Do we still care about COVID-19?

The other day, as I struggled to take in all the news, I found myself asking this question. And honestly I didn’t know the answer.

This Spring, when COVID suddenly seemed to have the world by the throat, it was almost all we thought about. But much has happened since then beyond the quarantine and social distancing and work and school and life from home. First the public outcry over police brutality across the country, and then lightning strikes that lit up the West. Each of these crises has been years in the making: crippling underinvestment in public health, enduring racial inequities, and a hotter, drier West due to climate change.

Together, this trio of COVID, inequality, and deteriorating environmental conditions has us down, and they feed on each other in pernicious ways. African Americans and Latinos experience dramatically higher mortality rates from COVID than whites; public health authorities and health care providers struggle to respond to traumatic events on multiple fronts; the effects of smoke exposure resemble and potentially mask COVID symptoms, and there are no longer massive shelters for people fleeing fires (no hugging, no dining-halls, etc.).

While each of these crises is a wake-up call, and they are more so together, where do we focus our attention? For many, the answer depends on the ease of accessing meaningful information in the moment. Everyone I know here in California, including my kids, has been checking air quality index numbers online every day for much of the past month. The AQI number for our current location, for our parent’s town, for nearby cities. It’s all so simple and user-friendly, a single number. In the spring, many of us monitored the COVID numbers, looking at the Johns Hopkins COVID Dashboard and state- and county-level figures. But these are more complicated than a single air quality number. 

Moreover, many Americans have rightly lost faith in the validity of the COVID figures they are presented with given our industry’s failure to accurately monitor COVID cases. Shame on us. Some important progress has been made, but with millions of rapid antigen tests now being distributed with no way to collect and synthesize many of the results, we will still be flying blind.* This lack of trusted data makes it very difficult for policy-makers to weigh risks and opportunities for us as a society, for local public health authorities to effectively intervene, and for us as individuals to make informed decisions about our own actions.

Staring at the dark orange sky over my house in the Bay Area a week and a half ago, COVID-19 was far from my mind. But I still wore a mask every time I left the house. Now that blue skies are back, normal life is resuming and we can breathe deeply. Normal life in a COVID world, that is, for a well-off white man like me. Many people seem willing to make the following level of trade-offs: masks, hand sanitizer, limited social gatherings outside, no baseball games, no kids’ sports (this is changing), school from home (now with pods), no bars or clubs, limited carpooling, no international flights but some travel across state lines, occasionally sit outside at a restaurant… and the corresponding number of sick, the number of deaths, do not impact most of us personally. We are not experiencing a 2% death rate among our circle of family and friends (of the 300 people closest to you have 6 died?). We are not seeing Italy or New York horror scenes in our hospitals. So we have come to accept this unprecedented but seemingly manageable level of trade-offs as it stands today, even as we mingle with others who are taking far fewer precautions. Based on our actions, we sort-of care about containing COVID-19.

Without a change in approach conditions are likely to deteriorate as we head into winter, exacerbating the long-term impacts of social distancing on our mental health and economy. And the hope for a vaccine – which I desperately share – increasingly acts as a seductive moral hazard in this environment: the more we believe that a vaccine will save us soon, the less accountability we feel to limit the spread of COVID today. As Dr. Fauci and others have begun to warn us, we will likely be living in quarantine conditions well into 2021. Even when we have a vaccine, it will not deliver us in a stroke of scientific brilliance. Rather, vaccinating the country, let alone the world, will be a slow and patchwork and messy public health mobilization, with inequitable access and imperfect information. So expecting someone else to save us – like big pharma – is not a viable strategy for how to live today.

But in a few weeks there will be an event that gives us as individuals a direct opportunity to participate in the collective will, to shape how we respond as a country to the trade-offs presented by COVID and to the momentous events of 2020 more generally. Please search your soul, talk to your friends and family, and review the numbers. Then cast your vote.

 

*Modern Healthcare. Lack of antigen test reporting leaves country ‘blind to the pandemic.’ September 16, 2020. As this article explains, rapid antigen tests produce results in minutes on-the-spot and outside of the nation’s lab networks. Many organizations administering these tests do not have an easy way to send results to public health authorities. This contrasts with PCR tests which are sent to labs that return results to ordering providers and public health databases in a matter of days.

How the COVID-19 Crisis has Advanced the use of Telehealth

The coronavirus pandemic has dramatically changed the way health care providers care for their patients. Although telehealth has been available for many years, it has not been widely adopted for reasons related to the way telehealth services are reimbursed, federal and state privacy and security requirements, and financial or technical constraints. However, the emergency response to the current crisis has led clinicians to quickly operationalize their telehealth capabilities to care for their patients while adhering to shelter-in-place guidelines. With virtual health care rapidly becoming the new normal, health systems will need to make informed decisions about how to balance the use of telehealth with in-person encounters, while policy makers will need to consider policy and regulatory changes that may need to be made to support the long-term sustainability of telehealth.

Health systems across the country have been urged to rapidly transition to telehealth when possible to prevent the spread of coronavirus. NYU Langone Health, a New York City-based health system that rarely used telehealth prior to the pandemic, went from zero to 5,500 telehealth visits within two weeks.[1] Kaiser Permanente is averaging 65,000 telehealth encounters per day as a result of the expansion.[2]  Telehealth has proven useful during the pandemic in many ways: urgent care centers are conducting assessments remotely for people who are symptomatic and recovering at home; individuals with chronic diseases are managing their conditions with their primary care providers in real-time; and health technology firms are rapidly advancing the development and deployment of tools to support at-home care, such as remote heart and glucose monitors, home lab testing, and app-based health tracking software. This dramatic uptick has been propelled by changes at the federal level to reimburse providers for services, allow telehealth care between states, and relax Health Insurance Portability and Accountability Act (HIPAA) regulations around technology use.[3]

Prior to the pandemic, significant regulatory and legislative barriers made telehealth adoption difficult. In 1997 Congress made telehealth a reimbursable service under Medicare, Medicaid, and the Children’s Health Insurance Program but only in limited circumstances: a patient had to be geographically located in an underserved rural area and the encounter could not take place inside a person’s home. Additionally, interstate licensure has been a barrier because most states require physicians to be licensed in the state where they are practicing medicine. In March of this year the Centers for Medicare and Medicaid Services (CMS) issued temporary policy measures to make it easier for individuals to receive medical care through telehealth during the COVID-19 public health emergency. These changes allow providers to:

  • Conduct telehealth with patients located in their homes and outside of designated rural areas;
  • Practice remote care, even across state lines, through telehealth;
  • Deliver care to both established and new patients through telehealth; and
  • Bill for telehealth services (both video and audio-only) as if they were provided in person[4]

The types of telehealth services covered by Medicare have also been temporarily expanded to include evaluation and management visits provided in inpatient, emergency department, and nursing facility settings, as well as in the patient’s home; certain physical, occupational, and speech therapy services, and psychiatric evaluations and visits. The full list of reimbursable telehealth services is on the CMS website.

At the same time, the U.S. Department of Health and Human Services (HHS) issued a notification of enforcement discretion to allow HIPAA-covered health care providers to use remote communications technologies that may not fully comply with HIPAA privacy and security requirements. During the national and public health emergency, HHS’ Office for Civil Rights will not impose penalties for noncompliance with the regulatory requirements under HIPAA in connection with the “good faith provision of telehealth.” Popular applications that were previously not considered fully compliant with HIPAA that are now permitted include Apple FaceTime, Facebook Messenger, Google Hangouts, Zoom, and Skype; public facing applications such as Facebook Live, Twitch, and TikTok are still prohibited.[5] While the waiver has offered providers more flexibility, the temporary nature of this waiver, along with a lack of clear guidance on which applications and/or services are approved or not, can be extremely challenging for providers to navigate, particularly for smaller physician practices.

Although these changes are temporary, health care leaders are hopeful that the trend will continue in the current, positive direction. During a May 26th press conference, CMS and the Trump Administration signaled that some of the policy changes may become permanent, stating that the president “has made it clear that he wants to explore extending telehealth benefits more widely.”[6]  If some of the temporary measures are made permanent, it will go a long way to address the challenges noted above with the current waiver. In addition to looking to Congress to pass legislation to make certain changes permanent, policymakers will need to carefully balance the benefits with unresolved privacy and security risks and ensure that existing protections in HIPAA are not undermined. Long before the current crisis, privacy and security concerns plagued telehealth technology, particularly lack of controls or limits on the collection, use, and disclosure of personal information. Even as providers and consumers are becoming accustomed to video chatting, platforms such as Zoom have recently come under fire for their lax security controls.[7] More oversight of approved telehealth tools and a comprehensive regulatory framework will be needed to bolster trust and confidence among consumers, health care providers, and privacy advocates.

Another critical factor for consideration is populations of people for whom telehealth might not be appropriate. A recent poll suggests that there still are limitations for remote monitoring among people ages 65 and older. While the majority of them say they have a computer, smart phone or tablet with internet access at home, only 11% have used a device to talk by video to a doctor or health care provider within a two-week period.[8] Patients with mental health, addition or abuse problems may not have a safe and confidential place for virtual visits. Older people of color and those with low socioeconomic status, which recent data has shown are at higher risk of health complications due to COVID-19, experience barriers to telehealth including lack of technology, digital literacy and a reliable internet.[9] If the impact of telehealth on different populations is not carefully studied, there is a risk of negatively impacting quality of care and exacerbating health inequities in our society.

To understand the impact of telehealth with the interventions and short-term policy measures that are currently in place, a structured series of data will need to be established as well as training for clinicians on how to capture this data will be needed. Zeke Silva, M.D., Medical Director of Radiology at Methodist Texsan Hospital, says:

“We are living through one of the largest telehealth pilot studies in history. 6, 12, 18 months from now, we will look back on this time to objectively evaluate what worked and didn’t work. And why. The quality of our interactions, patient experience, outcomes and documentation will be an important part of that analysis.”[10]

The rapid adoption of telehealth is another example of how policymakers and health care and community systems in this country have responded to the pandemic in a remarkable way. COVID-19 will have a long-lasting impact on the role of telehealth in our health care system. With the current ability to capture, share and analyze data, we should leverage this unprecedented opportunity to determine what that will look like in the future while ensuring the appropriate data protections are in place to foster trust and support long-term sustainability.

 

 

[1] Becker’s Hospital Review. “NYU Langone rapidly expands virtual care amid ‘explosion’ of COVID-19 pandemic in New York.” 2020: https://www.beckershospitalreview.com/telehealth/nyu-langone-rapidly-expands-virtual-care-amid-explosion-of-covid-19-pandemic-in-new-york.html.

[2] Becker’s Hospital Review. “Troubleshooting the rapid growth of telehealth, data-sharing during COVID-19: Key insights from Kaiser Permanente & Keck Medicine of USC.” 2020: https://www.beckershospitalreview.com/telehealth/troubleshooting-the-rapid-growth-of-telehealth-data-sharing-during-covid-19-key-insights-from-kaiser-permanente-keck-medicine-of-usc.html

[3] Jercich, Kat. “Telehealth’s post-COVID challenges: Integrating in-person care.” 2020. https://www.healthcareitnews.com/news/telehealths-post-covid-challenge-integrating-person-care

[4] https://www.hhs.gov/coronavirus/telehealth/index.html#waivers

[5] https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

[6] https://www.beckershospitalreview.com/telehealth/some-temporary-telehealth-provisions-will-become-permanent-cms-chief-says.html

[7] https://www.forbes.com/sites/kateoflahertyuk/2020/06/05/zooms-security-nightmare-just-got-worse-but-heres-the-reality/#586628dc2131

[8] Cubanski, Juliette. “During the COVID-19 Emergency.” 2020: https://www.kff.org/coronavirus-policy-watch/possibilities-and-limits-of-telehealth-for-older-adults-during-the-covid-19-emergency/

[9] Velasquez, D. Mehrotra, A. “Ensuring The Growth Of Telehealth During COVID-19 Does Not Exacerbate Disparities In Care.” 2020: https://www.healthaffairs.org/do/10.1377/hblog20200505.591306/full/

[10] Silva, Zeke. “Telemedicine amid COVID-19.” AMA Physician Innovation Network Discussion. 2020: https://innovationmatch.ama-assn.org/groups/ama-physician-innovation-network-public-area/discussions/Telemedicine-amid-COVID-19.