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Changing Medical Care with Telehealth

Only a few days after I wrote that one of the real benefits of the pandemic would be the advancement of telehealth, a new policy was announced by Seema Varna, Administrator for the Centers for Medicare and Medicaid Services (CMS). Ms. Varna announced the loosening
up of rules for providing patients greater access to their medical professionals via telecommunication. It is time to look deeper into the subject.

Prior to this policy change, CMS would only authorize charges for rural care. That recognized the practical aspect that doctors, etc., were not generally available in some areas and the only access for routine medical care was a lengthy trip across a county to see a doctor. Not only is this a problem for folks in rural areas but likewise for city folks. They have just as much of a struggle accessing their medical professionals because they are forced to fight crowded urban traffic for even a simple matter. Now that CMS has authorized these charges, hopefully all the private insurance companies will follow suit.

This issue came to the fore after I previously wrote a column about the undue burden that had been forced on doctors needing to maintain all their records electronically. Dr. Glenn Schundt contacted me and stated that I had not detailed half of it. He elaborated how after he finished a full day of seeing patients he would go home and spend four hours a night documenting his day for the electronic medical record requirements. Once the pandemic happened and telehealth became more routine, it was time to check in on how that was affecting his practice.

Dr. Schlundt, who is a pediatrician, stated he has not participated in telehealth during the COVID crisis. Most of his patients’ demands are being driven by the parents’ when what their children have are mostly common medical conditions.

I asked his thoughts about post COVID. He said telehealth is a convenience parents want (especially in an era of two wage-earner families). Then he stated that “given the state of technology, it is completely inferior to an in-face encounter and exam in every way.”

He went on to say “Take pink eye, a superficial infection of the surface of the eye. This is super common. Parents see this all the time and hate it, because it is very contagious. If their kids have it, they cannot go to school or daycare. The problem is there are a few conditions that look just like pink eye from the outside that affect the retina and can cause blindness if not promptly treated. I have diagnosed pink eye thousands of times, but the other situations only twice. If I had missed either of those two situations the child would definitely have gone blind.”

Schlundt then expressed his concern for liability in these situations. He stated “telemedicine claims are the up-and-coming low hanging fruit of the medical malpractice world.”

Dr. Reed Wilson, an internist and cardiologist who heads the group Private Practice Doctors, weighed in with his thoughts. As for the current situation, he stated “The vast majority of my patients are using telemedicine. Most have respiratory problems. Some patients need to be seen after we have screened them.”

He continued: “I can see patients and get a feel for them visually. It allows interaction without them being exposed to office patients and without staff being exposed to sick people who may be contagious.”

The downsides he conveyed: “I can’t examine them. I can’t listen to the lungs in the case of a coronavirus infection.” There are other ailments he expressed he needed to examine to get
a full sense of the problem.

In a response to a question about using telemedicine moving forward, he declared “I can see it for:

1. An elderly person who cannot leave their house.
2. Weekend or after hour items.
3. Showing me a lesion or infection to see the progress.
4. If the person has a blood pressure cuff at home, we can discuss what to do.
5. Reviewing lab results is a possibility.
6. Anything that requires a hands-on personal approach is obviously going to suffer with telemedicine.”

Nationally prominent dentist and USC Unruh Fellow, Dr. Joel Strom, is excited about this change and predicts that “that this administration or future administrations will not be able to reverse this much-needed service away from Medicare patients.” He continued that in addition to allowing billing and payment for telehealth services, the rules allow for:

1. Not enforcing Stark anti-kickback with regard to free provision of Telehealth.
2. Waiving HIPAA to enable use of Facetime or Skype.
3. Waiving the preexisting relationship requirement with a patient to be able to bill Medicare for Telehealth services.

Though Dr. Strom stated he loved the change he sees minimal application for dentistry. Most of his work does not allow for social distancing while enduring aerosols and droplets. He said, “But at least it gives the doc the right to decide and can help access to care, prevent unneeded waste of valuable PPE, reduce traffic and waiting at the office. The government dictating that they won’t pay for such services or not giving patients a choice further restricts us from helping patients get the type of care they prefer.”

Let’s review. Though there are challenges at the current time, there are multiple applications but there are still concerns. The issue of the ever-lurking lawyers must be dealt with and the technology must improve. Can you see a time that your doctor can just save the video of the discussion and not have to spend hours meeting draconian documentation rules? Initial diagnosis in many applications can be done and the doctor can triage those who need to be in the office in the short-term. Making doctors more efficient in a challenging environment where our country does not churn out enough trained medical help to meet demand would be a great benefit. Can you envision a time where classes in med school address how to properly handle Telehealth interactions?

Then there is the simple concept that the government should not intervene in a decision between a doctor and a patient. Have you heard that somewhere before?