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Caswell County, where William Crumpton works, runs on the northern edge of North Carolina and is a rural landscape with mostly former tobacco farms and the occasional fast-food restaurants.
“There are vast areas where cell phone signals just aren’t there,” says Crumpton. “Things like satellite radio are even a challenge.”
Crumpton, who grew up in the field, is the CEO of Compassion Health, a federally funded community health center. There is neither a hospital nor an emergency room in the district. And for much of the pandemic, roughly half of the center’s patients could only be reached the old-fashioned way: a simple voice call on a landline phone.
“We have people who live in houses who wouldn’t be able to use cell phones if they wanted to,” he says. “They do not have access to high-speed Internet, and in some cases they only have a connection to the outside world via a rotary telephone.”
When state and state governments temporarily relaxed privacy and security restrictions on telemedicine at the start of the pandemic, many patients across the country were able to be diagnosed and treated by doctors over phones without video or camera capabilities. This, in turn, enabled health care workers to connect with hard-to-reach patients – people who are poor, elderly, or who live in remote areas.
But today the rules are changing that temporarily relaxed the license and reimbursement restrictions, so the use of this type of telemedicine service has expanded.
There are approximately 1,000 pending proposals to state and state lawmakers to expand or expand telemedicine beyond the public health emergency of the pandemic. To date, about half of all US states have adopted measures to maintain audio-only telemedicine. In the remaining states, missing laws and old restrictions on telemedicine are or will be reinstated; some will go under when the state health emergency ends sometime after the year ends, while others have their own schedules.
Insurance policies are now also in flux. Medicare, for example, says it will only cover audio visits for mental and behavioral health treatments through 2023. However, some private insurers have already stopped reimbursing audio treatments only.
Taken together, the changes mean that patients may be abruptly disconnected from the care they have become accustomed to, remotely and easily accessible.
Without telemedicine “she could be dead by now”
Gail Grinius does not want to see such a return to normal. Grinius, a patient at Compassion Health, says that access to health care has always been a challenge in her community.
“There are a lot of people who don’t have transport,” she says. If they run out of medication or need an examination, they often call 911. Facilitating a doctor’s visit by phone, she says, would be a “blessing” for many people, as it was during the time of the pandemic.
Grinius is 71 and has diabetes as well as skin and vascular diseases that make walking difficult. She also needs 15 different medications, so being able to meet her doctor over the phone was crucial. “Otherwise I don’t know,” she jokes, “I may already be dead.”
While lawmakers and insurers debate whether this type of audio-only supply should continue to be allowed, the crux of the debate is whether this low-tech method of reaching more people is safe and effective.
The pandemic has changed Krista Drobac’s mind on this compromise.
“Before the pandemic, I only viewed audio as a quality issue; now I see it as an equity problem, “says Drobac, chief executive of the Alliance for Connected Care advocacy group.” It really does expand patient access to providers they might otherwise not see. “
What is missing if there is no physical exam
But the Texan psychiatrist Nidal Moukaddam sees the problem very differently. “The phone thing was terrible. Terrible,” she says.
Almost all of the patients in her clinic whose first appointment was by phone did not show up for follow-up, says Moukaddam. She is an Associate Professor of Psychiatry and Behavioral Science at Baylor College of Medicine and a member of Physicians for Patient Protection. “Audio-only didn’t give us that [a] Connection to the patient, “she says, who can often be reached with her cell phone when shopping, driving a car or using the toilet and is therefore not fully committed.
Moukaddam was also unable to tell whether they had tremors, skin discoloration or alcohol in their breath, she says. “The problem is, it kills medicine – you can’t do anything without a physical exam.”
According to a study by the McKinsey & Co. advisory group, telemedicine has grown 38-fold since the beginning of the pandemic – not only for therapy and mental health, but also for the treatment of physical illnesses.
This is a mixed bag for people like Rahul Shah, an orthopedic surgeon in southern New Jersey, who says he loves the ability to phone patients with 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 about the risks the doctor takes by never laying hands on this patient – I mean, this is mind blowing “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 indicated his pain was radiating from his lower back. But when the man stumbled off his chair, Shah suspected another culprit and ordered another MRI.
“Lo and behold, it turned out that the Lord had significant problems on the back of his neck,” says Shah. “If I hadn’t seen him get up from his chair, I would have missed this whole series of questions.” This type of diagnosis change after a personal visit, he says, happens in his practice every other week.
Towards a mix of remote and personal health care
Like many other doctors, Shah sees medicine moving towards a mix of remote care – where that is sufficient – and personal care. His home state of New Jersey has yet to pass a law authorizing the expansion of telemedicine flexibility or determining what insurance pays for those phone or video visits. However, given the changing regulatory and insurance landscape, it is also difficult to say how much his practice should invest in new ways to offer telemedicine appointments, according to Shah.
That’s a common complaint, says Courtney Joslin, a resident fellow at the R Street Institute, an open market think tank.
“There’s so much uncertainty about what’s going to be made permanent and what’s going to be the way things were,” she says. “Now many providers and even hospitals are asking: ‘Well, should we continue to invest in infrastructure for this? Will our state continue to allow this or not?'”
And that leaves many patients – and their doctors – in limbo.