Article originally featured on Medpage Today
Providers learn surprising, even shocking things from seeing patients in their home environments
These days, doctors peer through a telehealth lens and learn surprising -- sometimes shocking -- things about their patients they never would have known from an office visit.
They're taking in the home structure, meeting other people in the household, seeing environmental obstacles, and getting clues about causes or contributing factors behind their patients' symptoms.
This knowledge, gleaned since payers began reimbursing providers for video and audio visits at the same rates as in-person visits, has paved the way for more effective diagnosis and care.
The display monitor or phone encounter might reveal a situation, for example, a surprisingly large number of people in a small, noisy, cluttered, and perhaps unsanitary household. In such cases, there's little to nothing, practically speaking, a clinician can do to change the situation, even if these circumstances are contributing to the patient's illness or preventing treatment.
Overheard: 'We Can't Pay for Those Medicines'
Beverly Jordan, MD, a family practitioner in rural Enterprise, Alabama, has many examples on both sides: telehealth visits that proved useful and those that were frustrating and futile.
For office visits pre-pandemic, many of her elderly patients were driven and escorted into her practice by a variety of unrelated caregivers, so she didn't really know who actually lived with her patients.
Now in the telehealth encounter, she does. Her first such visit with a patient was, Jordan said, "enlightening."
A young "in-her-twenties" family member who was taking care of the patient "had a learning disability, was mentally challenged, and was not really capable of caring for herself." It was a co-dependent situation, she said. The patient was more mentally competent than her caregiver.
The caregiver didn't qualify to have a driver's license, and thus couldn't drive a car to buy food or pick up medicine. At one point during the visit, this young woman "blurted out, 'Well, it wouldn't matter anyway because we don't have money for groceries this week, so we can't pay for those medicines anyway,'" Jordan recalled.
Inquiring further, Jordan came to realize the patient's social security checks were being deposited in the wrong account and they hadn't been able to straighten out the situation because it required physically going to the bank.
"We literally have no money in our checking account, we can't go pick up our medicines, we can't go get any food, and we can't pay the person who typically runs these errands," Jordan said, summing up what the caregiver and her patient were saying.
Jordan was able to tap a chronic care management services program, and utilized donated Thanksgiving food baskets and funds collected for just this kind of situation. Problem solved, and Jordan can take steps to make sure the issue isn't repeated. "I would never have known that entire situation had we not had a telehealth visit," she said.
But solutions to such crises are rarely so easy.
Another patient's situation revealed through video visit was even more alarming. Before the pandemic, the patient -- a bedridden morbidly obese woman who had a stroke -- would come into Jordan's office for care by ambulance; "it required an entire ambulance crew to bring her in, very labor and time intensive," not to mention uncomfortable for her. Family members rarely accompanied her.
Now, with a video health visit, Jordan watched as several members of the patient's household – mostly teenage grandchildren -- came into her room, constantly interrupting the appointment. They needed all sorts of things, including money.
"We don't knock. We don't pull the door shut. We just barge in and ask what we want. It was really eye-opening and horrifying at the same time, one of those things you can do nothing about," Jordan said with frustration. During that 30-minute visit, Jordan said, she got to talk with the patient for about 30 seconds.
Jordan said she had tried several times to move the patient into a nursing home, but the family resisted, and with COVID, that became much less of an option.
"It makes you very concerned, with all the questions they had or asking for money, are they keeping her in the home so that they don't have to give up her disability income?" Jordan asked rhetorically.
Calling for a social services intervention was not an option, Jordan continued, because under Alabama guidelines, "as long as the patient is cognizant of what's going on, whether they can control it or not, if they are alert and oriented and they are an adult, then there's nothing we can do about that situation."
Life-Saving Opportunity
Tamaan Osbourne-Roberts, MD, a family practitioner for Iora Primary Care in inner-city Denver, told the illuminating story of how a telehealth visit provided information that may have saved one patient's life.
In that case, the patient called on the phone complaining of abdominal pain. "I asked all the usual questions: how long had it been going on, are you taking any medications. And he said none ... except for Tylenol."
If this were an office visit, the patient would have just responded that it was just the "normal dose," because an over-the-counter medicine would not be brought in with prescription drugs for the medication check.
But with telehealth, it was easy for Osbourne-Roberts to see the bottle and the labeling.
"It turns out he was taking eight times the recommended maximum daily dosage of Tylenol," Osbourne-Roberts said. He'd been taking that quantity for months. "That can cause all sorts of liver problems and abdominal pain -- really all the symptoms he had been experiencing," he said.
That revelation turned what would otherwise have been a "'This can wait' problem to an 'I'm sending you to the emergency department today' problem."
For another patient, several calls were accompanied by a lot of street noise, prompting Osbourne-Roberts to wonder if the patient was homeless. It made a lot of sense, because the patient frequently complained that his medications were stolen. Osbourne-Roberts decided to change the type of medication the patient was taking, making it less likely that it would be stolen.
James Santiago Grisolía, a neurologist in San Diego, remembers a telehealth visit with a Mexican-American patient with dementia. He was cared for by one daughter, "but they were part of a three-generation household," with many people -- children and adults -- coming and going in an area among the hardest hit by COVID-19.
With so many people living under one roof, Grisolía realized he needed to spend time explaining their heightened risk for bringing in the virus, "especially with young adult grandchildren who are working outside the home."
Window Closing?
As the latest wave of the pandemic appears to be subsiding, some providers are looking lovingly at their parity payments and wondering how long they will continue. For Medicare at least, CMS has declared parity payments for a phone, video, or an in-patient visit will remain for the duration of the Public Health Emergency.
CMS added more than 140 services reimbursed when delivered through telehealth, and allowed providers to waive beneficiaries' cost-sharing.
But the March report from the Medicare Payment Advisory Commission noted an "ongoing debate about whether the expansion should be made permanent," noting that a few trials comparing quality and cost for telehealth and in-person care are underway.
The commission recommended that CMS continue parity payments for one to two years after the PHE, but should use evidence to inform any permanent changes.
Lurking in the discussion is the potential for unnecessary spending and fraud. The commission recommended that CMS apply "additional scrutiny to outlier clinicians who bill many more telehealth services per beneficiary than other clinicians," and require in-person, face-to-face visits before ordering high-cost durable medical equipment or clinical laboratory tests.
"You always have bad actors who are willing to abuse the system," Jordan said, saying she agrees with much closer monitoring.
On the Medicaid side, Matt Salo, executive director of the National Association of Medicaid Directors in Washington, D.C., noted a huge increase in Medicaid utilization of telehealth, with one state reporting a 1,500% increase over the prior year.
With that much popularity, states will have a challenge deciding whether to extend parity for telehealth visits since states pick up between 21% and 47% of that cost.
"States are going to look at this 50 different ways," he said. "I know some states are saying, yeah, we think parity is important and we think that access is worth paying for... but I don't think that's going to be universally true."
Jordan, Osbourne-Roberts, and Grisolía all believe that parity payments should be made permanent, and applicable when appropriate, because the benefits of seeing inside the home and knowing what goes on in a person's environment can improve the quality of care, even if what's seen is sometimes disturbing.
Telehealth "works for certain patients in particular situations, and it should be reimbursed," Osbourne-Roberts said.