• Telemedicine Is Worthy of Payers' Long-term Investment

    It is hard to believe that the great telemedicine experiment is only a few months old, but we already have experienced one of those tectonic shifts in society after which nothing is the same. The evolutionary theory of punctuated equilibrium suggests that change is extremely rapid after a catastrophic event, and then a new homeostasis is reached. We have experienced such an event.

    Doctor comforting a disabled patient

    Like many family physicians, I set up telemedicine visits for our clinic in March. It was a project I had always planned on but never seemed to have time to implement. Once I was in state-mandated quarantine, I had time to spare. I know I was in good company because most of you did the same thing. An AAFP survey conducted in May found that 81% of respondents began providing virtual visits in response to COVID-19. (That was in addition to the more than 13% of members who were already using telemedicine.)

    I am interested in hearing about your experiences with telemedicine so far. Personally, I found that having a long-term relationship with a patient helped enormously when interacting via telemedicine. I have written previously about the role of empathy in diagnosis and the fact that I use all my senses in the exam room.

    There is no doubt that good medical care can be delivered through telemedicine, but I have found the paucity of clinical information when there is no physical exam to be a challenge. On the other hand, there is other information that can only be gleaned from telemedicine or home visits. I have appreciated being invited into people's homes because it has giving me new insights into their lives.

    My patients have appreciated not having to wait in my waiting room, which is now locked and in disuse. If I need to see a patient in person, my staff meets them at the door and brings them in.

    Payment has been a problem. Our clinic did not get paid for telemedicine for the longest time. It has been frustrating that at a time when insurance companies are making record profits, some are still not paying us appropriately for caring for their beneficiaries under the most challenging of circumstances. CMS, on the other hand, deserves a round of applause for paying for telephone visits as if they were in person. Also deserving a round of applause is the AAFP's government relations staff, which was relentless in advocating for payment to family physicians.

    So where are we riding this telemedicine train? I cannot see us going back to where we were before the pandemic. To quote former North Carolina AFP President and current ABFM Board member Mott Blair, M.D., "That genie done popped out of that bottle."

    There are many situations when telemedicine is effective and appropriate. Other times patients will need to be admitted to the ICU. Within that broad spectrum are many settings where family physicians care for patients. Ideally, we should be paid to take care of our patients regardless of the modality, which should be up to us.

    My experience has been that knowing the patient, having that longitudinal relationship that family physicians prize, makes the telemedicine appointment more effective, both at coming up with a correct diagnosis and with providing reassurance. This may not be true for everyone, but I suspect that it is.

    We should also be compensated for capacity and readiness. During the first two months of COVID-19, half of my time in Valdez, Alaska, involved meetings and task forces that did not contribute to our practice's bottom line. This was time freely given to protect my community, but many practices had to choose between viability and community health.

    Meanwhile, I worry that policymakers will see the success of telemedicine as the answer for medical deserts and workforce issues. As the AAFP and other organizations recently told the Senate Committee on Health, Education, Labor and Pensions, the growth of telemedicine could further disrupt care, especially in rural areas, if it is not well planned.

    Years ago, I talked a clinician in a neighboring community through an emergency dilation and curettage over the telephone. Due to weather, travel was impossible. This was an experience I truly never want experience again. The patient survived without complications, so it was a success. But how much better would it have been for the community had the clinician had those skills and capabilities to begin with? Telemedicine is a great resource, but it cannot replace a full-scope family physician.

    For all that it is shiny and new, telemedicine is just a tool. I strongly feel it works best within the context of a pre-existing physician-patient relationship where there is the option of a physical exam. Continuity is still important, as is an actual presence within the communities where our patients live. Within that framework, telemedicine is an excellent addition to the care we provide for our patients, especially now during the pandemic.

    I cannot tell you how proud I am to be a family physician and to be Board chair of the AAFP. Family physicians have risen to the challenge of caring for our communities under the most difficult circumstances possible. You have demonstrated incredible flexibility not only in embracing telemedicine, but also filling every role needed from staffing testing stations to covering ICUs. I know how hard it has been, and COVID-19 is far from over.

    The AAFP plans to provide feedback to CMS this summer when the agency publishes its annual proposed Medicare physician fee schedule, which is expected to address permanent expansion of reimbursement for telemedicine services. The Academy already has communicated with CMS on this issue, and we will continue to advocate on your behalf. The incorporation of telemedicine into our practices is vital to the health of our communities, and we will get it right.

    John Cullen, M.D., is Board chair of the AAFP.


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