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In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger discusses how telehealth is key to the future of patient care and the related advocacy and payment issues tied to its long-term use with Jack Resneck Jr., MD, the AMA’s president-elect and a professor and vice chair of dermatology at the UC San Francisco School of Medicine.
- Jack Resneck Jr., MD, president-elect, AMA
Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today, I'm joined by Dr. Jack Resneck Jr., the AMA's president-elect and a professor and vice chair of dermatology at the UC San Francisco School of Medicine in San Francisco, and we'll be discussing how telehealth is the key to the future of patient care and the related advocacy and payment issues tied to its long term use. I'm Todd Unger, AMA's chief experience officer in Chicago.
Dr. Resneck, thank you so much for joining us today. You've been a long-time telehealth advocate and you referred to this past year as a shining success in terms of how quickly telemedicine adapted during the pandemic. Let's start by talking a little bit about how telehealth has been a game-changer for medicine.
Dr. Resneck: Well Todd, thanks for having me and thanks for covering this really important topic. At the beginning of the pandemic, we really saw COVID just upend access for patients across the country as physician offices had to close or limit access for a little while. And so the AMA really jumped in to work with the federal government, primarily to get Medicare initially to start broadly covering telehealth visits and a lot of private insurers quickly followed suit, and the use of telemedicine really, really took off. And we saw a lot of our patients actually like it. It helped them maintain access during the pandemic. It helped with social distancing, so for some things they could stay home to see their doctor. And it helped with unexpected things like transportation time to get to physician offices or missing less work or having less issues with childcare. And it actually particularly helped in some areas where we saw underserved communities and rural areas and inner city areas, where they had long standing issues with a lack of medical services in areas that had contributed to health inequities, really improve access for those populations.
Unger: It's kind of like work from home. Things I thought I wouldn't like but it turns out telehealth is just a really important and convenient way to correspond with a physician. You're running a dermatology practice. How has that been for you personally? How'd it work for your patients and for you?
Dr. Resneck: Well, telemedicine's not brand new. A lot of specialties have been using it for years, even before the pandemic. As you mentioned, I'm a dermatologist, so my specialty was one that had been out front and had been doing this for a while. I've gotten to share some of those stories before Congress and other policy makers about how important it's been for my patients and I particularly often think of some who live further away. I live in the San Francisco Bay area. A lot of my patients are from close by but I also take care of a number of people from rural areas who drive three, four, five hours to come in and see us.
Dr. Resneck: And some of those folks have bad chronic disease problems in dermatology like psoriasis or lupus or others. And in some of those cases, an initial visit had been really important for those patients to maybe do a biopsy, make sure we had their diagnosis right, get them started on some medications, talk through all the pros and cons of different approaches but I felt pretty bad that some of those patients had to do repeated, long, several hour road trips just to come back and see me to get their progress checked on or make small modifications to their medications and some of those folks worried they'd get fired for missing work, sometimes they'd have to pile all their kids in the car if they had childcare issues. And I basically knew I could manage a lot of those issues by telemedicine but before the pandemic, neither Medicare nor a lot of private insurance companies would cover those visits remotely.
Now, a few of those patients who had commercial insurance would get a postcard saying that they could use some corporate internet based telehealth provider but when they tried to use them for a follow up for some complicated disease, they'd often get connected to a clinician from a totally different specialty who didn't know their medical history or have access to their records or sometimes hadn't even heard of their diseases, so they didn't find that very helpful. With the pandemic, that all changed for us because we were able, as physicians across the country were, to actually do follow up and continue to take care of patients who we knew and knew us and we could use telehealth with their existing health care teams.
Unger: We're going to dig in a little bit more into the payment related issues. Before we get started with that, I'm curious what do you see as kind of the go forward from here, hopefully in a post pandemic period, in terms of the balance between in-person and virtual services post pandemic?
Dr. Resneck: That's a tough question and I don't have a perfect crystal ball for this but I think over the last year and a half, once we saw this rapid expansion in coverage and patients started to use it more, physicians in every specialty and their patients really got to know, okay, in my specialty, this is the group of things that telehealth works really well for and maybe these are some other things where an in-person visit makes a lot more sense. So in my specialty, in dermatology for example, if I've got a patient who's had melanoma or another skin cancer in the past and they need to come in for a full body check to see if they have any new skin cancers, that really needs to be an in-person visit. That's pretty hard to do as they're moving their phone around and trying to show everything on video. Or if they have some complicated new rash that's likely going to need a biopsy, that's going to need to be in-person. So I think that optimal mix is going to vary a lot by specialty and really by condition.
What I hope we see if this goes really well, is that we see telehealth deployed where it's most needed. And so, as I said, that varies by condition and specialty but it most importantly, in some ways, varies by where do we have the most access problems that we need to dig in on and do better. So chronic disease is a big one. Patients with hypertension, pre-diabetes, substance use disorder, mental health issues, those are some of the places where real improvements in access can make a difference, as opposed to maybe some of the convenience care where telehealth early on got used for patients. Again, to go back to one of those corporate providers on the web that may have made it a little easier for them to get antibiotics they didn't need when they had the sniffles, a regular cold or something but those chronic disease areas are probably the most important.
Unger: Now, when we got ... At the beginning of the pandemic, like so many other things, the technology part is just one part of the issue. This is a whole system of things that had to come together to make that work and payment for telehealth services was a big potential roadblock then. Where do we stand currently on payment for telehealth services? And this concept of fair coverage, why is that so important?
Dr. Resneck: You make a good point. And the reason that we saw telehealth just take off early in the pandemic was really because the payment issue, at least temporarily, got fixed. What was standing in the way wasn't licensure, it wasn't technology, it was payment. And at the AMA, we believe very strongly that telemedicine services need to be covered and so we've supported parity laws in states around the country that require that coverage to be comparable to in-person services. We've got over 30 states now that have parity laws like that in place.
And we think the coverage really needs to, as I alluded to in one of your previous questions, shouldn't just be with select online providers, that patients really need to have access to their existing health care teams for telemedicine or to get new consults from a new physician in a health system that already knows them and in practices that work together. That payment has to be fair. That payment has to be reasonable. We are pushing for payment at the same rate for services that are comparable to something done in the office. For a physician in practice, whether you're in a small office or a mid-size group or a larger practice, all the sudden implementing telehealth as sort of a coordinated part of what you're offering your patients doesn't mean you can all the sudden stop paying rent on your building or doesn't mean you can stop having your staff of nurses and front desk staff, so we think that payment needs to be fair and reasonable and with parity.
Unger: And in some cases, I mean, just through my own personal experience and talking to other physicians, that's a lot of additive work, to be systematic about the approach to it and there's no less time that I'm spending with my physician in those discussions.
Dr. Resneck: No. A lot of us have discovered that it actually takes longer in some cases to do a telehealth visit than an in-person visit and particularly as our patients have learned to use the technology better, as we've learned to use the technology better but I think that's right.
Unger: Now, speaking of technology, not everybody has access to, of course, high speed connections and coverage for audio only visits was an important thing here. What's your view on that?
Dr. Resneck: Yeah, I was actually surprised by how many of my patients ... Now I live, as I said, in Northern California, a real technology hub, and yet I found I had plenty of patients who actually struggled with this. So you mentioned the audio, that really just means using the telephone to have a visit with your physician. And obviously telephones are not new and they're not typically our first choice for having an encounter between a physician and a patient but they're an important part of being able to deliver telehealth, especially to those patients who live in rural areas, marginalized patients who may not have the newest smartphone technology. A surprising number of patients live in areas with limited broadband access, so it's really important for health equity that ... Again, even though it's not typically the first choice, that we have this backup option. I know a lot of clinicians in my practice have been taking care of patients who literally may be farm workers who call in from a field for their health services, so that audio only component's really important.
Unger: Absolutely. Retaining telehealth services for Medicare beneficiaries has been a point of contention but one that the AMA obviously strongly believes should continue. What's the issue here and why might this put seniors in jeopardy of losing access to services they received throughout the pandemic?
Dr. Resneck: Well, we have some pretty old Medicare rules on the books and they date from 1997. And that doesn't sound like that long ago but from a health care technology standpoint, 1997 is actually a while back.
Unger: And that's the year I started to work at AOL, so I'm going to tell you that was a long time ago.
Dr. Resneck: That pretty well illustrates it. So at the end of the pandemic or the federally declared public health emergency from the pandemic, those 1997 rules, from when you were at AOL, are automatically going to snap back into place. And essentially what that means for Medicare patients is that unless they live in a rural area, their telehealth coverage will just end. It also means that even for those Medicare patients who can use telehealth because they live in a rural area, that they won't be able to use their own phones or the computers in their own homes anymore, that they actually have to go to a presenting site. So there are these very outdated Medicare rules that would snap back into place.
Unger: Well, obviously the AMA is paying close attention to this and acting. Can you talk about how the AMA is confronting the challenges here?
Dr. Resneck: So Congress has to act to prevent this from happening and to maintain this coverage so that it doesn't get pulled away from our Medicare patients or else we go back to that world I described where only a very small select number can use those telehealth services and have it covered under Medicare. So we have supported permanently fixing those, they're called originating site and geographic restrictions, on telehealth coverage for Medicare patients. There are a couple of bills out there that we've actively supported. One's called the Telehealth Modernization Act of 2021. The other one's called the Connect for Health Act. And we're also, this is not just about Medicare because the same threat exists in the private insurance marketplace, so we're working to ensure that commercial insurers also don't retreat to no longer covering telehealth.
Unger: Now, Dr. Resneck, you've been very vocal on this issue. You've testified in front of Congress on this. What should and can other physicians do to help this effort? It's so, so important to continue this right now.
Dr. Resneck: Well, I mentioned that Congress plays an important role here, so I think the first thing that all of us as physicians can do is to email or call our members of Congress or our senators to let them know how vital this coverage expansion has been for our patients, really share your stories, share your patients stories. If you feel comfortable doing so, even encouraging your patients who've benefited from telehealth to let their members of Congress know how important that's been. And if you happen not to have time to write those emails or make those phone calls, I would ask that at least just join the AMA, join your state and specialty medical societies, showing leadership through that membership helps to support these efforts to help us all support our physicians and our patients.
Unger: It is so important to speak with a unified voice. It's such an opportunity that arose from the pandemic and we can't take it for granted that that will continue. So, thank you Dr. Resneck for being here today and sharing this really important perspective.
We'll be back soon with another Moving Medicine video and podcast. Be sure to click subscribe on AMA's YouTube channel, Spotify, Apple or wherever you listen to your podcasts. You can find all of our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.