By MARY SELL, Alabama Daily News
Prior to the coronavirus altering the way Alabamians work, learn and socialize, the state’s largest health insurance provider saw about 2,000 telehealth claims per week.
By early April, when the state was in its tightest emergency restrictions and patients couldn’t physically get into medical facilities except for emergency care, there were about 80,000 claims per week, said Darrel Weaver, Blue Cross/Blue Shield of Alabama’s vice president of health care network services.
By May and June, as traditional care re-opened, telehealth claims averaged 17,000 to 20,000 per week.
“It’s about that now,” Weaver said.
Dr. Eric Wallace, the medical director for telehealth at UAB, has been working for years to create a statewide telehealth network in Alabama. He said telemedicine is saving lives during the pandemic.
It’s helped keep numbers down in facilities and waiting rooms, making them safer for the patients that must have in-person care. It’s allowed continued care for elderly and at-risk populations without risking exposure. It’s laid the groundwork for monitoring people at home, and in some cases it’s allowed patients to stay at smaller hospitals while still connected to specialists at UAB.
“It absolutely has saved lives,” Wallace said.
Wallace estimates 30% to 40% of care can be delivered via telehealth, but its usage will increase as the ability to assess and monitor people’s conditions and vital statistics in the home become cheaper and more widely available.
Wallace said he sees a future where some people who currently get in-patient care at hospitals will be able to get care at home.
In New York, Mount Sinai Health System has a “hospital at home” option where, if hospital beds run out, people are monitored from their residences and visited multiple times a day by nurses.
“So, ‘hospital at home’ is going to change even the distribution of in-patient care,” Wallace said.
And he said it could be an option in Alabama early next year.
“We’re working on it now,” Wallace said.
Because of the COVID-19 emergency, many insurers, including BCBS, expanded telehealth coverage, and it helped that some federal rules were relaxed, including the platforms that could be used to deliver the care.
Not everyone is sold on telehealth. Sen. Larry Stutts, R-Tuscumbia, is a practicing obstetrician and gynecologist who says his specialty can’t be done over the phone or internet. And in most cases, he said he thinks patients should see their providers in person.
“(Telemedicine is) probably better than no medicine, but it’s close,” he said. “There is no substitute for face-to-face contact and physically examining a patient.”
“But if you figure out a way to deliver babies over the internet at 3 in the morning, let me know. I might change my mind.”
Sen. Tim Melson, R-Florence, the other medical doctor in the Senate, said telehealth has allowed patients and providers to communicate when they otherwise couldn’t this year.
“I think it’s obviously something that will have to be expanded, and there are good opportunities there,” Melson said. “It’s definitely the way of the future; COVID-19 has changed a lot of ways of thinking.”
Behavior health a ‘jewel’ of 2020 telehealth experience
The BCBS tenfold increase in claims are from a variety of practices, including primary care, rehab and physical therapy.
But Weaver said remote behavioral health care has been the “jewel” of the year.
By Dec. 31, the overall amount of medical health care covered by BCBS will be down slightly compared to 2019, Weaver said.
“Except for behavioral health, behavioral health is up either 15 or 20%,” Weaver said. “And at least 40% of that is being done by telehealth.”
Weaver said 2020 saw new patients seeking treatment for depression and anxiety, and people with previously established behavioral health problems needing continued treatment.
“The ability to get on the phone and talk to your therapist or your counselor has been just phenomenal,” Weaver said.
Dr. Amanda Williams, a psychiatrist in Montgomery, has used telehealth to reach her patients since the pandemic began.
“It’s worked really well for the most part. I think the biggest struggles have been service areas especially for people in more rural communities,” said Williams, vice president of the Medical Association of the State of Alabama.
Some insurers require a video meeting for behavioral health services, not just audio.To make up for scratchy video connections that cut in and out, Williams often has her patients on the phone at the same time to ensure they can hear each other.
“And then the other big struggle still is for the elderly patients,” Williams said. “A lot of times if they have family members that can help that makes it much easier.”
Williams uses a HIPAA-secure video platform. It’s not as easy to use as something like FaceTime, but that’s not HIPAA approved.
“There are a lot of flip phones still out there,” Williams said. “Some people just don’t have the technology available.”
While behavioral health treatment doesn’t require physically touching patients, seeing their expressions and body language is key, Williams said. If it’s working right, video meetings are a good replacement to in-person appointments.
She’s seen people from their cars or closets as they seek a private spot to talk from home, so that’s been a bit of an issue. But for many, meeting online has been very convenient.
And it’s allowed her to see patients throughout the state.
“We didn’t offer it before, but now I think it’d be hard to (eliminate the option),” Williams said.
“We’re hoping that insurance companies will continue to allow it.”
Wallace also is advocating for continued coverage of telehealth and the regulations that expanded it this year.
Weaver said BCBS’s intention is to continue telehealth coverage in a post-COVID-19 future, after it works through some benefit coverage details.
“Our goal is to continue this as much as we can in the future, with a few bumps in the road around benefit changes, et cetera, but we’re going to make telehealth as accessible as possible, because it’s the right thing to do for everybody,” he said.
Many states have laws defining telehealth and requiring insurance coverage. Starting last year, several Alabama lawmakers began discussing that option here and ways to expand online access to doctors. Sen. Dan Roberts, R-Mountain Brook, in early 2020 filed legislation to require insurers in Alabama to provide coverage for telemedicine services, including interactive audio or video, for the purpose of diagnosing or treating a patient, providing remote patient monitoring services, or consulting with other health care providers regarding a patient’s diagnosis or treatment.
Because of the COVID-19 shortened session, however, that bill didn’t advance. Roberts recently said discussions continue with multiple parties.
“We are working to come up with a solution for Alabama,” Roberts told Alabama Daily News.
Weaver said BCBS largely opposes legislative mandates because they can complicate and increase costs for the delivery of care.
“We want people to be as healthy as possible,” he said. “Healthy people spend the least amount of money.”
Earlier this month, Alabama Medicaid Commissioner Stephanie Azar told a panel of lawmakers that she’s receiving “immense pressure” to continue telehealth options beyond the pandemic. One reason for the push is that medicaid pays doctors the same amount for remote visits as it does in-person visits.
“That is going to be the single biggest push I get from providers,” Azar said.
She said it’s a good option for some of the more than 1 million Alabamians on Medicaid.
“Our population doesn’t always show up when they’re supposed to and doesn’t always like you coming to their house,” she said.
Gaps in coverage
In April, Wallace said he was concerned about gaps in care among the state’s population. This month, he said those played out as expected.
“There are large disparities that are opened up when you start delivering telehealth in the home,” he said. “Specifically, the two biggest drivers seem to be socio-economics. For instance, patients on Medicaid are less likely to be able to do video than commercial patients with commercial insurance.”
He also said age is also a factor. The older a patient is, the less likely they are to be able to do video communications with providers. Tech literacy, especially among older populations, is also needed.
“So, yes, there are disparities, it doesn’t mean we need to throw out the baby with the bathwater,” he said. “It means we need to now work to get this to everyone. But unfortunately it’s not something that health care alone is going to be able to solve.”
Besides rural broadband expansion, Wallace said there are disparities in urban areas where there is the infrastructure, but people can’t afford to access it.
“We need to get broadband across the state and make sure it’s affordable so that people can access it,” he said. Expanding broadband access across the state has been a priority of lawmakers for years, but progress has been slow.
Weaver said BCBS has seen a greater increase in telehealth in urban areas as opposed to rural areas.
“I think it’s more that physicians and practices in urban areas have the ability to buy the equipment more to do this kind of care,” Weaver said.
Medicare requires a video component. For commercial care, BCBS can set the rules.
“The progression has been toward video,” Weaver said.
In the future, more monitoring of people’s vital statistics in their homes will require broadband, Weaver said.
“To be able to check your blood pressure at home or to monitor high-risk pregnant women at home, that requires broadband,” he said.
Dr. Don Williamson, the former state health officer and current president of the Alabama Hospital Association, said he doesn’t think physician-patient interactions will ever go back to what they were before COVID-19.
“I think for a lot of patients, telehealth makes a lot of sense because, depending upon what their issues are, there are a lot of things you can manage quite well with telehealth,” Williamson said.
But even now, a lot of “telehealth” is simply telephone, Williamson said.
“I think to get the better picture of the patient you really need video, and that’s going to require more broadband than we have,” he said.