Cynthia Peeters' stomach started hurting in mid-February as COVID-19 began dominating the news.
By April, the pain was overwhelming, but she was too anxious about the virus to go to the doctor. Her gastroenterologist did a cellphone video visit with her and suggested a diet change. When it got worse last month, Dr. Christopher Ramos did another video call and told Peeters to come in for a colonoscopy.
The diagnosis: Colon cancer, caught just in time.
"If telehealth was not available, I fear that we would have gotten to her diagnosis too late, and the cancer would have spread," said Dr. James Weber, CEO of Texas Digestive Disease Consultants, where Ramos works. "Telehealth access most certainly allowed us to take care of this patient and likely save her life."
After federal regulators said Medicare would cover such phone and video telehealth visits starting March 1, major insurers followed as COVID-19 started to shut down much of the U.S.
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Weber was happy to be reimbursed as the chain was losing money because patients were too scared to show up for screenings — and that was when his state was still spared from most of the virus' wrath.
Now, as Texas shuts back down amid soaring COVID-19 cases, Weber and doctors across the now-hardest-hit states face insurers that are starting to back away from the widely embraced approach to doctor appointments. They are scaling back telehealth to pre-COVID levels, which were limited, resuming out-of-pocket payments and using time consuming prior authorizations which can deter doctors.
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In early May, Blue Cross Blue Shield of Texas set the expiration date for telehealth expansion at May 31. It has moved the date three times since then, including twice in the last two weeks to an August 31 expiration date.
Most other insurers plan to reduce coverage of the visits in September even though Medicare and Medicaid is expected to cover them far more generously through the end of the year. Some of the expanded telehealth coverage was planned until the end of the "public health emergency," which is ill defined with no end in sight, said Weber.
He seldom used telehealth before COVID-19 because of all the restrictions.
Other insurers have also set and moved deadlines for when they will stop covering these remote visits and started charging co-payments and cost sharing again for many, Nearly all say they are continually reevaluating their coverage. Further complicating matters for doctors and patients are employer health plans that are exempt from the telehealth coverage expansion.
In Arizona, COVID-19 is now surging and hospital ICU units are nearly full, both with patients who need life-sustaining breathing treatment and non-COVID cases. Until some recent last-minute changes, insurers there were starting to drop telehealth coverage.
Dr. Paul Berggreen, a gastroenterologist who is president of Arizona Digestive Health, said his office staff must constantly check insurers’ websites to see current policies. He said policies on payment rates and co-payment waivers for telehealth seem to change week to week.
The information is vital because patients might refuse telehealth and instead request an office visit if they are not covered at comparable levels.
A 2017 study found the average cost of a telemedicine visit was $79, far less than $146 for a doctor’s office visit. However, the study may not reflect existing charges with doctors often billing the same rates for virtual and in-office visits. The amount a consumer pays out of pocket varies based on plan details such as co-pays, deductibles and cost-sharing requirements.
“A lot of my patients still don’t want to come in to my office,” Berggreen said. Older adults who might be more susceptible to COVID-19 complications in particular are staying home, he said. His practice is operating on reduced staff during the pandemic.
“Now is probably not the time to walk back any telehealth provisions,” he said. ”We don’t know when this thing is going to end. It seems like you would want to keep the telehealth channel open, particularly for the vulnerable populations.”
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Telehealth offers other benefits. Ramos is bilingual, which is a big plus whether patients visit in person or virtually in Fort Worth, Texas, where the population is more than 36% Hispanic.
Dr. Joy Cooper, an obstetrician and gynecologist in Oakland, California, co-founded the telehealth company Our Culture Care, to link black women to black doctors for telehealth appointments. She hopes to expand nationally and to connect patients of other races, ethnicities, gender and sexual identities to doctors more likely to understand them.
But payments remain a barrier, so if medical practices didn’t have telehealth set up before COVID, then it’s difficult to transition, she said.
"All I have heard is that the reimbursements for telehealth are small and cannot sustain a practice," said Cooper. "Some insurance companies are paying just $16 for a telephone visit, whereas some pay more for video visits."
Dr. Wyatt Decker, CEO of Optum Health, which is part of UnitedHealth Group, said there must be a "fair conversation" on appropriate payment rates for types of telemedicine. "The jury is still out."
While virtual visits are widely popular, they tend to be shorter and more focused than in-person care. Clinics need to pay for technology to support virtual care while often maintaining office and clinical staff to administer tests, physical exams or other types of in-person care.
Dr. Joe Kvedar is a professor of dermatology at Harvard Medical School and president of the American Telemedicine Association, which says Medicare should pay equal rates for virtual and in-person care.
Doctors are paid based on three factors: time spent on patients, complexity and expense. Even when working remotely, doctors need to spend time with patients and make decisions about their care, Kvedar said.
But he acknowledged it might be less expensive to provide care remotely, with patients taking their own blood pressure or temperature and, in some cases, doctors working from home.
Telehealth to 'go down the tubes'?
After a surge in March and April, virtual visits nationwide are beginning to decline, said Dr. Ateev Mehrotra, a Harvard Medical School associate professor of health care policy and medicine
A major reason: Doctors are frustrated.
He said doctors worry the costs of purchasing telehealth software, training staff and patients is an investment that could "go down the tubes" once the public heath emergency is over and policies revert to pre-COVID levels.
"A lot of plans, Medicaid and Medicare have made all these new regulations and payment policies to support the use of telemedicine in the pandemic," Mehrotra said. "What we’re hearing from providers is they submit the bills and they are getting rejected or getting a different dollar amount than they expected."
As insurers start to reverse policies that incentivized patients to use a safer way to do appointments during a pandemic, national insurers' policies and COVID-19's geographic patterns conflict.
BCBS of Texas said the insurer is monitoring the pandemic and will make benefits adjustments as needed. The insurer already covers telehealth services, including waiving out-of-pocket costs for COVID patients, according to a statement from parent company Health Care Service Corporation.
Aetna eliminated telehealth co-payments and other cost sharing early in the pandemic, but started charging them again June 4 based on plans and coverage, not states. Aetna said it's "continually evaluating our policy liberalizations based on the needs of our customers and the trends we see emerging within local markets."
Aetna has now dropped all out of pocket costs for mental health and addiction treatment visits, which Aetna CEO Karen Lynch said addresses COVID-19's "deadly undertow: a mental health crisis with significant impacts on all Americans."
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"We are living through unprecedented times of social distancing, isolation, economic uncertainty and racial injustice, which is causing a correlated increase in stress, anxiety and fear," she said. "We’re committed to helping our members get the care they need without the added worry of wondering how they will pay for it."
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Even though many large companies' self-insured plans did allow more generous coverage, Katherine Wetzel, spokeswoman for parent company CVS Health, says several that hired Aetna to administer their plans wanted the insurer to set a deadline for telehealth due to the expense.
Cigna currently plans to end its expanded coverage of telehealth coverage July 31. In a statement, Cigna said it "is committed to protecting customers, providers and communities against COVID-19, and we are actively monitoring the situation."
'Patients in greatest need'
For Peeters, who stopped driving due to COVID-19-induced anxiety, telehealth meant she didn't have to ask family members or her working husband to drive her to the doctor.
"After COVID, (telehealth) should still be around," said Peeters. "There's too much goodness — it resolved me finding a ride to the doctor’s appointment and makes doctors more available to people in the community who can’t drive themselves."
Weber couldn't agree more. He has many elderly and morbidly obese patients for whom travel is difficult.
"I really do think, 'why can’t we have this service for people who are elderly so they don't have to beg someone from church to give them a ride?" he said. "What my anxiety is, I need to provide services for our patients in greatest need and telehealth provides that opportunity. And then, to threaten to pull that away?"
Some say there's no going back, however. When it comes to telehealth, "now that we’ve experienced this, I have no question of wanting to retain it," said Heather Gates, CEO of Community Health Resources, a chain of mental health and addiction treatment and service centers in Connecticut.
"For so many people, it's been a life saver, " she added.
O'Donnell can be reached on social media as @JayneODonnell. Email her at firstname.lastname@example.org. Alltucker is on Twitter as @Kalltucker and email at email@example.com