When Diane Dooley needs to consult with her doctor in Bristol, she picks up her landline phone.
The 53-year-old lives on a hillside in rural Lincoln where the cellphone service is spotty and internet connection is unreliable. Video calls? “I don’t even try,” she said.
An in-person visit would be a treacherous affair. There’s the snow to contend with and, even more problematic, Dooley has an autoimmune disease, meaning contracting Covid would be risky, even lethal.
So before a call, she checks her own pulse and vitals and makes a list of the questions she hopes to raise with her doctor. “There’s an element of trust and teamwork there,” Dooley said of her relationship with her physician. “She makes sure that everything is taken care of.”
Dooley is among a number of Vermonters who have come to rely on the phone for medical care over the past 11 months as the pandemic has shifted such services from the office to the virtual realm.
People with quality internet and technological knowhow have turned to video calls. But phone calls have become a necessity for many who live in rural areas, have limited internet, face challenges with transportation or child care, or are unfamiliar with the ins and outs of Zoom.
Now, lawmakers are trying to determine whether to extend the changes wrought by Covid by requiring insurers to continue covering appointments by phone at the same rates as care provided in-person or by video through June 2022. The House Health Care Committee is scheduled to vote later this week on a bill that would do just that.
At the heart of the discussion is the question of what constitutes quality in health care. Supporters of the measure say phone appointments allow patients more flexibility and help vulnerable Vermonters get the care they need; others argue that the change would lower the quality of care while increasing its cost.
“If this committee moves to allow audio-only health care to be billed at the same cost … you are likely going to contribute to misdiagnosis, which may result in further degradation of the patients’ health and/or premature death,” wrote Liam Fracht-Monroe, a Rutland resident, in a letter to the House committee. A doctor who can’t see a patient “will be expected to make some diagnosis or offer some level of care and can certainly charge for his/her time (at full price!).”
Rep. Anne Donahue, R-Northfield, summarized the message she had heard from doctors about offering care by phone: “It’s not as good, but I’d rather get something than nothing.”
Health care from home
Before the pandemic, phone call medical appointments — “audio-only health care” in legislative parlance — weren’t covered by health insurance. People called their doctors, but anytime a patient phoned a clinician for advice about their kid’s ear infection or requested a prescription refill, the doctor had two options: have the patient come to the office or offer the service for free.
Video telemedicine visits were rare — or technologically impossible.
Once Covid hit, hospitals closed their doors to all but the most seriously ill patients. Doctors, insurance companies and the federal government scrambled to move medical care online, increasing telehealth in some cases by more than 100 times over pre-pandemic levels. Medicare, Medicaid and private insurers agreed to pay clinicians full price for online and phone visits. Prices stayed the same for patients, too.
Those policies, enacted under the state’s emergency rule-making authority, expire at the end of June. Now, the Legislature is considering whether to codify those rules into law.
Lawmakers wrestled last week with fundamental questions: How much is a phone visit worth — to doctors and to the patient? How can patients ensure they get quality care?
Under the current proposal, a patient could be charged the same as, but no more than, the cost of a similar, in-person visit. Insurers would pay doctors standard rates for all visits by phone — including therapy and primary care appointments, as well as visits with specialists such as oncologists, physical therapists or hematologists.
The state just doesn’t have the data to know whether medicine by phone is helpful in every case, said Rep. Lori Houghton, D-Essex. An extension would give lawmakers the chance to collect the data.
Even so, she added, allowing phone calls will help address some of the challenges that Vermonters face in obtaining health care: long drives to the doctor, transportation difficulties, or trouble getting time off work for an appointment. “It really goes back to the fact that access is still a problem,” Houghton said of her support for the bill. “We need to make sure people can get medical care.”
Of cats, snowmen and medication
Dr. Katie Marvin, a family practitioner at Lamoille Health Partners, has been calling a 94-year-old patient who no longer wants Marvin to visit her at home. The phone calls have covered the woman’s failing appetite, her loneliness and a sore shoulder that, for the first winter ever, prevented her from building a snowman, Marvin wrote in a letter to the House Health Care Committee.
“We talked about her cats, and which movies she is watching, and what medications she is taking,” she said. “It was a full visit.”
Most of Dr. Alison Landrey’s patients have moved back to in-person, primary care visits at the Hardwick Area Health Center. But of those she sees remotely, roughly 70% choose to communicate with her by phone, Landrey said.
Most are older; many live in remote reaches of the Northeast Kingdom. Often they require tech support on Zoom. After enduring frozen video and several sessions of helping people to click on the link, “it became clear pretty quickly that folks were not able to do the telehealth,” Landrey said.
Phone visits work because she knows her patients, Landrey said. She knows who won’t be forthcoming about their health and which patients need to have an in-person visit so she can get their blood pressure readings and examine their feet.
Besides, patients are happier. “It’s been a patient satisfier, to do a telephone follow-up and not worry about Covid,” she said. A phone call “can be perfectly safe and effective.”
Under the committee’s current proposal, patients would sign a consent form stating that they know they would get a bill for a phone visit and that they know that they can choose in-person care instead. It would allow patients more choice, said Rep. Brian Cina, P-Burlington, “We need to make decisions that are individualized and make sure people can get services when they need it, in the best possible way,” he said.
A lower-quality visit?
There may be unforeseen consequences of telehealth, including worse care, warned Sara Teachout, spokesperson for Blue Cross Blue Shield of Vermont. The state’s largest insurance company supports some reimbursement for such visits, but not full payment. Blue Cross has suggested paying doctors 55% of the standard cost for phone visits.
Doctors just can’t do as much when they don’t see the patient and they won’t catch problems the patient isn’t already aware of, Teachout said.
Some Vermonters have also found it too pricey. Blue Cross has received calls from customers angry that they were billed when they called their doctor to ask a question, Teachout said. “What we don’t want to do is put out an incentive to have telephone calls in place of in-person visits,” she said.
Teachout pointed out that there’s very little research on the value of medicine by phone, citing a report by the Vermont Program for Quality in Health Care. Referring to hours of testimony she followed this summer as part of a Vermont Program committee, Teachout said, “I don’t think any of them advocated for audio-only as a means of delivering medical care to most people.”
Quality likely varies between specialties, Teachout said. A psychotherapy appointment should be considered in a separate discussion from cardiology.
“Certain things don’t make sense” by phone, she said. Teachout called the Legislature’s “blanket” policy “disturbing.”
Not every kind of appointment works by phone, agreed Dooley, the Lincoln resident. Oncology appointments, for example? Not great. She goes in person when she needs to see a cancer doc.
But most of the time, her physicians find ways to make her appointments work on her landline. Specialty doctors within the University of Vermont Health Network will occasionally ask her to upload a photo to the patient portal MyChart when they need a visual, for instance.
Dooley said she’d take a therapy visit by phone any day. “I was comfortable in my own home,” she said. And just as important? “I didn’t have to worry what I was looking like.”
