Although I have been studying it for years, telehealth has taken over my house in recent months. From my home office, I have conducted interviews with physicians about telehealth implementation since the COVID-19 pandemic began. My husband, an emergency department physician, has been conducting telehealth visits from our basement. Even our kids have been in on the action as telehealth patients, pointing the webcam at their poison ivy or pink eye infections. For our family and countless others, telehealth has truly been one of the great success stories of the COVID-19 pandemic. It has helped to maintain continuity of care for millions of Americans, preserve personal protective equipment, and facilitate social distancing. Many patients, anxious about the pandemic and the disruptions it caused, were relieved that there was a safe way to access their care team. Yet, its increased use in this unprecedented time does not necessarily reflect a large-scale embrace of telehealth by patients and their providers.
To be sure, telehealth advocates are thrilled with the exponential increases in uptake. Surveys conducted in April 2020 suggest that up to 90 percent of physicians were offering telehealth visits in response to COVID-19. The Centers for Medicare and Medicaid Services has announced that 22–30 percent of Medicare beneficiaries received telehealth services from March through June. Estimated growth rates are in the thousands of percentage points. But even as the pandemic persists, evidence is already emerging that telehealth use has peaked, and providers are starting to abandon it.
Providers told me in interview after interview that they transitioned to telehealth in March 2020 not because they were convinced of its value, but because they had to out of desperation. They needed to offer telehealth to offset the reduced demand for in-person care, keep their clinics afloat, and avoid exposing vulnerable patients to the virus. They felt a palpable “relative advantage” of telehealth because in-person services could kill themselves, their patients, or both. The fact that we are now seeing a retreat from telehealth may be because providers never really embraced it in the first place. And with widespread re-openings across the country, and patients' increased comfort with in-person care, providers can go back to what they know.
By signaling their intentions regarding payment policy sooner rather than later, policymakers could reduce uncertainty and encourage investment in sustainable telehealth models.Share on Twitter
COVID-19 disrupted the typical innovation life cycle in which providers would thoughtfully weigh the advantages and disadvantages of a large-scale delivery change in advance of its implementation. The pandemic didn't allow providers the opportunity to pilot test and refine telehealth services prior to rollout, or to have much agency in the initial decision. Accelerating this life cycle helped providers surmount two major obstacles to innovation: lack of familiarity and resistance to change. Now that most U.S. physicians have had a taste of telehealth, what still stands in the way of sustained use, and what can policymakers do to cultivate its growth?
Early Negative Experiences
While some physicians have acknowledged being pleasantly surprised (PDF) by how easy it was to shift to telehealth, this sentiment was not universal. Those less enamored with telehealth explained in interviews how time-consuming it was for staff to prepare patients for telehealth, triage technical issues, and change clinic workflows. Many felt video visits were often difficult to implement due to challenges at the patient (for example, lack of devices or digital literacy) or clinic levels. Notably, one-third of all telehealth visits in spring 2020 were audio-only (telephone) visits despite a clear preference for video among the providers I spoke to. By supporting strategies to improve digital literacy, increase platform usability, and bring devices and broadband to underserved populations and health care settings, policymakers could encourage providers to revisit telehealth.
Some physicians also expressed concerns over the quality of telehealth visits, such as an inability to conduct a physical exam. Although many appreciated the new flexibilities provided by temporary pandemic policy changes, concerns about quality and liability prevented them from taking full advantage of those changes. Physicians treating patients with opioid use disorder (OUD) were permitted, for example, to do buprenorphine inductions via telehealth without a prior in-person visit (PDF). Despite the relaxed regulations, however, few were planning to do this because they felt that they could not fully evaluate a new patient over video or build the trust necessary for treatment adherence. Furthermore, for providers too many things may have changed at once, making it difficult for them to assess the independent impact of telehealth on quality of care. As a psychiatrist treating patients with OUD explained to me, “We stopped doing urine toxicology screening [to minimize in-person visits] at the same time we started telehealth and it feels a bit like we are flying blind.” For policymakers, it could be critical to understand that expanding reimbursement is only a first step in ensuring high-volume use. Updated clinical practice guidelines, peripherals, and mobile applications that facilitate remote patient monitoring could help providers feel more confident in their clinical decisionmaking when operating in a virtual environment.
Uncertainty Over Long-Term Viability
Multiple physicians mentioned that the lack of certainty regarding the post-pandemic policy environment reduced their willingness to invest in telehealth over the long term. By signaling their intentions sooner rather than later regarding payment policy, policymakers could reduce uncertainty and encourage investment in sustainable telehealth models. For example, Congress should act to permanently remove geographic and originating site requirements for telehealth in Medicare. This would encourage providers to perfect processes as well as infrastructure to serve patients in their homes. In contrast, increasing access to telehealth by permitting the use of non-HIPAA compliant platforms in the early days of the pandemic was good temporary policy, but use of these platforms may not prove to be a long-term solution and probably should be discouraged for providers who want to permanently incorporate telehealth into their practice.
Despite the initial desperation that fueled their adoption of telehealth, some of the providers I interviewed found telehealth ideal for improving access and supporting high-quality care in certain cases. Like my now basement-dwelling husband, many transitioned to telehealth reluctantly but will offer it as long as the policy environment remains supportive. Nonetheless, telehealth visits are already declining and may continue to decline unless states enter lockdown again. Without permanent policy changes, it is unclear if telehealth services will represent a significant proportion of U.S. health care visits in the long run.
Lori Uscher-Pines is a senior policy researcher at the nonprofit, nonpartisan RAND Corporation.
This commentary was first published on August 14, 2020 on Health Affairs Blog. Copyright ©2020 Health Affairs by Project HOPE—The People-to-People Health Foundation, Inc.
Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.