Telehealth and Telemedicine Before and After the COVID-19 Pandemic
From 2019 through 2020, spending on telehealth services increased massively, from $306 million to almost $3.7 billion. One leading cause for that spending increase was the COVID-19 pandemic, which began in early 2020.
The pandemic increased the awareness of and the use of telehealth services worldwide. However, the usefulness of telemedicine and telehealth have extended far beyond the passing global health crisis.
Read on to discover exactly what telemedicine is, its origins, uses, and benefits, as well as how COVID-19 affected the use of telehealth.
What is telehealth and telemedicine?
Telemedicine is the use of communication technologies, such as video chat, to allow healthcare providers to offer healthcare delivery remotely. Providers typically offer telehealth to save time for their staff and their patients, or when in-person visits aren’t possible due to geographical distance.
While some clinicians and healthcare providers may define telemedicine slightly differently from others, the general consensus is that the term telemedicine is not synonymous with the term telehealth.
Telehealth is a broader term that describes a remote health system beyond primary care. This may include training and education, administration, virtual outpatient visits, and follow-up consultations — not just remote patient visits.
The history of telehealth
Telehealth has no clearly-defined starting point, but its origins date back further than you may think. An 1879 Lancet article explains that doctors were among the first professionals required to have a telephone. The same article suggests that many patients may prefer a phone call from a clinician to in-person care during an office visit.
In 1905, a laboratory recorded the first “telecardiogram” and sent it via telephone wire to a hospital. And in the 1920s, clinicians aboard ships began to receive medical advice via radio. Audio-only telehealth services remain an important aspect of telemedicine today.
One famous early example of “virtual visits” occurred in the late 1950s and early ‘60s, when the Norfolk State Hospital and the Nebraska Psychiatric Institute used a CCTV link for mental health consultations. Today, with the ubiquity of smartphones and broadband internet, this healthcare delivery channel has now found its way into the mainstream.
Modern healthcare providers can offer telehealth visits in a number of different ways. In addition to using video platforms, they can consult and follow up with patients via phone calls or instant messaging, send referrals and prescriptions through apps and email, and allow patients to book appointments or check symptoms online. The applications of digital healthcare are potentially limitless.
Benefits of telehealth for providers and patients
Here are a few telehealth benefits for both patients and the providers who serve them.
Improves healthcare access
As pressure on healthcare systems continues to mount, telemedicine offers new hope of removing barriers to access to in-person care. At the same time, it reduces the need for in-person visits to health centers for diagnoses, taking some of the burden off providers.
This is particularly true in remote rural areas, where health centers are often only in more central areas. For instance, Alaska’s population is among the most rural in the U.S., and the state has been a model of telehealth service implementation and development for decades.
Reduces wait times
Telehealth reduces wait times in doctor’s offices and it can decrease the need for emergency room or urgent care visits.
Telehealth improves safety by reducing providers’ exposure to disease and lowering the likelihood of viral transmission in health centers.
Provides greater access to people with disabilities
Telemedicine visits can provide crucial access for people with disabilities or chronic conditions, for whom in-person visits may not be feasible due to reduced mobility. This approach is highly cost-effective, since the 100 million Americans living with chronic disease account for roughly 75% of healthcare spending.
Telehealth before COVID-19
For more than a decade, many in the industry touted telehealth and telemedicine as the next big thing in healthcare. However, despite these predictions, the utilization of telehealth evaluation and management services remained minimal.
Companies invested billions of dollars in technologies, apps, and websites offering virtual consultations with clinicians. The rationale that attracted investors was that tech-savvy millennials would naturally prefer a more convenient digital option to a real-life visit to the doctor’s office if given the choice.
Despite this wave of enthusiasm and investment, telemedicine failed to gain traction in the mainstream before the onset of COVID-19. In fact, research sponsored by Avizia — a telehealth provider — in 2017 found that 82% of Americans didn’t use telemedicine. The small percentage that did use these services was mostly restricted to rural areas or locations where access to care was difficult.
Reasons for lack of telemedicine adoption before COVID-19
Multiple factors contributed to the lack of adoption of telehealth services before the COVID-19 pandemic, including:
A lack of user awareness was a driver of the early low adoption rates for telehealth services. Many American consumers were still unaware they had the option to consult with a clinician via video, online platform, or phone call.
Early telemedicine services were often prohibitively expensive. For example, in 2018, one platform charged users $75 for a video consultation. Even patients who may have been aware of telemedicine apps worried they couldn’t afford the price, particularly if they were unsure whether their health insurance coverage would reimburse the cost.
According to a 2018 CNBC article, the terms “telemedicine” and “telehealth” may not have been easily understandable or appealing to many users. A doctor quoted in the article suggested the terms “virtual visit” or “video visit” may be preferable. Many providers opt to use “virtual care” when discussing services with users.
Insurance policy and coverage
The lack of uniform coverage policies across states and insurers curtailed the growth of telemedicine before COVID.
The Peterson-KFF Health System Tracker assessed a sample of health benefit claims from the IBM MarketScan Commercial Claims and Encounters Database. Among those enrolled in large-company health plans that provided outpatient services, 2.4% had used at least one telemedicine service in 2018 — a 0.8% increase from 2016. In line with this, the use of telemedicine by traditional Medicare and Medicaid and beneficiaries enrolled in managed care plans was increasing, but adoption still remained low.
Quality of care
Another common concern in the telehealth of years past was the quality of clinicians and the care they provided. Potential users worried that doctors willing to work with telehealth providers may lack the relevant experience to provide accurate diagnoses.
There may have been some merit to this misgiving, particularly with lower-quality suppliers. In a 2016 study led by Dr. Jack S. Resneck, a dermatologist at the University of California San Francisco, researchers posed as patients to assess the quality of telemedicine care from 16 different telehealth providers.
Their stated outcomes and measures were: “Choice of clinician, transparency of credentials, clinician location, demographic and medical data requested, diagnoses given, treatments recommended or prescribed, adverse effects discussed, care coordination.”
The results were not encouraging. The researchers received responses for 62 clinical interactions from 16 DTC telemedicine websites between Feb. 4 and March 11, 2016. None of them asked the researchers to provide any identification, nor did they raise concerns about the researchers’ use of fake names and photos.
In the study, 68% of these interactions, users had no choice of which clinician they saw, and 26% disclosed information about clinician licensure. Some providers used physicians based outside of the United States, who did not have licensure in California.
Only 23% took the name of patients’ existing primary care physicians or offered to send a record of the consultation to the patient’s usual doctor. 77% of users received a diagnosis. Although clinicians prescribed medications in 65% of cases, they only discussed adverse effects of these medications in 43% of cases, and only discussed pregnancy risks in 32% of cases.
Regardless of the diagnoses made, the treatments clinicians prescribed sometimes did not adhere to current guidelines. The researchers conducting the study found that the telehealth apps in their sample often failed to ask relevant questions regarding their patients’ medical histories. The result of this was multiple misdiagnoses.
Lack of suitable clinicians
While the aforementioned study is by no means indicative of the state of telehealth across the board, it suggests a clear link between the underperformance of early models and a lack of suitable clinicians.
Many MDs may have had concerns regarding liability, such as the worry that they may miss an important detail during a virtual consultation. And for some time, it was unclear whether telehealth clinicians would receive as much compensation for video visits as they would for in-person consultations.
Questions of reimbursement were still being resolved across different states before the COVID-19 pandemic brought about sweeping reforms to policy and regulations. These reforms meant beneficiaries could feel assured they would receive reimbursement, and that high-quality clinicians would receive fair payment for their services.
Telehealth increase during COVID-19
Telehealth adoption rose sharply during the COVID-19 pandemic,. As the availability of in-person care visits tightened due to new restrictions, telehealth’s usefulness was apparent. Many healthcare providers and hospitals instructed patients to use telehealth services or call their doctor’s office before visiting emergency rooms.
In response to the increasing demand for telehealth, we saw widespread changes to healthcare policies worldwide from governments and health insurers alike. The U.S. federal government relaxed restrictions on telehealth policy in the Medicare program, allowing Medicare beneficiaries from any location to access services from home. HHS also issued a waiver on the enforcement of HIPAA for telemedicine.
The results were game-changing. According to a study, NYU Langone Health reported a 683% increase in telemedicine visits and an 80% decrease in face-to-face visits between early March and mid-April of 2020. Chinese telemedicine provider JD Health reported a massive increase in the use of its telemedicine services since the outbreak of the COVID-19 pandemic.
Wisconsin-based Aurora Health partnered with a telemedicine provider and modified emergency department procedures so it could intake patients remotely, to facilitate faster COVID testing. Many providers also saw a sharp uptick in people accessing mental health services as a result of the so-called “shadow pandemic.”
Telehealth after COVID-19
In the wake of the pandemic, telemedicine has emerged as an indispensable tool for safe at-home monitoring after discharging patients from the hospital.
According to McKinsey insights, the use of telehealth services has stabilized at levels 38 times higher than before the pandemic. A 2022 research paper published in the journal Primary Care December 2022 states that telemedicine healthcare is set to remain a permanent and “integral part of medical care.”
Some of the changes in regulation ushered in during the pandemic are here to stay. Among these are the extension of the reimbursement for telehealth billing codes for the 2021 fee schedule by the Centers for Medicare & Medicaid Services.
Will telehealth continue in 2023?
Telehealth will almost certainly continue to serve an ever-larger segment of the healthcare system in 2023 and beyond.
According to a report from the AAMC, the national shortage of physicians is projected to reach numbers of up to 122,000 in the next ten years. Contributing factors include longer life expectancy leading to population aging, clinician retirement, and burnout.
The causes of burnout include staff shortages, lack of social, professional, and personal support systems, unmanageable workloads, and lack of flexibility and autonomy. As the demand for patient care increases, telehealth will increasingly be key to combating many of these issues.
Wheel for telehealth job opportunities
Telehealth is a much-sought boost to what we in the healthcare community care about the most — patient outcomes. Research published in the American Journal of Managed Care shows nearly all patients surveyed found the standard of both care and communication in telehealth to be as good as or better than with in-person visits.
Almost 25% of those surveyed actually reported that they found the standard of telehealth care to be better than it is with a traditional visit to the doctor’s office.
Where technology goes, healthcare soon follows, creating greater parity of care provision and improving quality of care for underserved communities.
The COVID-19 pandemic served as a catalyst for the rapid expansion of telehealth services across the globe. The resulting change in our conception and delivery of healthcare is vital and permanent for clinicians and patients alike.
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