Thursday, October 29, 2020

Virtual visits

One of the myriad ways that Covid-19 has changed our lives is the explosion in “telemedicine.” As hospitals, clinics and doctors’ offices shut down for non-critical illness visits, many shifted quickly to the use of “virtual” visits: visits done by connecting patients to their doctors and nurses via computer. While this has been done on a small scale for several years, most insurance plans had limited coverage for virtual visits, a major stumbling block to having them widely used in a revenue-driven fee for service environment. Medicare and most commercial insurers rapidly offered to cover these visits as the pandemic unfolded, and their use expanded 100-fold during the spring and summer.

Somewhat to their surprise, most patients found virtual visits to be satisfactory. It is obvious that for mental health visits, just as much can be done via remote communication as in person. Neither psychiatrists nor other mental health professionals normally do anything other than talk or listen. For other types of care, a virtual visit can be less than ideal. A good quality smart phone can allow the doctor to see a rash, but not to listen to the heart and lungs or feel an abdomen. As I noted in a prior post, the large majority of the information needed to make a diagnosis comes from a patient’s history – and this is done as well virtually as in person.

Advantages that have turned many patients into supporters of virtual visits include convenience and cost. Rarely does a patient with a 10 AM visit get seen at 10 – and cooling your heels in a waiting room is not high on most of our lists of favorite things to do. In-person visits also involve driving and parking (or taking public transportation), which add considerable time and often expense to the visit.

Doctors who were skeptics have widely come to accept this type of visit as well – having a patient seen conveniently and comfortably makes for a happier patient.

Are virtual visits for everyone? Almost certainly not. Specialties in which most of the data can be conveyed verbally will certainly continue to do this type of visit much more than those requiring high touch. A follow-up visit for diabetes revolves around reviewing test results and symptoms and is an easy one to do virtually. A visit for congestive heart failure requires much more physical examination and would be much harder to conduct via teleconferencing.

Another problem is access. Recent surveys found that 13% of the population, some 42 million people, do not have high speed internet access. Beyond that, many people do not have the technical skills to feel comfortable doing virtual visits, and these people are predominantly elderly and/or from minority communities that are already underserved. 25-30% of Medicare recipients and people with household incomes below $30,000/year lack both smart phones and high-speed Internet. An alternative for these people is the good old-fashioned telephone. This loses the ability to see facial expressions and other visual clues, but still allows for two-way communication “in real time,” which email does not provide.

Clearly virtual visits, no matter how high-tech, cannot (and should not) replace all in-person visits. Along with the inability to do more than a rudimentary physical exam, at a virtual visit one cannot give vaccinations or do procedures. Lab tests may be needed and require an in-person visit somewhere.

Our forced conversion to virtual visits in these uncertain times has, however, shown us that this is often a valuable addition to the medical care armamentarium. I think it is here to stay.

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