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Friday, Jul 19, 2024
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A Different Era for Telehealth

SAN DIEGO COUNTY – Among countless other changes it brought on, COVID-19 altered the landscape in healthcare needs and healthcare access for patients and providers.

The pandemic, coupled with an ever-increasing reliance on technology in general, has made telemedicine and telehealth services – medical consultations and administrative processes that connect people through digital technology – a far more popular choice for healthcare needs than ever before.

According to Statista, in 2024, more than 116 million people were using online methods for doctor consultations, up from about 57 million in 2019.

Telehealth, and telemedicine under its umbrella, reached some of their highest levels after the start of the COVID pandemic in March 2020. The National Center for Biotechnology Information reports that telehealth services made up 0.2% of all outpatient evaluation and management services in February 2020 and reached a peak of 50.7% by April 2020.

The NCBI said use dropped after that initial surge and ranged from 13.5% to 18.3% from July 2020 through December 2020.

A 2022 survey by Rock Health in collaboration with the Stanford Center of Digital Health reported that 80% of respondents said they had accessed care through telemedicine at some point in their lives, up from 72% in 2021.

Rock Health also reported that there were noticeable increases from 2021 to 2022 in telemedicine use among groups considered underserved, including those 55 years of age and older, those living in rural areas, people lacking health insurance, women, Hispanic community members, and those who are LGBTQ+ and non-binary.

While there has been some level of volatility in the telehealth industry – UnitedHealth announced in April that it was shutting down its Optum Virtual Care; Teledoc Health is cutting jobs; Let’s Talk Interactive announced it had filed for Chapter 11 in September; Kaiser Permanente reported a decline in virtual visits since 2021 in a February 2024 report – telehealth services continue to be a big part of what is offered by Federally Qualified Health Centers (FQHC).

FQHCs are community-based organizations that provide comprehensive primary care and preventive services to individuals of all ages, regardless of their ability to pay or their health insurance status.

Hospital Settings vs. FQHQs

Hospital settings and FQHCs are vastly different environments, and so the types of telehealth each engage in is also different, says Art Mejia, vice president of Clinic Operations at San Ysidro Health.

San Ysidro Health is an FQHC originally established along the U.S.-Mexico border in 1969.

Founded by a group of women seeking medical services for their children, San Ysidro Health now provides innovative care through an integrated network of 50 program sites across San Diego County.

Art Mejia
VP Clinic Operations
San Ysidro Health

“We could see hospitals using telemedicine to engage in specialty consults in support of in-patient or ER care, but the acuity of the patient makes that experience somewhat different,” Mejia said. “In the FQHC environment, we are dealing with episodic care, where the patients immediate need, be it a sudden onset of a minor condition or management of an ongoing condition, is what is primarily addressed.”

Mejia said that because FQHC care is generally much less acute than that of someone who is hospitalized, telehealth works well for San Ysidro Health, offering its providers “yet another way to interact directly with patients, asking questions, reviewing results and discussing next steps in their plan of care.”

San Ysidro Health currently offers telemedicine in all its primary care, medical specialty and behavioral health service lines. The propensity of telehealth to in-person can vary based on the service line, but overall, in-person visits still comprise the vast majority of its appointment offerings, Mejia said.

Hospitals sometimes do telehealth follow up visits after a procedure, something which improves outcomes, says TrueCare Chief Medical Officer and Chief Operations Officer Dr. Marie Russell.

Founded in 1971, TrueCare is a nonprofit community health center serving North San Diego and South Riverside counties and offers telehealth visits in primary care and behavioral health.

Dr. Russell said also differently from hospital systems, FQHCs also place an emphasis on addressing equity.

Dr. Marie Russell
Chief Medical Officer, Chief Operations Officer
TrueCare

“Some patients may not have access to quality internet or transportation,” Dr. Russell said.

“Telehealth can be great for patients in rural communities or with transportation barriers whereas those without internet access can come for in person visits or meet with specialists through telehealth visits at our facilities.”

Dr. Russell said there is no turning back to pre-pandemic times regarding the use of telehealth.

“We must continue designing the optimal system for the future,” she said. “The expansion of telehealth was a significant dynamic during COVID, emphasizing the importance of developing comprehensive guidelines and infrastructure. We must find the right way to move forward with telehealth that is sustainable and provides quality outcomes for patients.”

Studies on telemedicine suggest that it can benefit both patients and health care providers, and bring outcomes that are not inferior to in-person care as well as provide cost-saving implications.

Alejandro Nunez, chief growth officer at Neighborhood Healthcare, said that FQHCs tend to focus on providing more comprehensive, whole-person care, so telehealth takes on a preventative as well as urgent care role with them vs. hospital settings.

Alejandro Nunez
Chief Growth Officer
Neighborhood Healthcare

Neighborhood Healthcare, another FQHC founded in 1969, provides a range of medical, dental and behavioral health services along with programs and resources for communities in San Diego and Riverside counties.

Nunez said that Neighborhood Healthcare sees telehealth as a great value in its behavioral health services, in addition to providing patients’ access to urgent care needs.

“As we continue to see the need to strengthen our telehealth services, we are committed to expanding our reach and services,” he said.

Changes After Apex of COVID

Mejia said he believes that the volatility in the post-COVID era “really comes from the reality that not all care can and should be done through telemedicine.”

Mejia said that some examinations and evaluations are still best suited for a physical office visit and an in-person discussion between a patient and their provider.

“One could easily argue that the increases in telehealth offerings during the COVID-era came in response to the need for care during a period where in-person care was deemed risky and therefore severely limited,” he said. “The industry extended itself rapidly and integrated telemedicine because patients still needed to have their chronic conditions managed, their medications provided and access for other non-COVID-related medical services available.”

With COVID now less of a threat four years after it hit the United States, most FQHCs are looking into how to best keep telehealth a part of their offerings.

Mejia said behavioral health is an area where the shift to more telehealth has been necessary as a direct result of the pandemic.

With considerable increases in demand for behavioral health, San Ysidro Health pivoted to hybrid models that help increase access and meet the expectations of its behavioral health professional workforce.

“Most professionals today are looking for a balance between remote and in-person care and expect their employers to offer this as an alternative,” Mejia said.
Nunez said that telehealth is very much an integral part of Neighborhood Healthcare, and the service continues to receive high demand among its patients.

“Since last year, we have grown our ‘On-Demand’ program, which serves as a virtual urgent care, allowing sick patients to be seen on the same day,” Nunez said. “All these visits are conducted via video. Both daytime and after-hours evening visits are available to break through barriers on access due to time and transportation issues some of our patients may face.”

Nunez said the monthly average telehealth visits for Neighborhood Healthcare are about 6,200, with 74,544 completed visits in the past 12 months. He said it is an increase of about 2,000 visits compared to last year.

Nunez said he doesn’t foresee any cutbacks and feels that the telehealth service will only continue in its importance as Neighborhood Healthcare operations expand to other parts of Riverside and San Diego counties.

“The need to offer quality, compassionate, whole-person care to individuals and families, regardless of their situation or circumstances, remains high,” he said. “Continuing to support access to the care remains the biggest need. We see that as paramount in this service.”

Evolving Environment Post-Pandemic

Telehealth continues to be an evolving environment, one that continues normalizing in the post-pandemic era, Mejia said.

“On one hand, it has real benefits when you consider patient convenience and the ability to have patients and doctors interact in an expedited way,” Mejia said. “There is value here to both parties, particularly if you are dealing with simple or limited conditions or concerns.

However, working through more complex situations, whether it be multiple medication questions, chief complaints — reasons for seeking care — or the acuity of a particular condition can make the telehealth visit somewhat ineffective and likely not the correct format to provide extensive care.”

Dr. Russell said that identifying the right candidates for telehealth vs. those who would benefit more from in-person care is key.

“Our behavioral health team has the highest rate of telehealth patients, and we expect this trend to continue,” Dr. Russell said. “However, we have also seen a rise in the number of in-person visits as more patients are seeking face-to-face interaction post-pandemic. We continuously monitor the demand for telehealth versus in-person care to ensure we are effectively meeting the needs of the community we serve.”

Dr. Russell said that during the pandemic, TrueCare saw a dramatic increase in telehealth visits out of necessity, but she said that “this method of care may not be ideal for every patient… currently, we are witnessing an effort to right size.”

Dr. Russell said clinics and health centers need established guidelines from medical professionals to ensure each patient receives the appropriate form of care for their specific needs.

“For example, procedure-related care cannot be adequately provided through telehealth alone, whereas many behavioral health patients, particularly those with social anxiety, greatly benefit from telehealth services,” Dr. Russell said.

Dr. Russell said that TrueCare will continue to offer telehealth to meet the diverse needs of the communities it serves.

“Our clinicians assess each case individually, considering the different variables that may affect whether a patient should be treated through telehealth or in-person,” she said. “We cannot pull back on flexibilities that many patients have come to rely on. Telehealth has become an essential tool that allows patients access to healthcare who otherwise may face barriers to receiving care.”

Government’s Involvement

Continued concern about Congress making permanent the COVID-era changes to Medicare billing for telehealth, such as the CONNECT Act and the Telehealth Modernization Act, are on the minds of many in the field.

The U.S. Department of Health and Human Services took a range of administrative steps to expedite the adoption and awareness of telehealth during COVID-19. Some telehealth flexibilities have been made permanent while others are temporary.

For Medicare beneficiaries, many of the telehealth flexibility waivers were extended, including geographic and originating site restrictions, so that Medicare patients can continue to use telehealth services from their home and allowing audio-only telehealth services through Dec. 31, 2024.

Permanent Medicare changes include FQHCs and Rural Health Clinics being able to serve as a distant site provider for behavioral/mental telehealth services.

Other changes: Medicare patients are able to receive telehealth services for behavioral/mental health care in their home; there are no geographic restrictions for originating site for behavioral/mental telehealth services; behavioral/mental telehealth services can be delivered using audio-only communication platforms; and Rural Emergency Hospitals are eligible originating sites for telehealth.

Temporary Medicare changes that run through Dec. 31, include in-person visits within six months of an initial behavioral/mental telehealth service, and annually thereafter, is not required; telehealth services can be provided by all eligible Medicare providers.

In December 2022, Rep. Mike Thompson (D-Calif.) was one of several government officials who helped secure the inclusion of provisions from the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act to the 2023 fiscal year government funding bill that temporarily extended access to expanded telehealth services.

Those provisions are set to expire in 2025, which concerns Mejia and others.

“It is incredibly important to see Congress make the telehealth environment a permanent one,” he said. “It is becoming more and more unthinkable to imagine a care environment where telehealth doesn’t have a place or a future. With the increasing number of seniors reaching Medicare-age and the shortfall of medical school graduates, the demand for care is going to become even greater, and the need for patient options to handle minor acute situations will be critical.”

Had Congress not extended the availability of telehealth, “we would be working actively today to adjust our care models in the coming months and brace for the impact of the major change,” Mejia said.

Without the extension, patient access would likely decrease and patient compliance with appointments would likely suffer. The extra time given will allow San Ysidro Health to continue down the path it has been working on since the pandemic first hit, Mejia said.

“Having the security of knowing that telehealth has a permanency also allows us to continue making investments into the technology that can help further improve that patient and provider telehealth experience,” he said. “What must also be considered is the convenience factor that patients demand and will continue to demand. It is vital that healthcare providers offer services in a manner that meets the lifestyle and needs of its patients.”

Mejia said telehealth will continue to be available to FQHCs for some additional time. Health Resources and Services Administration formally approved telehealth as a billable visit.

“San Ysidro Health believes that in the future we will have more criteria outlining the use of telehealth visits based on specialty,” Mejia said. Our goal today is to make sure we continue to improve our telehealth offerings, We want to make sure the amount of telehealth we offer and the effectiveness of those visits are in alignment with our quality and patient satisfaction goals and that the type of care we provide through telehealth is always safe and appropriate.”

Other Issues in Telehealth

Dr. Russell said another place where regulators need to step in is to assure appropriate reimbursement.

“As our healthcare system increasingly focuses on value-based care, additional modalities, such as case management via telehealth is going to become even more important,” she said. “Telehealth follow-ups can often be conducted by an RN, pharmacist, case manager or patient advocate, freeing the physicians to serve more patients. If during the follow-up it is determined that there is a need for further intervention, then an appointment with the clinician can be arranged.”

Dr. Russell said that other improvements and changes to telehealth that would make it better for patients and providers include clear clinical guidelines, driven by the medical community.

“(Clear clinical guidelines) need to be implemented along with addressing the infrastructure for telehealth,” she said. “Factors such as access to transportation, managing childcare, and availability of smartphones and internet in rural communities must be considered to ensure equity in healthcare access.”

Dr. Russell said that the United States has developed infrastructure and systems that can help reduce those inequities, but expressed concern that legislators often overlook some of the barriers to care.

“This is not a small issue, as one third of the state is on MediCal and 70% percent of TrueCare patients are on MediCal,” she said.

San Ysidro Health
FOUNDED: 1969
CEO: Kevin Mattson
HEADQUARTERS: San Ysidro
BUSINESS: Nonprofit healthcare
REVENUE: $426 million
EMPLOYEES: 3,000
WEBSITE: syhealth.org
CONTACT: 619-253-0140
SOCIAL IMPACT: San Ysidro Health’s mission is to improve health and well-being of communities with a focus on equitable access for all.
NOTABLE: San Ysidro Health was originally established by a group of mothers seeking medical services for their children.

Neighborhood Healthcare
FOUNDED: 1969
CEO: Rakesh Patel
HEADQUARTERS: Escondido
BUSINESS: Nonprofit healthcare
REVENUE: $189 million
EMPLOYEES: 3,000+
WEBSITE: nhcare.org
CONTACT: 833-867-4642
SOCIAL IMPACT: Neighborhood Healthcare and Feeding San Diego work together to help end hunger. Free produce, dried goods and frozen foods are distributed once a month all year long.
NOTABLE: Among Neighborhood Healthcare services are dental care, chiropractic, podiatry, acupuncture and tattoo removal

TrueCare
FOUNDED: 1971
CEO: Michelle D. Gonzalez
HEADQUARTERS: San Marcos
BUSINESS: Nonprofit healthcare
OPERATIONAL BUDGET: $118 million anticipated
EMPLOYEES: 780
WEBSITE: truecare.org
CONTACT: 760-736-6767
SOCIAL IMPACT: TrueCare offers a sliding scale of low to no-cost services for self-paying patients who qualify along with flexible payment options.
NOTABLE: The San Diego Business Journal honored two TrueCare leaders as 2024 Women of In-fluence: 50 over 50 – Tracy Elmer, Chief Innovation Officer, and Dr. Maria Sebiane, a Clinical Lead at TrueCare San Marcos Pediatrics.

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