with Paulina Firozi
Millions of Americans being quarantined may be what finally gets telemedicine widespread acceptance in the United States.
The pandemic is prompting a seismic shift among policymakers, providers and patients as they contemplate how to ensure Americans can get needed care even as most of the country practices social distancing.
“I think this may be just what we needed to get us to adopt telemedicine,” Farzad Mostashari, former national coordinator for health information technology during the Obama administration, told me. “There were all these barriers. … In the midst of this pandemic, it’s amazing what can happen.”
The coronavirus crisis is exposing broad inconsistencies in the use of telehealth in the United States, as primary-care doctors beg patients to stay at home unless they have urgent symptoms requiring an in-person evaluation.
Until now, the nation’s health-care system was slow to adopt new technologies allowing doctors, nurses and other medical providers to see or monitor patients remotely. State Medicaid programs and private insurers have vastly varying rules around paying for telehealth. Until the pandemic, Medicare refused to pay for nearly all medical services rendered remotely. Just 1 in 10 Americans use telehealth services, research suggests.
Experts say two chief barriers have stood in the way of delivering more care via video. One, many patients and providers remain skeptical. And two, regulations are standing in the way.
Now the coronavirus and subsequent need to stay at home is spurring demand like never before. Telehealth providers are reporting massive spikes in use of their services in recent weeks.
Banyan Medical Systems, a virtual-care provider that partners with nearly 800 hospitals, has seen a 900 percent increase in patients using telehealth services, according to its chief executive Tony Buda. Its technology is being used not just by patients trying stay home – but also by hospitalized patients in California, Michigan and Florida who are being cared for in isolation rooms.
“The pandemic has made [providers] realize they can deliver care without being physically present,” Buda told me. “So we’re seeing a shift in thinking about virtualization of care delivery.”
The electronic medical record company Epic, which also provides telehealth software, says its clients across the country are experiencing a surge in demand. They include:
— North Carolina’s Novant Health, whose chief medical officer Keith Griffin said its video visits have gone from 200 a week to more than 12,000 a week.
— UC San Diego Health, where more than half of primary-care visits are now conducted via telehealth, up from 6 percent.
— New York University’s Langone Medical Center, which went from 20 virtual-care clinicians to 1,300 over a few days, and is now conducting more than 70 percent of its visits virtually.
That second barrier — regulations — is also loosening. Policymakers have taken rapid steps to expand payments for telehealth services and ease restrictions on the types of technology that can be used.
Lifting extensive telehealth restrictions in the Medicare program was one of the first steps the Trump administration took in responding to the pandemic. Seema Verma, administrator of the Centers for Medicare and Medicaid Services, announced in March that Medicare would begin broadly reimbursing providers for virtual services.
Roger Severino, civil rights director for the Department of Health and Human Services, said providers could use popular apps such as Skype or FaceTime without worrying about being penalized for violating medical privacy laws.
The new — albeit temporary — Medicare rules are a welcome relief for primary-care doctors, especially because of the increased risk of exposing elderly patients to the virus.
“It’s a total game-changer,” Mostashari said, adding that CMS should get “huge credit for really jumping on it and realizing how critical it was going to be for the health of beneficiaries.”
“They really have made it possible for this to become a routine part of primary care,” he said.
Helping patients stay home is also a major concern for providers serving Medicaid patients, as they try to help hospitals preserve precious space for covid-19 patients by keeping other patients out of emergency departments.
While state Medicaid programs already had less stringent telehealth rules compared with Medicare, no two states have written the same rules, resulting in a patchwork of different regulations and payment rates that can be confusing to doctors and nurses. Especially in states with the most restrictive rules, providers are facing severe financial hardship as they see their in-office visits decrease by as much as 70 percent.
Sally Goza, president of the American Academy of Pediatrics and a Georgia pediatrician, told me her office saw 41 patients on April 1. On the equivalent weekday one year ago, there were 90 visits. She said she feels lucky to be working in a state that does pay for certain telehealth visits for Medicaid patients — but many providers aren’t so fortunate.
“We’ve already furloughed some of our staff,” Goza said. “We are trying not to furlough anyone else. Our providers have all decreased salaries … we are the last people who will be paid if there’s money at the end.”
Every state Medicaid program does provide some payments for live video visits with certain providers, according to a report by the Center for Connected Health Policy in California.
But there’s wide variation in what types of visits are allowed and with what types of providers. For example, Pennsylvania’s Medicaid program will only pay doctors, certified nurse practitioners and certified nurse midwives for telehealth visits, while Virginia’s Medicaid program includes 16 different kinds of eligible providers.
Twenty-two states pay Medicaid providers for monitoring patients remotely. Fourteen states pay providers for what’s known as “store-and-forward,” where providers and patients can record messages that are saved so they can be accessed later.
Just eight state Medicaid programs — including Alaska, Arizona, Maryland, Minnesota, New York, Texas, Virginia and Washington — pay for both types of services, both remote monitoring and store-and-forward. And payments vary dramatically in a program already known for drastically lower rates for in-person care.
“There are providers in some states are getting paid $13 for a telehealth visit,” Goza said.
AHH, OOF and OUCH
AHH: Federal agencies are discovering stashes of N95 respirator masks and protective body suits in darkened government labs, federal health clinics and storage spaces across the country, as the nation's strategic stockpile runs low, our colleagues Lisa Rein and Todd C. Frankel report.
But actually getting the supplies to those in need is another story.
“Some federal agencies have struggled to donate items they’ve located, stymied by red tape and an apparent lack of adequate coordination within the government’s emergency response, according to interviews with agency officials and documents reviewed by The Post,” they write. Some agencies haven't been able to get FEMA to take their equipment.
The Consumer Product Safety Commission, for example, has a stockpile of respirator masks, plus loads of gloves, safety glasses and full-body protective suits that are normally used in a lab. “Our PPE is packed up and ready for distribution to those who need it most,” acting CPSC chairman Robert Adler said in a statement, “as soon as we are told where to send it.”
The Environmental Protection Agency said this week it found 225,000 pieces of medical supplies; the National Archives found masks and full-body protective suits; the Internal Revenue Service discovered 50,000 respirator masks; and the Energy and Agriculture departments also found supplies.
— More than 1,000 private-sector companies responded to FEMA's request two weeks ago to provide needed supplies. But only three actually have supplies so far that the agency can buy, the Wall Street Journal’s Rachael Levy reports.
“Many of the offers, for items ranging from protective medical gear to tests and body bags, didn’t work out, according to people familiar with the matter, because some companies have asked for payment up front, something FEMA can’t agree to,” Rachael writes. "Another issue: Some companies have oversold what they can actually get to FEMA.”
FEMA officials are labeling this problem “vaporware,” when the pledged products never materialize.
“Never before has FEMA struggled to find supplies in such a way, say current and former employees,” Rachael writes."
OOF: There's been no rationing of ventilators yet, but state officials and doctors warn it's inevitable in some hot spots. So some states and hospitals are working toward guidelines to decide who should get a ventilator when they run short.
“If — or when — that point is reached, many hospitals would activate grim triage plans that would rank patients based on who is most likely to benefit from the intensive care," our colleagues Ariana Eunjung Cha and Laurie McGinley report.
For example, Pennsylvania officials adopted guidelines to prioritize access for sick doctors and other front-line medical workers if there’s a scarcity. But a Maryland panel rejected such an approach, arguing those sick enough to need the life-sustaining machines would be unlikely to return to their jobs anytime soon and that defining who is and who is not a health-care worker in a crisis is too morally fraught.
In most if not all plans, pregnant women would get priority, hospital officials and ethicists say. “There also has been some discussion about whether high-ranking politicians, police and other leaders should be considered critical workers at a time when the country is facing an unprecedented threat,” our colleagues add. “The elderly, people with terminal cancer and those with chronic conditions, on the other hand, fare poorly in many plans, as do people with disabilities.”
OUCH: There’s still no national strategy for testing Americans for the coronavirus. That has left states to fend for themselves, developing a patchwork of testing systems, leaving states with more funding and more-robust medical industries far ahead of those without, Laurie, Juliet Eilperin, Steven Mufson and Josh Dawsey report.
“Public health experts say that widespread testing for the novel coronavirus is key because it would determine who is infected and needs to be isolated, as opposed to ordering the entire population to stay at home,” they write. “The development and use of antibody tests, meanwhile, could identify those with immunity to the virus who are able to return to work, school and everyday activities.”
In recent days, the White House coronavirus task force has begun debating what a national testing strategy would look like. Deborah Birx, White House coronavirus response coordinator, and HHS assistant secretary for health Brett Giroir are leading the effort.
“At a Monday task force meeting…Birx and Giroir debated where to send the newest coronavirus tests — a version produced by Abbott Laboratories that can deliver results on-site in as little as five minutes, as opposed to tests that can take hours and must be processed by a laboratory,” our colleagues write.
— Some Wisconsin voters waited for hours at crowded polling stations yesterday, following the state Supreme Court’s controversial order to proceed with in-person elections, The Post's Elise Viebeck, Amy Gardner, Dan Simmons and Jan M. Larson report.
The state was the only one to move forward with its presidential primary contest this month, while a dozen other states have postponed their elections. It operated far fewer voting locations and the state election commission said results will not be released until Monday.
“We decided to risk our lives to come vote,” a 40-year-old Ellie Bradish told The Post. “I feel like I’m voting for my neighbors, all the people who don’t have the luxury to wait this long.”
“The nearly unprecedented challenge for election officials hit hardest in Milwaukee, which opened five voting locations out of the typical 180 because of worker shortages, and Green Bay, which offered only two polling locations instead of the usual 31 and had waits of two to three hours,” our colleagues write.
— Trump removed the Pentagon’s acting inspector general who was set to oversee the about $2 trillion coronavirus stimulus package.
It was the second inspector general Trump ousted in four days, our Post colleague Ellen Nakashima reports, adding it’s a “pattern that critics say is a direct assault on one of the pillars of good governance.”
A council of inspectors general had selected Glenn Fine, who had been the acting Pentagon inspector general, to lead the Pandemic Response Accountability Committee, created by the March 27 law.
Fine "was informed Monday that he was being replaced at the Defense Department by Sean W. O’Donnell, currently the inspector general at the Environmental Protection Agency,” Ellen writes. “O’Donnell will simultaneously be IG at the EPA and acting IG at the Pentagon until a permanent replacement is confirmed for the Defense Department.”
The move comes on the heels of an announcement last Friday by Trump that he was removing Michael Atkinson as the inspector general of the intelligence community, “a decision that Trump acknowledged was in response to Atkinson’s having alerted lawmakers to the existence of a whistleblower complaint about the president’s dealings with Ukraine,” Ellen writes.
— At yesterday's coronavirus task force briefing, Trump chided the World Health Organization and threatened to “put a hold on money spent to the WHO." “We’re going to put a very powerful hold on it,” he said.
The president later reversed and said he’s merely weighing such a move.
“Trump criticized the WHO for opposing his travel ban on China in March. He added that the WHO ‘seemed to be very China-centric,’ and he has suggested that the organization has not been critical enough of China’s coronavirus statistics,” our Post colleague Jesse Dougherty reports. “China is a WHO member state.”
“We want to look at the World Health Organization because they called it wrong,” Trump said. “They called it wrong. They missed the call. They could have called it months earlier. They would have known. They should have known, and they probably did know, so we’ll be looking into that very carefully.”
Trump dismissed his own downplaying of the crisis, per The Post's Josh Dawsey:
"I'm not going to go out and start screaming, this could happen, this could happen," Trump says, asked about his comments downplaying the coronavirus for many weeks. Says he is a "cheerleader" for our country.— Josh Dawsey (@jdawsey1) April 7, 2020
— As the coronavirus-fueled economic fallout continues, more than 1.5 million newly unemployed American workers will lose their health insurance, according to a new study published in the Annals of Internal Medicine.
Researchers at Harvard Medical School and the City University of New York's (CUNY) Hunter College also predicted another 5.7 million could lose their health coverage soon, so that by June 30, a total of 7.3 million Americans will have lost their health insurance. The future loss predictions are based on projections from the Federal Reserve that 47 million workers will lose their jobs by the end of June.
The authors suggested states should expand Medicaid if they haven’t already to fill the coverage gap, and in a news release, study co-author David Himmelstein argued that “Congress should make all of the uninsured automatically eligible for Medicare.”
— Other news to catch up on this morning:
The Trump administration’s response:
- Two of Trump’s close advisers predicted this week that the economy will be revived later this year, but the “halting Chinese recovery offers sobering lessons for U.S. policymakers about what is shaping up to be a more protracted economic convalescence than the White House wants, according to business executives and economists,” our Post colleague David J. Lynch reports.
- The White House is already using the emerging rapid-turnaround coronavirus tests, administering the tests at the Eisenhower Executive Office Building. There, guests visiting Trump and Vice President Pence have been required to undergo the exam, our Post colleagues Josh and David Nakamura report.
- The government has “opened a tool kit of exceptions to its standard policies on hiring, assigning and paying federal employees,” as it looks to hire and retain workers to bolster agencies stressed by the pandemic, our Post colleague Eric Yoder writes.
The hardest hit:
- A Washington Post analysis finds that the coronavirus is infecting and killing black Americans at a disproportionately high rate, our Post colleagues Reis Thebault, Andrew Ba Tran and Vanessa Williams report.
On the front lines:
- The family of a Walmart worker who died of coronavirus complications has filed a wrongful-death lawsuit against Walmart, “one of the first such cases publicly known against the retailer,” NPR’s Alina Selyukh reports.
Good to know:
- Sen. Amy Klobuchar (D-Minn.) spoke with NBC News about her husband, who has now recovered from the coronavirus. “It's one of the hardest, hardest things, and I can't even imagine those families where they hear the opposite news, you know, after he's there for five days and it turns for the best,” she said.
- After 76 days, Chinese authorities allowed residents to travel in and out of Wuhan, the city where the coronavirus outbreak was first reported late last year, our colleague Miriam Berger reports.
- In New Zealand, it took just 10 days for the country’s strict coronavirus lockdown to show signs that the approach is working, our colleague Anna Fifield reports, with the number of new cases dropping for two consecutive days even with a ramp-up of testing.
- Officials say they've seen signs that the pandemic's toll may not be as bad as the worst projections, our colleagues Brady Dennis, William Wan and David A. Fahrenthold report.