Telecommunications health with only speech can disappear when the pandemic rules expire

Caswell County, where William Crumpton works, runs along the northern edge of North Carolina and is a landscape with mostly former tobacco farms and the occasional fast food restaurant.

“There are big areas where cell phone signals just don’t exist,” Crumpton says. “Things like satellite radio are even a challenge.”

Crumpton, who grew up in this area, is the CEO of Compassion Health, a federally funded health center. The county has neither a hospital nor an emergency room. And for a large part of the pandemic, about half of the center’s patients could only be reached in the old-fashioned way: a basic voice call on a landline telephone.

“We have people living in homes who would not be able to make a cell phone call if they wanted to,” he says. “High-speed internet is not available to them; moreover, the only connection they had to the outside world in some cases is a rotary telephone.”

So when state and federal governments temporarily eased privacy and security restrictions for telecom health early in the pandemic, many patients across the country were able to be diagnosed and treated by doctors over phones that do not have video or camera features. This, in turn, made it possible for healthcare professionals to get in touch with hard-to-reach patients – people who are poor, elderly or living in remote areas.

But today, the rules that temporarily eased licensing and reimbursement restrictions in ways that expanded the use of this type of telecommunications health service are fast.

There are about 1,000 proposals pending for state and federal lawmakers that address the expansion or expansion of telecommunications health beyond the public health emergency pandemic. To date, about half of all U.S. states have adopted measures that keep telecommunications health only with sound in place. In the remaining states, absent legislation, old telecom health restrictions have been repealed or will; some will sunset when the federal public health emergency ends sometime after the end of the year, while others have set their own timelines.

Meanwhile, insurance coverage is also changing. Medicare, for example, says it will only cover audio visits for mental and behavioral health care until 2023. But some private insurance companies have already stopped reimbursing coverage for audio-only care.

Taken together, the changes mean that patients may be subjected to an abrupt separation from care they have become accustomed to accessing externally and easily.

Without telesealth, she is “maybe dead now”

That kind of return to normal is not what Gail Grinius wants to see. Grinius, a patient at Compassion Health, says access to medical care has always been a challenge in her community.

“There are a lot of people who don’t have transportation,” she says. When they run out of medication or need a checkup, they often resort to calling 911. Being able to visit the doctor through a phone call, she says, would be a “blessing” to many people, as it has been for her in during the pandemic.

Grinius is 71 and has diabetes and skin and vascular diseases that make it difficult for her to walk. She is also addicted to 15 different medications, so the ability to see her doctor by phone has been critical. “Otherwise I do not know,” she jokes, “I may be dead now.”

While lawmakers and insurance companies are debating whether to continue to allow this type of audio-only to continue, at the heart of the debate is whether this low-tech way to reach more people is also safe and effective.

The pandemic changed Krista Drobac’s opinion on that trade-off.

“Before the pandemic, I only thought of sound as a quality issue; now I think of it as a stock issue,” said Drobac, CEO of the advocacy group Alliance for Connected Care. “It really expands patients’ access to providers that they would not otherwise be able to see.”

What is missing when there is no physical examination

But Texas psychiatrist Nidal Moukaddam views the issue very differently. “That with the phone was awful. Awful,” she says.

Almost all patients in her clinic, whose first appointment was by telephone, did not show up for follow-up treatment, Moukaddam says. She is an Associate Professor of Psychiatry and Behavioral Sciences at Baylor College of Medicine and a member of the Physicians for Patient Protection. “Only sound did not give us [a] connection to the patient, “which was often reached on a mobile phone while shopping or driving a car or in the bathroom, she says and therefore is not fully engaged.

Moukaddam also could not assess whether they had tremors, discoloration of the skin or alcohol on the air, she says. “The problem is, it’s killing drugs – you can not do things without a physical examination.”

Telehealth has grown 38 times since the pandemic began, according to a study by consulting firm McKinsey & Co. – not only for therapy and mental health, but also for the treatment of physical conditions.

It is a mixed case for people like Rahul Shah, an orthopedist in southern New Jersey who says he loves the ability to telephone patients with their family members, but also hears about patients meeting their surgeons for the first time in the operating room.

“It’s scary,” he says. “It’s scary. Think of the risks the doctor takes by never laying hands on the patient – I mean, it’s amazing” and would never have happened before the pandemic.

There is still no substitute for personal health care, he says. For example, he recently saw a patient in his office who had come in with various medical tests and scans that showed that his pain was radiating from his lower back. But when the man stumbled out of the chair, Shah suspected another perpetrator and ordered another MRI.

“Look and see, it turns out the lord had signs of significant problems in his throat,” Shah says. “If I had not seen him come out of the chair, I would have missed this whole series of questions.” That kind of change in diagnosis after a personal visit, he says, happens every other week in his practice.

Movement towards a hybrid of remote and personal health care

Like many other doctors, Shah sees that medicine is moving toward a hybrid of both remote care – in the types of cases where it is adequate – and personal care. His home state of New Jersey has not yet enacted a bill approving the extension of telecommunications health facilities or specifying what insurance to pay for those phone or video visits. But given the changing regulatory and insurance landscape, Shah says it is also difficult to know how much his practice will have to invest in new opportunities to offer telecommunications healthcare deals.

It’s a common complaint, says Courtney Joslin, a resident fellow at the R Street Institute, a free-market think tank.

“There’s so much uncertainty about what needs to be done permanently and what goes back to the way things were,” she says. “Now many providers and even hospitals are like, ‘Well, should we continue to invest in the infrastructure for this? Will our state continue to allow this or not?’

And that leaves many patients – and their doctors – in limbo.

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