Dr. Andrea Green had never used telehealth before Covid-19.
But the pediatrician found that her New American patients, who comprise nearly her entire caseload at the University of Vermont Medical Center, took to it quickly. Parents no longer had to take time off work or find transportation to get their children to an appointment. Otherwise-reserved teenagers felt more comfortable asking questions about their mental health, flipping the camera up to the ceiling to obscure their embarrassment.
“I’m asking questions and answering questions,” seeing kids in their homes and with their families. “It feels like a very complete visit,” Green said.
When Covid-19 forced doctors to shutter their offices and hospitals to cancel their elective procedures in March, doctors made a rapid, full-scale transition to telemedicine. After nearly two months, many say they’ve discovered the myriad benefits of connecting with people in rural areas, and meeting patients where they’re comfortable — in their own homes. Even those who acknowledge the limitations of seeing patients from behind a screen or experienced challenges say the shift has changed Vermont’s medical landscape for good.
Dr. Michael Lyons, a partner at White River Family Practice, didn’t offer telemedicine until March. Now, “I can’t envision when my daily practice wouldn’t be at least 30% telehealth,” he said. “I never want to see it go away.”
Up until March, the University of Vermont Medical Center was scheduling 60 telemedicine visits a week. By April, after Covid-19 had forced the cancellation of non-essential in-person appointments, it had skyrocketed to 6,000 visits a week — 100 times the previous total, Green said. Many small primary care practices, and even rural hospitals such as Northeastern Vermont Regional Hospital, had never offered virtual visits until the coronavirus hit.
So far in 2020, the number of health care providers using virtual technology has increased tenfold, up to 2,165 in 2020, according to BlueCross BlueShield spokesperson Sara Teachout. More than half of those telehealth appointments were for mental health, including psychiatry and therapy; 40% were medical evaluations.
The move to virtual appointments has been largely obligatory, but doctors overwhelmingly saw benefits in the shift. In a Telehealth Providers Roundtable convened on Zoom by Rep. Peter Welch, D-Vt., last week, health care workers said video calls had helped them check in on those receiving medication-assisted treatment, and allowed them see patients interact with their families at home.
In the Northeast Kingdom, where patients routinely have to drive an hour to visits, moving therapy meetings online has improved attendance, said Gary Mitchell, a drug and alcohol counselor and a clinical supervisor for Northeast Kingdom Human Services. “In our part of the country, transportation has been, and always will be very very difficult,” Mitchell said at the town hall.
No-show rates are down and his agency is adding new groups, he said. “I can't see us really going back if we don't have to,” he said. “I'm reaching people that we just have never been able to get to before.”
Since the pandemic, insurance companies cover all telehealth and telephone appointments at the same rate as in-person visits. The Vermont Legislature is considering how long to extend those requirements. The Department of Financial Regulation may also create a work group to discuss the issue, according to Nissa James, spokesperson for the Department of Vermont Health Access.
The changes haven’t come without challenges. Josh Green, a naturopathic doctor and president of the Vermont Association of Naturopathic Physicians, said about 80% of patients at his practice have had video freezes or weak connections.
But once they had it, only 5% to 10% of patients had to revert to a phone call due to issues with video call, “either due to not having camera access or because they couldn't figure out how to use it,” Green said in testimony to the Legislature last week.
Only two Medicaid members — both residents of the Northeast Kingdom — had reported issues with video calls to the Department of Vermont Health Access, said James.
Online visits can also be less lucrative for doctors, and depending on who you ask, less effective. Josh Green told lawmakers that the time it required to set patients up with the technology could make appointments run over time. Dan Goodyear, a doctor and partner at Richmond Family Medicine, said he connects patients online to screen them, and then if necessary, has them come into an office for a follow-up; only one of those visits can be billed to insurance companies.
Because of the time requirements, his office is seeing 80% of the pre-Covid patient load, but making just 70% of the revenue.
When patients do come into the office, he sees those who are healthy in full protective gear in the office, and cares for patients with Covid-like symptoms in an 8-by-12 foot enclosed trailer parked outside. The system works for now, he said, but he worries he may overlook some maladies that he would notice when all his visits are in-person. “The telemedicine allows us to take care of people’s most acute needs,” he said. “A lot of things can be missed without someone face to face.”
Some care will never be replaced by technology, Lyons said.
On Tuesday, a man whose wife was struggling with Alzheimer's disease called for an appointment at the White River Family Practice this week. Lyons could have seen the woman via telemedicine, he said, but “to feel cared for, he wanted to come in.” There’s value in the small gestures between a doctor and his patient, Lyons said: “The touch and looking in their eyes, and making people feel like that’s going to help. We need to meet that demand.”
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