Outpatient Practice

Telemedicine In The Post-COVID Era

During the COVID pandemic, most physicians used telemedicine to some extent in their outpatient practices. Many of us even used it for inpatient care. Now that the worst of the pandemic is behind us, many regulatory agencies are adopting restrictions on when telemedicine can and cannot be used. There are as many opinions about telemedicine as there are doctors in the U.S. Some practitioners are strong adopters and prefer telemedicine over in-person encounters. Other practitioners dislike telemedicine and will not use it in any situation. Most of us fall somewhere in-between… telemedicine encounters are sometimes the best option and in-person encounters are sometimes the best option.

What the DEA says

Last week, the Drug Enforcement Agency (DEA) proposed new regulations about the use of telemedicine for prescribing controlled medications. During the COVID pandemic, these rules were relaxed in order to ensure that patients could get needed prescription medications without risking COVID exposure during trips to physician offices. The new rules are for the initial prescription of schedule III-V drugs and for the initial prescription of buprenorphine for opioid-use disorder. The regulation states that for the initial prescription of these drugs, a 30-day supply can be prescribed by telemedicine but the patient must have an in-person visit with the prescribing physician within that initial 30-day period. After that first in-person visit, the medications can then be prescribed by telemedicine without a requirement for additional in-person physician visits. A caveat is that if the patient has previously had an in-person visit with that practitioner at anytime in the past, they are not required to have an additional in-person visit after initial prescription of these drugs by telemedicine. In other words, what the regulation says is that to prescribe more than 30 days of schedule III-V drugs or buprenorphine, a practitioner must have at least one in-person visit with a physical examination before or shortly after the prescription. There has been a lot of misinformation that the regulation requires an in-person visit to the prescribing practitioner every 30 days and this is not true. As long as the practitioner has seen the patient in the office one time, the practitioner can prescribe these drugs by telemedicine for as many months as necessary.

Schedule III drugs include codeine, anabolic steroids, ketamine, and testosterone. Schedule IV drugs include Xanax, Valium, Ativan, Ambien, and Tramadol. Schedule V drugs include Lomotil and Lyrica.

Buprenorphine is used to treat opioid-use disorders. It is often prescribed in combination with naloxone; the combination drug is called Suboxone. Although buprenorphine is itself an opioid, Suboxone has relatively little euphoric effect and is used to help prevent opioid withdrawal. The ability to prescribe buprenorphine by telemedicine allows physicians who treat substance abuse disorders to get patients started on treatment immediately. This can be a great advantage in opioid-dependent patients who have transportation barriers or who seek treatment for their addiction on weekends or evenings. Telemedicine for buprenorphine prescription is likely underutilized. The DEA reported that during the COVID pandemic in 2021, there were a total of 1,929,151 Medicare Part D buprenorphine prescriptions associated with 1,332,353 Medicare beneficiaries. Of these prescriptions, 11,956 were prescribed during telemedicine. In other words, only 0.43% of all buprenorphine prescriptions were made by telemedicine.

Schedule II drugs have different DEA regulations. These drugs include opioids, Ritalin, and Adderall. Schedule II drugs cannot be initially prescribed during a telemedicine encounter and initial prescriptions for these medications must be made during an in-person encounter. The new DEA regulations only address the initial prescription for schedule II drugs. These regulations do not prohibit using telemedicine for schedule II refills, as long as there has been at least one previous in-person visit.

What the state medical boards say

The DEA regulations address what controlled drugs can legally be prescribed by telemedicine. Each state’s medical board issues additional regulations that dictate when telemedicine can and cannot be performed. Because these regulations vary from one state to another, physicians need to be familiar with the specific regulations in the state(s) that they are licensed in.

Telemedicine encounters are legally considered to occur where the patient is located and not where the doctor is located. State medical boards have different rules about the legalities of telemedicine when a patient is located in a different state than the doctor. In most situations, a doctor must have a state medical license in every state that he/she practices in. In other words, the doctor must be licensed in every state that their patients are in during telemedicine encounters. The interstate medical licensure compact makes cross-state licensing easier but does not eliminate the requirement for multiple state medical licenses when patients are in a different state than their doctor.

What CMS say

The DEA and the state medical boards dictate what can be legally prescribed during telemedicine and when telemedicine is allowed. CMS dictates when Medicare will reimburse physicians for telemedicine encounters. During the COVID pandemic, CMS relaxed rules about the use of telemedicine for Medicare patients as part of the public health emergency declaration. The public health emergency is set to expire on May 11, 2023. However, when Congress passed the Consolidated Appropriations Act of 2023, they extended some of the telemedicine flexibilities through the end of calendar year 2023. So, for the rest of this year, physicians can continue to perform telemedicine visits with Medicare patients and get paid. Telephone calls are not considered to be telemedicine encounters by CMS so telemedicine encounters must include both audio and video communication. Each commercial insurance company makes their own rules about reimbursement of physician services but they generally follow Medicare’s rules.

What malpractice insurance companies say

For telemedicine to be viable, it must not only be legally allowed and reimbursable, but it must also be covered by the physician’s medical malpractice insurance. Prior to the COVID pandemic, not every malpractice insurance carrier embraced telemedicine and some did not even offer telemedicine coverage. Most malpractice carriers now either include telemedicine in the regular malpractice insurance policy or offer it as an add-on to the standard policy. With the pandemic winding down, it is important for every physician who uses telemedicine to be sure that their policy covers telemedicine after the public health emergency expires in May 2023.

Because telemedicine encounters legally occur in the state that the patient is physically present in, if the physician does perform inter-state telemedicine, they not only need a license in that second state but they also need malpractice coverage in that state. For example, if a physician has an office in Ohio but wants to perform telemedicine encounters for patients who spend the winter in Florida, that physician needs an Ohio and a Florida medical license and also needs Ohio and Florida malpractice coverage. There are substantial differences in the cost of malpractice premiums in different states with Florida being one of the most expensive. So, in this example, unless the physician has a very large number of patients in Florida, the additional cost of malpractice coverage in Florida to be able to perform telemedicine visits may be too great to justify doing telemedicine for patients in Florida.

The use of telemedicine during COVID

A survey by the American Medical Association published in 2022 found that 85% of U.S. physicians were using telemedicine during the COVID pandemic. 60% of physicians reported that they believed that telemedicine enabled them to provide high quality medical care. 54% of physicians reported that telemedicine improved their job satisfaction. 44% of physicians believed that telemedicine decreased the cost of care.

The National Health Interview Survey during the COVID pandemic in 2021 reported that 37% of American adults used telemedicine the the preceding twelve months. The highest utilization was in Whites (39%) and American Indian/Native Alaskans (41%). The lowest utilization was in Hispanics, Black, and Asians (all 33%). Women (42%) used telemedicine more frequently than men (32%). Telemedicine use was also higher in Americans who were older, had higher incomes, and had higher educational attainment. Geography also makes a difference: 40% of adults living in large metropolitan regions used telemedicine versus 28% in rural areas. A survey of 307,000 patients by the Mayo Clinic in 2022 found that patients were equally satisfied with telemedicine visits as they were with in-person visits.

There is a learning curve to doing telemedicine – both on the part of the physician and on the part of the patient. Many patients struggled doing their first telemedicine encounters. But usually after a couple of encounters, they got the hang of using their computer, tablet, or phone to do telemedicine and their proficiency improved. It became clear that providing patients with instructions about how to do telemedicine before the encounter was essential. During the first months of using telemedicine, I had patients try to do their encounters while shopping at the grocery store and even while driving their car (!!!!).

Where should telemedicine go from here?

From the various surveys of telemedicine during COVID, it is clear that telemedicine is preferred by some patients and not others. It is also preferred by some physicians and not others. Intuitively, many physicians would have predicted that telemedicine would be more enthusiastically adopted by rural patients than urban patients because of the geographic distances that must be surmounted to get to the physician office. Intuitively, many physicians would have also predicted that telemedicine would be more enthusiastically adopted by younger patients than older patients because of familiarity with technology. It turns out that just the opposite was true. In my own practice, I had many patients who lacked internet access (or had too low of bandwidth) in their homes and lived in areas with marginal cell phone service – reception was often good enough to do audio phone calls but not good enough to do effective video. These patients were simply unable to do telemedicine encounters.

Regardless of patient preferences, there are some specialties that lend themselves better than others for telemedicine. For example, a cardiologist who specializes in valvular heart disease needs to be able to do an in-person physical examination of the heart with most patient encounters. On the other hand, a cardiologist who specializes in lipid management does not have the same need to do a regular in-person physical examinations. Each physician needs to decide for himself or herself about how necessary a regular physical exam is for their clinical practice. In addition to physical examinations, some medical conditions require regular in-office testing that is typically done at the same time as their physician office visit. EKGs, chest X-rays, hemoglobin A-1Cs, and urine drug screens are examples. Telemedicine is less useful for patients with these conditions.

So, when will telemedicine be most useful in the post-COVID era?

  • When patients prefer telemedicine over in-person encounters
  • When physical examination adds relatively little value to the encounter
  • When in-office procedures are not a usual part of the physician office visit
  • When patients are physically located in the same state as the physician (or in a state in which the physician has a medical license and malpractice coverage)
  • When patients have sufficient skill, technology, and internet bandwidth to effectively complete telemedicine encounters
  • For follow-up encounters for prescription of controlled substances after an initial in-person visit

In addition, telemedicine requires that the physician be capable and comfortable with telemedicine. This includes having HIPAA-compliant audiovisual communication software that can interface with their electronic medical record. It also includes having office staff that are equally capable and comfortable with telemedicine.

What is the best way to schedule telemedicine encounters?

There are several ways to incorporate telemedicine encounters into the outpatient schedule. The three most common are dedicated telemedicine schedules, interspersed telemedicine schedules, and blended schedules.

  • Dedicated telemedicine schedules. This allows a physician to see only telemedicine patients on a given day or half-day. For example, a physician might do in-person office visits 4 days a week and then on the 5th day do telemedicine encounters only.
    • Pros: The advantage of scheduling an entire day or half-day of telemedicine encounters is that the physician can use less office space and less office staff. There is no need for exam rooms, a parking lot, or a waiting room. Patients can often be registered in batch the day of or the day before the telemedicine encounter thus eliminating the need for dedicated registration staff throughout the entire workday. Moreover, the registration staff can often work from home, which facilitates part-time work and can improve job satisfaction for staff who would otherwise have a long commute to the office. Usually, a single medical assistant or nurse can prep the encounter by updating medical history information in the electronic medical record and also perform check-out tasks including scheduling tests or procedures ordered by the physician. This is also a great option when a physician is required to be physically present for supervision purposes; for example, during pulmonary rehabilitation, during hyperbaric oxygen treatments, or during cardiac stress testing. These procedures are often performed in areas that are not equipped for in-person outpatient office visits but that can be used for telemedicine.
    • Cons: There has to be a critical mass of patients to set up a telemedicine-only schedule. Because the nurse does not need to obtain vital signs and the doctor does not need to perform a physical exam, the encounters can be shorter than a regular in-person office visit. This can result in more patients seen in a full-day or half-day schedule. If the physician does not have a sufficient number of patients who are able and willing to do telemedicine, then there may not be enough patients to fill an entire day’s schedule. There also may be limited ability to accommodate patients needing urgent same-day in-person office visits for acute medical conditions.
  • Interspersed telemedicine schedules. In this model, the physician has some in-person office visits alternating with telemedicine visits during the same day.
    • Pros: This model gives flexibility. Patients who unexpectedly cannot arrange transportation to the office can be converted to telemedicine visits to avoid cancelations. This model is also preferable when the physician has an insufficient number of telemedicine patients to fill an entire day or half-day schedule. By carefully scheduling telemedicine encounters in-between in-person encounters, a physician who previously needed 4 exam rooms for optimal operational efficiency might be able to get by with only 2 or 3 exam rooms, thus reducing overhead expenses. Patients frequently call the office for medical advice or because of acute illnesses. Many physicians provide a great deal of medical care over the phone and get paid little or nothing for those patient calls. Having the ability of the office staff to screen patient calls and convert those that can appropriately be telemedicine encounters can improve  revenue and also improve patient care by allowing the physician to see as well as hear the patient.
    • Cons: There is less efficiency savings since the physician has to maintain a fully staffed office and a sufficient number of exam rooms, just as they would for a full schedule of in-person office visits.
  • Blended schedules. In this model, the physician has some days with dedicated telemedicine-only schedules. On other days, there is an interspersed schedule with some in-person and some telemedicine visits.
    • Pros: This model has the advantages of both types of schedules. The physician does not need the parking, exam rooms, or office staff on days that there is a telemedicine-only schedule thus reducing overhead expenses. On the other hand, in-person visits can be converted to telemedicine encounters at the last minute when patients are unable to arrange transportation or in event of bad weather, thus reducing cancelation rates. Patient sick calls can be converted into billable telemedicine encounters.
    • Cons: There has to be a sufficient number of patients to warrant a full day or half-day dedicated exclusively to telemedicine.

The future of telemedicine is what we make it

The COVID pandemic gave patients and doctors a taste of telemedicine. However, the U.S. healthcare system had to adopt telemedicine quite quickly and with rapid adoption there was inevitably problems. Many medical practices went through several telemedicine software systems trying to find the best system for their particular practice. We are now entering a time when we can more thoughtfully select telemedicine software and we can plan for the efficient use of telemedicine in the future.

Most physicians will likely continue to utilize telemedicine as a component of their outpatient practice. Telemedicine fills a needed practice efficiency gap by reducing last minute cancelation rates and by reducing barriers to healthcare for those patients who are immobile or live great distances from their doctor. When possible, physician practices should adopt blended schedules in order to reduce overhead expenses and convert phone calls into billable telemedicine encounters while still maintaining the capability of doing in-person visits when medically appropriate.

But we also need to know if telemedicine will continue to be reimbursed by Medicare and commercial insurance companies. Since the current telemedicine reimbursement rules expire at the end of 2023, we need to advocate for CMS to make telemedicine reimbursement permanent. Otherwise, it is difficult to justify purchasing expensive telemedicine videoconferencing software and camera systems. It is also risky to schedule telemedicine encounters beyond December 31, 2023 since we do not yet know if these encounters will be reimbursable in 2024.

Telemedicine cannot and should not replace all in-person office visits. But neither should we abandon telemedicine completely as the COVID pandemic (hopefully) fades away.

March 3, 2023

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital