Telemedicine surges, fueled by coronavirus fears and shift in payment rules

Reviewed by James Ives, M.Psych. (Editor)Mar 27 2020

Lukas Kopacki, home from college after the coronavirus pandemic closed his campus, was feeling lousy for days with headaches, sore throat and difficulty breathing through his nose. But he worried that a trip to a doctor's office might make him sicker.

"I had no desire to go into that cesspool of bacteria and viruses," said Kopacki, 19, of Ringwood, New Jersey.

So, last week the University of Vermont student called Teladoc, a company that connects patients to doctors by phone nationwide. Its physician diagnosed his sinus infection and sent a prescription for an antibiotic to his local pharmacy. With his Aetna health coverage, which earlier this month temporarily waived its $45 patient copayment for virtual care, Kopacki paid out-of-pocket $1.44, which covered his costs for the drug.

"It was quick and easy," he said.

Getting heath care by phone or video conferencing has been around for several decades, but the outbreak of coronavirus has led to an increase in telemedicine use as never seen before, according to health systems and provider groups across the country.

Millions of Americans are seeking care by connecting with a doctor electronically, many for the first time. Health systems, insurers and physician groups said it allows people to practice social distancing while reducing the spread of the disease and protecting health workers.

Private technology companies such as Teladoc, Doctor On Demand and Amwell and large health care systems can provide a doctor directly to someone who contacts them. Other patients may seek a telemedicine appointment with their regular physician, who can use computer applications through smartphones and computers. All types of primary and specialty care and mental health services can be provided via telemedicine.

Many hospitals have recently added telemedicine services to keep patients concerned about the coronavirus from clogging their emergency rooms.

Also spurred by the goal to keep patients away from crowded medical facilities, government and private insurers have increased the payment for telemedicine visits so they are on par with in-person visits. Before the outbreak, insurers paid less than half that amount, which dissuaded many doctors from offering the services.

Medicare last week allowed all enrollees to use telemedicine — an option that previously was available only to people living in remote areas and for a specific, short checkup. The federal government also said doctors could practice across state lines during the pandemic to treat Medicare patients virtually, even if not licensed in the patient's state. California, Florida and other states have also waived their requirements that a physician be licensed in the state to provide care.

The Cleveland Clinic is on track to log more than 60,000 telemedicine visits in March, according to officials there. Before March, that health system - which has hospitals in Ohio and Florida — averaged about 3,400 virtual visits a month.

Its Express Care Online system serves patients across the country 24 hours a day. About 75% of the calls now come from people worried they have COVID-19, said Dr. Matthew Faiman, medical director of the service. Like many other health systems, Cleveland Clinic's virtual urgent care is waiving patient copays during the pandemic.

"We are seeing a significant upsurge in demand from patients seeking care - both the worried well and patients who are sick and wanting to know how to manage their symptoms," Faiman said. The clinic has pulled more doctors into the telehealth work since elective surgeries were canceled and fewer patients are making in-person visits.

He applauded the Medicare changes and predicted such changes will likely stay after the national emergency ends.

Dr. Manish Naik, chief medical information technology officer at the Austin Regional Clinic in Texas, also predicted it will be hard to go back.

"Telemedicine has been on the brink for a while now," Naik said. "And doctors and patients are going to find that when this is all over and the dust settles there are a lot of people who are going to want the telemedicine option to stay."

Of course, such visits have limitations, such as when doctors need to listen to a patient's lungs or order an X-ray to check for pneumonia. But Naik said telemedicine also gives doctors a more complete view of the patients through "observation around the home" and interactions there that shows "things we never could see before."

Before March, NYU Langone Health in New York had about 50 virtual visits a day through its urgent care telemedicine platform. During the week of March 23, the hospital system is averaging about 900 a day.

For 80% of telemedicine visits, cough is the chief complaint followed by fever, said Dr. Paul Testa, its chief medical information officer. NYU Langone has 170 doctors who attend to telemedicine patients, up from 35 two weeks ago, he said.

"We are not recommending testing for everyone, but we are recommending self-care, hydration and self-isolation," Testa added. "The goal is to create a new front line for these patients rather than have them rush into an urgent care or ER."

If a patient is having trouble breathing or otherwise is in distress, an NYU telemedicine provider will direct them to call an ambulance if necessary or go to the ER and alert the hospital the patient is coming.

Teladoc is averaging 15,000 patient visits a day in the United States, 50% higher than in February. Wait times have increased from minutes to hours in some cases, a spokesperson said.

At the Austin Regional Clinic, which has 340 doctors in 28 offices, nearly half of patient visits are now virtual compared with a fraction before the outbreak.

"With the COVID-19 situation, we have patients who are nervous about coming in, and we don't want patients with symptoms coming in and exposing others," Naik said.

He said that for years the clinic made the telemedicine option available, but it did not make sense financially to promote it because insurers paid less than half the rate they would for an in-person visit.

The Medicare payment change can't be understated, he said, because it covers such a large number of patients and because private insurers usually follow Medicare policies. "That's really allowed us to open things up," Naik said.

Advocates for decades have called on Medicare to expand telemedicine coverage, but federal officials held back because of concerns about increased costs. Critics worried telemedicine would not replace in-person doctor visits but lead to more total visits because of the ease with which people could connect to their doctors via telemedicine.

The Trump administration had been moving to widen telemedicine options even before the pandemic. In 2019, it allowed Medicare for the first time to pay doctors on average about $14 for a five-minute "check-in" phone call with their patients.

Ken Prussner, 74, of Herndon, Virginia, used his home computer Monday to connect with his longtime physician.

Prussner had a gastrointestinal illness and a low-grade fever and his family wanted to make sure he didn't have COVID-19. His doctor's office sent him a website link and his physician spoke to him as if he was in the office. He allayed Prussner's fear, telling him he had a typical lower-bowel infection that would clear up on its own within three to five days.

"It was pretty seamless," said Prussner, a retired U.S. Foreign Service officer.