What if telehealth could shrink the size of the world to allow patients to access high-quality, physician-led care, wherever they’re comfortable, whenever they need treatment?
“Why shouldn’t we root for that?” asked El Paso infectious disease specialist Ogechika Alozie, MD.
The past chair of the Texas Medical Association’s Committee on Health Information Technology got a glimpse of that reality during the COVID-19 pandemic, when he saw more than half of his patients – many of whom were immunocompromised or bed- or wheelchair-bound – switch to telemedicine appointments.
Now, almost a year since the end of the public health emergency (PHE), Dr. Alozie and some of his patients still look to telehealth for increased access to care.
“For patients hesitant to come into the clinic because of the potential exposure to communicable diseases or for those unable to leave their nursing homes, telehealth provides safe care options that still prove beneficial after the pandemic,” he said.
His practice’s adoption of telehealth, which largely evolved out of patient necessity, was bolstered by pandemic-era flexibilities by the U.S. Department of Health and Human Services that removed geographic site restrictions, permitted some services to be delivered through audio-only or video technology, and allowed more flexible pathways to physician payment. These adjustments remain largely the same after the end of the PHE. “What we saw from the pandemic is that health care has evolved and, with it, access to care,” Dr. Alozie said.
That’s especially true for certain services and patient populations that otherwise might not get the prompt care they need, says Austin family physician Jacob Childers, MD.
While Medicare telehealth services jumped across all physician specialties during the pandemic – from approximately 5 million to over 53 million, according to a September 2022 study by the U.S. Government Accountability Office – office visits and psychotherapy appointments were the most common services to see a spike in numbers.
Dr. Childers sees many such patients with behavioral health needs who turn to telemedicine for otherwise inaccessible specialists because of distance, a lack of appointment times, or cost.
He also anticipates telehealth acceptance will continue to increase as patients and physicians become more adept at and comfortable with using technology instead of face-to-face interaction, where appropriate, and as recent developments expand broadband access across Texas, particularly in rural areas. (See “Texas’ Physician Workforce,” page 18.)
A January 2023 Texas Medical Association survey showed roughly 75% of Texas physicians use telemedicine.
“When we talk about improving access to care, it’s hard not to mention how the pandemic exacerbated not only problems for physicians but also for patients who find it hard to get appointments for the care that they need,” Dr. Childers said. Telehealth and its evolving technologies “can improve that and bring patients to doctors quite literally over the screen.”
Bolstering broadband
Supporting that sentiment while still promoting in-person visits, the TMA House of Delegates adopted policy during its 2022 session that emphasizes the importance of physicians educating their patients about telemedicine options in their practice and advising patients of after-hours options their practice may offer. The policy also advocates for payer practices that do not unfairly favor health visits with telemedicine-only companies by waiving copays or offering other imbalanced pricing incentives.
TMA’s telemedicine resources include specific policies and procedures that practices can download and modify, for example as the federal and state landscapes adapt.
Changes recently adopted by Congress under the Consolidated Appropriations Act of 2023 aim to further reinforce telemedicine by allowing payment parity through the end of 2024, for which Dr. Alozie is grateful.
“Payment parity should continue,” Dr. Alozie said. “It is fair from the physician standpoint to be paid for the work that you’re doing, which often is to evaluate the patient, have a conversation with them, review their labs, and set a treatment plan. And you know what? All those services can easily be done by telemedicine.”
The act also extended many pandemic-era flexibilities through the end of 2024, including:
- Eliminating the originating and geographic site restrictions on telehealth services, such that anywhere in the U.S. where a patient is located at the time of a telehealth appointment, such as an individual’s home, qualifies as an originating site through Dec. 31, 2024;
- Delaying the requirement of an in-person visit with a physician within six months prior to initiating mental health telehealth services and again at subsequent intervals, as well as similar requirements for rural health clinics (RHCs) and federally qualified health centers (FQHCs);
- Continuing coverage and payment of telehealth services included in the Medicare telehealth services list until Dec. 31, 2024;
- Extending coverage of certain audio-only services;
- Continuing payment for telehealth visit services by occupational therapists and qualified physical therapists, qualified speech-language pathologists, and qualified audiologists;
- Continuing payment for telehealth services furnished by RHCs and FQHCs established during the COVID-19 pandemic; and
- Adding mental health counselors and marriage and family therapists as distant site practitioners for purposes of providing telehealth services.
Other changes allow teaching physicians to use audio or video real-time communications technology at all residency training locations through the end of 2024 – an exception to a 2021 provision that, after the end of the pandemic, required teaching physicians to attend training sessions in person to bill for their services involving residents, including Medicare telehealth services.
Beginning Jan. 1, 2025, however, patients receiving tele-behavioral health services will be required to have an in-person visit at least once within six months of initiating services and every 12 months thereafter, forcing some patients to return to clinics.
At the state level, TMA’s Committee on Health Information Technology is monitoring the rollout of the $1.5 billion Texas Broadband Infrastructure Fund the state adopted last year. The TMA-supported measure aims to expand internet connectivity to roughly 7 million Texas residents who lack access to affordable and reliable high-speed internet that TMA says is critical to providing high-quality, physician-led telemedicine care. Proposition 8, an amendment to the Texas Constitution that TMA also supported, was adopted by the Texas Legislature after Rep. Trent Ashby (R-Lufkin) called for the change to supplement federal dollars to upgrade and expand broadband networks.
The amendment, which took effect on Jan. 1, gives Texas almost $5 billion of collective federal and state dollars – financed through money allocated by the state legislature, gifts, grants, and investment earnings and administered by the state comptroller – to expand internet access.
Other state funding is going to institutions like Texas Tech University Health Sciences Center Lubbock, which has a history of using telemedicine dating back to 1989 and received $10 million, effective Sept. 1, 2023, to establish the Institute for Telehealth Technology and Innovation. The institute will leverage “digital technologies to expand access to underserved areas and also to transform health care through proactively managing acute and chronic diseases and engaging the patient in their own health care as preventative measures.”
With additional broadband funding, Dr. Alozie is hopeful patients will continue to be seen, even in Texas’ most rural designations.
“If you don’t have broadband access, and you live in an area with a physician shortage, you often don’t get the care you need. And with broadband funding, we can change that,” he said.
Behavioral health benefits
Telehealth also can change what Dr. Childers calls “one of the biggest issues” that primary care faces when it comes to mental and behavioral health: access.
“When we determine a patient is better served by a mental health professional, we count on two things: one, that the patient is going to have a very hard time finding an appointment; and two, that when they do find one, it’s going to likely be expensive.”
Telehealth reduces wait times and offers more flexible appointments for busy or home-bound patients to be seen during their lunch breaks or from home, he says. It also provides prescheduling tools, which allow physicians to populate patients’ medical records in advance to streamline visits and adjust physician workflows, allowing for a better work-life balance.
Still, tele-behavioral appointments can vary in cost depending on several factors, including:
- Differing insurance coverage among patients, whose specific coverage may affect any associated copayments or deductibles;
- Varying costs of virtual mental health appointments, which can range from $40 to $90 per session without insurance;
- Different cost structures across physician specialties; and
- The complexity of a patient’s condition and the specific services they require.
As examples of ways to decrease cost while increasing telehealth’s potential, Dr. Childers points to sliding-scale fee systems that allow mental health care professionals to adjust their fees based on a patient’s income level and to online therapy service platforms, such as Talkspace or BetterHelp.
Dr. Childers works with Televero, a digital psychiatry and counseling service based in Austin. Televero takes referrals from primary care physicians like him and then pairs those patients with available mental and behavioral health professionals, bypassing long wait times and providing care often much quicker than traditional in-person appointments.
He describes the benefits of such telehealth advancements as a win-win for patients and physicians.
“Telehealth opens a pathway to more appointment options and thus more timely care for patients and a more flexible work schedule for physicians.”