as someone who’s researched this and really turned this over. Are we getting our money’s worth?

AM: I believe that the benefits that we’re seeing from telehealth are worth it. And it’s clear that the American public really wants it to be around but how do we make sure telehealth is being used in the most cost-effective or high-value way? 

DG: How do we get the most bang for our buck with telehealth? That’s one of the policy questions Congress is wrestling with right now. Another related one has to do with access. Lots of folks who talk about people in rural areas who are many many miles away from providers were excited about telehealth closing some disparities. Ateev, has it in fact done that? 

AM: So, the concern has been that the very nature of how you use telehealth, you’ve got to use technology, you know, smartphone, broadband connection, a computer, that there is a digital divide in the United States and that this could actually widen disparities. And unfortunately the evidence is that the rural patients are much less likely to receive telehealth visits. So, that I think, has been quite concerning. As we think about telehealth deployment right now, it could widen the existing disparities in the U.S. health care system. 

DG: We just talked about the rural/urban disparity. But what about other kinds of disparities? Has telemedicine helped patients of color, or low income people get better care?  

AM: We had hoped that telehealth would be used by those who are most struggling to access care. Unfortunately, we’re finding the opposite. And within a community, we’re finding that, uh, Hispanic patients receive fewer telehealth visits than non-Hispanic whites. And the difference is pretty substantial – 13% fewer visits. The bottom line is we as a society need to invest more in terms of what tools can we deploy to ensure that all Americans have access to a telehealth encounter. And in particular a video encounter or a video visit.

DG: After the break, Ateev translates his telehealth research into recommendations for Congress and pinpoints the area of telehealth that leaves him most excited.  

MIDROLL

DG: Welcome back. We’re talking with Ateev Mehrotra, professor at Brown University School of Public Health.  

So, Ateev Congress has until the end of the year to either return to much more restrictive pre-Covid rules; make permanent new rules; or just temporarily extend these flexible rules that we’re living with right now. Put on your prognostication hat, sir: Which of the three doors do you think Congress is most likely to choose and why?

AM: Door number three, Dan, which is called the kick the can down the road door. 

DG: One of Congress’s favorite moves. Yeah

AM: Yea, given the evidence that’s emerged, a permanent expansion of telehealth is going to increase Medicare spending. How are you going to pay for that? And that’s a difficult policy question. I think there’s general enthusiasm for making permanent policy. But in this political environment, in the setting of a presidential election this year, I think the “kick the can down the road” is likely the approach that the Congress will take.

DG: As lawmakers have been deciding what to do they called you Ateev, to testify.  They wanted to hear what changes to the rules you would make. Let’s talk through two of them. The first one is about phone calls. Right now, Medicare covers those calls just like video visits. But it sounds like from what you told Congress, you’re not a huge fan of these audio-only visits. Can you explain? 

AM: Yes, I am concerned about audio-only visits for several reasons. One is that they may be more prone to overuse. And second, there are some places where I don’t feel just a phone call is sufficient. And so I would prefer a system where everybody uses video visits. Because I’m concerned about a future with a two-tiered system where the poor receive phone calls and the wealthy have video visits.

DG: Personally, I’ve always thought about phone visits as a way for older patients who don’t know how to video chat or rural patients with shoddy internet as a way to have telehealth visits. Is there another reason that you’re worried about a two tiered system you are talking about?

AM: One underappreciated reason that some patients receive a phone call is that their clinician – their physician, nurse practitioner – only offers them a phone call. It’s because some practices don’t – still, in 2024 – offer video visits, and in other cases, they’re making assumptions that this patient can’t do a video visit. So I’m only going to offer them a phone call. We should make sure Medicare and other payers require clinicians providing an audio-only visit to say, look, I offered the patient a video visit and the patient asked for the phone call; I didn’t assume.

DG: I see. So it’s important to you that the patient gets a choice. Another tweak to the rules that you are suggesting is payment. Right now, Medicare pays the same for a telemedicine visit as an in-person visit. Many hospitals and doctors want that to continue. You can imagine why. They say, even if they offer telehealth visits, they still have to pay overhead,, the building staff, all these things. You say, though, that doctors and nurses should get paid less for telemedicine. Why?

AM: Telehealth visits do not require the same overhead and therefore should be paid less. That’s one reason. The second reason is that I am concerned if we pay the same amount, we’ll introduce new distortions in the market. It will give virtual-only companies a competitive advantage.

DG: Right, you’re point is that virtual-only companies – because they have less overhead – would have a leg up against brick and mortar providers like physician practices and hospitals. OK, so Ateev, we’ve talked a lot about what the evidence on telemedicine shows right now. But let’s look forward, what’s one area of telemedicine you think has the most promise in terms of efficiency and effectiveness?  

AM: One that I have been particularly excited about is remote patient monitoring. That’s the idea that a patient with, say, high blood pressure I give a blood pressure device that’s Bluetooth-enabled or cellular-enabled. And I say, “Every day, check your blood pressure, and it’s going to come to me and I’ll adjust your medications.” And so remote patient monitoring facilitates a better type of care I am excited about – that proactive model. 

DG: Evidence on that is emerging. I look forward to checking in with you in a few years about whether these devices are delivering on the hopes. Ok, final question, Ateev. If Congress continues to practice the temporary policy-making around telehealth. Is there a downside?

AM: If you were the chief financial officer of a big health system, or running a small practice, do you invest or not?  And that’s hard when there’s just the kick-the-can-down-the-road strategy, because you’re not sure. At the end of the day, money is tight, and you may choose to not make those investments that you want. So I think that’s the real downside with this sort of “keeping telehealth in limbo” has sort of pushed off a lot of these decisions and in some ways is discouraging telehealth because clinicians are unwilling to make those investments, given that uncertainty.

DG: Ateev thanks so much for taking the time to talk to us on Tradeoffs.  

AM: Thank you for having me. 

DG: As Ateev predicted Congress appears to be kicking the can down the road. Two different committees in the house have voted to extend the rules for another 24 months. The full House and Senate face an end of year deadline to act.   

I’m Dan Gorenstein. This is Tradeoffs.