Telemedicine During a Pandemic with Osteopathic Considerations

Abby Rhoads, DO | abby.rhoads@sluhn.org

The author(s) declare no relevant financial affiliations or conflicts of interest.

INTRODUCTION

Telemedicine history dates to its first successful launch back to the 1960s when NASA developed it to find ways to improve telecommunication technology to provide health care to astronauts.1 In 2013, the future of telehealth started to emerge, with 52% of hospitals using its features in some capacity.2 The following year in 2014, eVisit launched. Before the COVID-19 pandemic, telehealth's focus areas included mental health, specialist care and improving the delivery of care for those in rural areas across the U.S. It was already expected that in 2020 that telehealth visits would increase to 158 million from 19 million.3 Primary care has been forced to transition to virtual visits with the current pandemic and as a result, this projected number will likely be exceeded. In April 2020, my health network conducted 80,000 virtual visits, with half performed by primary care providers, to protect both patients and providers from COVID-19.

Before the pandemic, telemedicine was drastically different. The Centers for Medicare and Medicaid Services (CMS) has been promoting telemedicine services since 1999. However, it had limited criteria. These criteria include the beneficiary receiving those services must be located in a designated rural area and the visit would have to be conducted in a medical facility, known as an originating site. With the start of the COVID-19 pandemic, CMS approved the 1135 waiver, which is a disaster proclamation effective for services starting March 6, 2020 and to last for the duration of the COVID-19 public health emergency. The waiver states that Medicare reimburses for Medicare telehealth services furnished to beneficiaries in any health care facility and their home.4,14 Medicare can also pay for office, hospital and other visits furnished via telehealth across the country in the patient's place of residence starting March 6, 2020. There are four main technology applications under telemedicine: synchronous live video conferencing, synchronous (store and forward), remote patient monitoring and mobile health (Figure 1)8,13

FIGURE 1:

Types of telemedicine technology

TABLE 1:

Common telemedicine platforms used in the pandemic14

Present Professionally

Before the telehealth visit, ensure the video device is stable. Providers can utilize video capabilities from a laptop, desktop camera or the provider's mobile device. Ideally, the patient should be able to see the provider from the shoulders up. The provider should be directly facing the screen and avoid turning away from the camera to engage with direct eye contact. This also allows the ability of the provider to capture their hands on the screen for gesturing. If possible, set up in a room where the provider can take off their mask to demonstrate facial expressions to the patient. Take caution to what may be situated behind the provider and any external noise. Identify yourself with credentials by showing your I.D. on the screen. Ensure to correctly identify the patient with their name and date of birth before the visit starts. If attention is taken away from the screen, do not hesitate to explain to the patient why this is happening, such as charting or placing orders on the computer.

Empathy

When utilizing telemedicine, we lose physical touch - something that an osteopathic and primary care physician fosters daily. Even though we cannot reach through the phone to examine our patients, we can still show our patients empathy in the virtual encounter. This can be accomplished by fostering a supportive environment by active listening, asking open-ended questions and responding to cues with support.5 Nonverbal displays of empathy are a major aspect of our everyday communication and can still be displayed on a screen.5 As providers, we can demonstrate these nonverbal displays by maintaining eye contact, showing emotional concern through facial expressions or demonstrating active listening with an occasional head nod. Patients will display nonverbal cues by changes in their facial expressions or verbal cues by stating words of emotion, such as "worried" or "afraid."5 It is also important as providers that we try to focus on not interrupting the patient, as it can lead to increased patient frustration on the virtual platform.

FIGURE 2:

Online mindfulness resources7

Treat the Whole Person

Our osteopathic imprint allows us to focus on our osteopathic tenets, such as treating the whole person with the interrelation of mind, body and spirit. We have unique training to recognize patient distress signals. Our patients have an extreme increase in anxiety during the pandemic due to lockdowns, battling illness, loss of income or employment and grief from lost loved ones. We can guide our patients to cope with this increase in stress.

Research shows that physicians that have an empathic relationship with their patient can positively impact patient outcomes such as improving self-efficacy, compliance to treatment plans and decrease psychological stress.6 Advise patients to keep a consistent schedule that includes self-care. Self-care may look different in quarantine but can still be accomplished. Encourage patients to reduce exposure to news and media, utilize the extra time to exercise regularly and direct them to online mindfulness resources. (Figure 2)7

Extending a helpful hand by incorporating osteopathic manual medicine does not have to halt in the virtual visit altogether. Providers can teach patients simple techniques that a caregiver at home can perform or that the patient can perform on themselves. Taking the time to explain simple techniques to patients will improve the provider-patient relationship and increase patient gratitude. (The OFP Patient Education Handout: Osteopathic Home Exercises for Caregivers of COVID-19 Patients available for download at acofp.org/peh)

TABLE 2:

National telemedicine CPT codes for Medicare plans and some commercial insurers16

TABLE 3:

New CMS HCPS codes for virtual check-in9

TABLE 4:

New CMS HCPS codes for telephone visits4,14,17

TABLE 5:

Telemedicine modifiers

TABLE 6:

Additional HCPCS and CPT codes allowed for telemedicine by CMS during the COVID-19 pandemic

Reimbursement of a Telemedicine Visit

CMS offers equal reimbursement for telemedicine visits as in person-visits, as well as increasing the payment of telephone visits codes when all documentation requirements are adequately satisfied. (Table 4)4, 14,17 On April 30, officials at the CMS announced the temporary telephone visit rate increase from $14–$41 per visit to about $46–$110 as well as expanded eligible services, including patient education services.12 This pay increase will retroactively take effect from March 1, 2020. Private payors' reimbursement depends on the state and negotiated reimbursement rates with that private payor.

States with telemedicine parity law in place have the best reimbursement.8 When a state passes a telemedicine parity law, it means private payors in that state have to reimburse for telemedicine care in the same way they would for in-person care. Twenty-nine states have passed parity laws for telemedicine, including eight additional states that have proposed parity laws pending in-state legislation. The five biggest commercial insurers are Aetna, Cigna, Blue Cross-Blue Shield, Humana and United Health Car. Commercial payors are always increasing telemedicine coverage due to cost-saving benefits and consumer demand. For a detailed summary of parity law in your state, visit: https://www.cchpca.org/telehealth-policy/current-state-laws-and- reimbursement-policies

Legal Considerations

There are many legal considerations as a health care provider such as credentialing and malpractice insurance - telemedicine is not immune to these considerations. First and foremost, you must be credentialed and licensed in the state that you are conducting telemedicine visits. In most cases, the patient must also be located in the state that you are in when doing these visits; this rule varies by state. The Interstate Medical Licensure Compact has also allowed health care providers to extend their patient population and there have recently been states added to this during the pandemic to help hard-hit states. Also, you must check with your malpractice insurance carrier to ensure your policy has coverage for telemedicine visits, as this may reveal a gap in protection for the provider. Some states have placed restrictions on certain medications that can be prescribed via telemedicine, especially in cases where the patient is new to the provider as well as controlled substances.8

Informed consent is also an important aspect to make sure patients understand the basic procedures of telemedicine as well as the potential privacy risks. Some states have instituted requirements for consents that are specifically for telemedicine. Some practices may embed this telemedicine statement into their general consent for treatment as well as in the note template to be rehearsed with the patient during the time of the visit. This may include statements such as a "full exam cannot be completed" or directly notifying the patient when a non-HIPAA compliant platform is used. There are multiple areas of content to include in the telemedicine consent beyond risks, benefits and alternatives. These include a description of telemedicine care, types of transmissions permitted (i.e., prescription refills or education), privacy and security risks and safeguards, technical failure risks, the physician determines if care if appropriate for telemedicine, physician misdiagnosis or mistakes due to nature of video visits and where to go for ongoing care.8

CONCLUSION

Telemedicine continues to make strides in technological advancements as well as reimbursement to providers. With the COVID-19 pandemic, telemedicine has become embedded into primary care, allowing providers to reach their patients in the comfort of their homes while decreasing office no-show rates. More and more payors will allow for telemedicine as they uncover cost-saving advantages and have increased customer demand. The pandemic has improved Interstate Medical Licensure Compact and quickly broadened states participating in telemedicine parity laws resulting in better reimbursement and further provider outreach. A future practice with a blended telemedicine model can decrease health care costs, increase patient compliance and health outcomes, and start to take steps to close the gap for health care disparities.

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10. “Coding for Telemedicine Services.” American Academy of Pediatrics, April 13, 2020. Accessed May 2020.

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13. Lynn, J. “Telehealth Reimbursement Gets Really Hard Really Quick” Healthcareittoday.com. Accessed May 2020. https://www.healthcareittoday.com/2020/05/05/telehealth-reimbursement-gets- really-hard-really-quick/

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16. Telemedicine Coverage by Payer. EMPClaims. Accessed May 2020. https://www.empclaims.com/

17. Nicoletti B. “Payment for Telephone Calls: CMS Update.” Codingintel.com. Accessed June 2020. https://codingintel.com/payment-for-phone-calls- cms-update/