To keep non-emergency patients out of hospital and focus on Covid-19 patients during lockdowns, nations around the world declared a public health emergency. Under such conditions, many existing telehealth rules changed. Telemedicine was allowed for the first time in some countries such as France, which removed the requirement for patients to have physically met a doctor and for the first time and enabled 100-per-cent reimbursement rather than 70 per cent.
US federal departments waived penalties for healthcare professionals using technology not compliant with the US Health Insurance Portability and Accountability Act (HIPAA) so doctors could talk to consumers for the first time using WhatsApp, Zoom, FaceTime or Skype. The requirement to conduct an in-person exam before prescribing controlled substances via telemedicine was relaxed too. Most US states implemented temporary executive orders or released guidance on telehealth access, removing arcane requirements, to use a doctor’s office for a telehealth appointment, for example, or to be in a defined rural area.
Meanwhile, telemedicine has gained widespread approval amongst doctors, patients and even policymakers. Cigna’s Covid-19 Global Impact Study suggests patients really like telemedicine: 59 per cent in the UK would be more likely to use a virtual GP with their regular doctor and 21 per cent would prefer to use it over a face-to-face GP visit. And the US Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma said about telemedicine: “I can’t imagine going back.”
However, telemedicine providers worry that whenever countries declare the end of public health emergencies, as nations including the US and Australia may do at the end of the year and many of the original regulations snap back into place. France’s reimbursement level was due to revert to the typical 70 per cent at the end of its period of emergency, for instance.
Previously the fear of data loss, data breach or incorrect healthcare being practiced led many smaller governments to over-regulate, therefore denying people access to care via the internet or phone. Pre-Covid-19, Voice Over Internet protocol was not even allowed in the UAE, for example. Video consultations have been banned, or special licenses required, which were often denied. With Covid-19, regulators have largely been playing catch up with both the technology and the way it can be used.
Luckily, regimes that changed under Covid-19 are unlike to change anytime soon or overnight. “Countries are extending the programmes and playing it safe right now rather than saying we are not going to do this anymore, let’s get back to normal,” said Adam Wears, a Research Analyst at Juniper Research.
However, new rules may have to be passed in countries, such as the US, to stop the automatic return to the old rules when the time comes, said Kyle Zebley, Director of Public Policy at the American Telemedicine Association (ATA). “If Congress does not act, and the public health emergency ends, the old regulations that were put in place when you needed a CD-Rom and a hard phone line to access the internet will snap back into place,” he said. “That’s what we call the telehealth cliff.”
Kim-Fredrik Schneider, CEO of telemedicine micro-consultation provider Abi, is optimistic that regulatory environment will largely remain after the pandemic, in most countries where his company operates (27 countries across four continents). “In environments where there is an undersupply of physicians, new methods of interaction which have become available during the pandemic will continue to flourish,” he told ITIJ.
Across many high-growth markets in Asia, for example, a universal definition of telemedicine developed by the World Health Orgaization has been adopted during the pandemic. “It provides instant clarity and regulatory uniformity which is very helpful to multi-national businesses like ours,” he said. “India is a prime example of a country which has really thrown the door open to telemedicine, with regulations which protect patient safety, but also allow for innovative approaches which would be impossible in the US.”
Indeed, India released guidelines in March 2020 to enable more patients with chronic conditions and those in isolated rural areas to access healthcare and prescriptions.
ATA’s Zebley said thousands of bills have been proposed at state and federal level, to entrench the gains made over the last year in the US. A bipartisan Connect for Health bill has been proposed by Senator Brian Schatz of Hawaii for example. In addition, 23 states have passed executive orders or other provisions to change the rules permanently. Arkansas did so in April. “Arkansas went from possibly the most regressive state in the US to right up there with the best states in terms of the ability to access telehealth,” he said.
The fight against healthcare fraud
However, concerns around preventing fraud, privacy violations or opioid prescription abuse remain. Personal Health Information (PHI) available through telemedicine exchanges is increasingly a target for cybercriminals. In recent years, consultancy DarkOwl has observed information from compromised medical record systems openly traded on the dark net, including sensitive patient records and medical evaluations. “Many threat actors have expressed specific interest in gaining unauthorised access to telemedicine applications that [have] rapidly risen in popularity since the coronavirus pandemic,” said one lead research analyst at Dark Owl. “Exploiting telemedicine programs provides criminals the opportunity to not only steal personal information of patients, but circumvent health insurance reimbursements and defraud government health benefit programmes.”
Zebley said any incoming rules that enhance cyber security are welcomed as is the reinstatement of rules on privacy. “We think that HIPAA rules should snap back. Health data should be protected,” he said. US providers are currently trying to make their platforms much more user-friendly in advance of such changes. “It will affect us, but the industry has been preparing for that,” he added.
But, said Dr Sneh Khemka, CEO of Simply Health, healthcare systems also self-govern and quality-assure themselves. They require a secure technical environment, which doesn’t keep dropping out, and has the right digital access points. “Then there’s a layer of clinical governance and quality accreditation that sits on top of this, so that people can aspire to even higher levels of patient safety,” he said. Steps should be taken to achieve this, just like in any physical healthcare organisation. “Monitoring, continuous quality improvement, self-audit, external audit and accreditation. Happily, we’re seeing them happen very rapidly in the telemedicine provision space,” he added.
Dr Peter Mills, European Medical Director at Cigna, agrees that telehealth actually helps to maintain quality of care. “Across the world, care levels vary and telehealth helps us manage these issues and to have consistent service levels,” he said. That’s because expanding telehealth from different providers, combined with the demand for greater transparency, means quality and consistent care levels are easier to audit. “The more we use the telehealth services that are already available, the more data we can access, so we can therefore be more transparent with what we can provide our customers,” he said.
Including the digitally excluded
But more is required to overcome existing problems with telehealth. AI that does not take into account the diversity of users on every measure – age, gender, race, and hereditary and social class – is known to display bias. Citing the Second JD Power US Telehealth Satisfaction Study, which looked at dozens of telemedicine services, it still takes an average of 17 minutes to sign up, nine minutes to wait for a doctor, and 18 minutes for the consultation to be completed, said Schneider. “Imagine if using Uber or Amazon was that slow,” he said.
Telehealth has also not improved the outcomes of traditionally underserved digitally excluded communities. “The people who need these services the most are very often the least able to use them,” said Juniper’s Wears. “They need good devices, technology, knowledge to use Zoom, Skype or the provider’s platform, but that’s not there.”
Providers say telemedicine tech must be easy to use, like Facetime or WhatsApp being successfully used by grandparents to speak to their grandchildren. “The security has to be there because these are medical consultations and not just recreational conversations. And the accessibility has to be there for those with impairments or disabilities,” said Khemka.
Interestingly, one of the largest cohorts of telemedicine adopters are in the 45 to 65-year-old age bracket, so it’s not necessarily the digitally savvy teens and 20-somethings who are accessing telemedicine (although younger age groups prefer asynchronous, text-based, relatively anonymous interactions), he said.
ATA said access to phone-based telemedicine is as important as digital means for those who do not use the internet. Abi’s services are available via SMS, as well as popular chat apps. “This also expands access for older people who may struggle to use a new app interface but are already familiar with WhatsApp,” said Schneider.
New innovative thinking on telemedicine post-Covid will change the industry, however. “It is the perfect opportunity for employers to look at the whole health of their employees in a completely new and different light,” said Cigna’s Mills.
Think about the Amazon retail experience in healthcare – that is where Virtual Health 3.0 is heading
He advocates blended virtual and ‘bricks and mortar’ healthcare delivery, where telehealth is one part of the solution. “Rather than just having urgent solutions being solved by telehealth, telehealth needs to be integrated into ongoing and chronic care – not in place of it, but as part of a wider health strategy,” Mills added. In theory, a digital platform could collate different services a cancer patient requires in one place. “For example, consultations with pain management specialists, psychologists and after care,” he said. “If you can utilise the virtual environment to optimise patient care, it’s a win-win for the patient and clinician.”
Patients also want to increase access to their own health record via telehealth too. “They want to be able to access health information from one central location – from an appointment about back pain, to a therapy session,” he added.
Khemka agrees that patients want access to healthcare on their terms. “Rather than feeling trapped in a confusing system where healthcare is dictating to the patient where they have to go, the patient is at the centre, using the tech around them to get the healthcare they need,” he said. “Think about the Amazon retail experience in healthcare – that is where Virtual Health 3.0 is heading.”
Parity between reimbursement for telemedicine sessions compared with face-to-face appointments has been crucial to driving adoption. However, many payers may now re-evaluate their telemedicine strategies with a stronger focus on return on investments. Some believe the cost of a physician’s time is the same whether it is via a video, phone connection or in person, but the reality is that different levels of investment in buildings, other staff and telemedicine infrastructure must also be recouped. Symptom checkers too have failed to impact on the healthcare journey in a useful way, said Abi’s Schneider.
“Payers have increasingly realised that replacing a 15 minute in-person visit with a 15-minute virtual visit is not good maths,” he said. “Unless the unit of interaction with the doctor is fundamentally transformed, telemedicine does not provide a long-term answer to the problems of healthcare costs and limited physician time.”
What’s required first, however, is making permanent many Covid-19-era telemedicine regulations, said ATA’s Zebley. “If we don’t solve these geographic or site requirements and other regulatory barriers, we will never get to the conversation on payments,” he concluded.