Does anyone else have concerns about Telehealth?
Don’t get me wrong, I’ve long believed that Telehealth could do a lot to increase access, decrease some costs, and help improve clinical outcomes. However, with the flight to Telehealth in recent weeks due to the pandemic (as I write this, we are currently in the throws of the novel caronavirus and the disease that it causes, Covid-19), I am noticing a worrying trend in the arguments being used to advocate for this method of service delivery.
What worries me most is the argument being made that “Telehealth is just as good as in-clinic or in-person treatment”. I see people pull articles and studies that show comparable results between virtual and in-clinic rehab services (studies like this one). Now, while we should be advocating for best practice and evidence-based methods, we also need to look at them in the entire context of assessment & treatment, and what these studies suggest as far as the implementation of these service delivery methods go. For example, the study mentioned earlier concludes that telerehabilitation has the potential to increase access to rehab “on a large scale”. And, as I mentioned earlier, I think increasing access is great. The issue is when we conflate in-person healthcare services and virtual or Telehealth services, as if in-person healthcare delivery and virtual healthcare delivery are different ways of delivering the same treatment or service. They are not delivering the same service.
Let’s look at some of the reasons why providers, administrators, and policy-makers may consider telehealth to be the magic bullet to solve many of the issues plaguing healthcare delivery, access, and cost. Afterwards, I’ll discuss my concerns about it and some of the hidden dangers posed by this line of thinking.
Why Some Believe Telehealth to be a Panacea
It is no secret that healthcare costs are constantly increasing, with equal access to healthcare services appearing to continue with limitations and shortcomings. Put simply: the costs are out of control and plenty of people don’t have access to the services they need. The common reason for lack of access seems to be associated with cost, but there are also factors such as location, complexity, etc. And now, especially in this time of a public health crisis, where social distancing and limiting person-to-person contact is mandated to prevent the spread of this disease, many at-risk patients or clients find themselves unable —or unwilling— to take the risk of traveling to a clinic to receive care.
So why do policy-makers, providers, and administrators see telehealth as the solution? They see it as a low-cost, easily implemented, and almost universally available means of providing “the same” services to clients and patients who may not be able to afford in-person healthcare, who may reside in rural locations far from healthcare centers, or who have difficulty attending in-person appointments. And, if you think about it, their logic easily follows: 1) almost everyone has internet access and a device on which to stream video 2) with the appropriate security features (end to end encryption and the like), sessions can be secure & HIPPA compliant (for those of us in the US) 3) several options exist for virtual meetings, patient portals, and even home-based virtual rehabilitation programs 4) it saves the patients or clients money/time by eliminating the need for travel, and it can save the healthcare centers by decreasing the amount of disinfecting and cleaning that is required following in-person appointments. This is my no means an exhaustive list of potential benefits of Telehealth, and I’m sure I’ve left out some prominent benefits, but you get the picture. This method of service delivery offers many potential benefits to providers, payers, and recipients/patients.
On top of that, there is evidence to suggest that telemedicine and telehealth services can be effective in improving clinical outcomes in certain situations. This means it has the support of providers, academics, and researchers who see this method of delivering services as a valuable tool in their toolbox when it comes to providing quality, evidence-based treatments for their patients and clients.
All About The Numbers
Now, as I’ve eluded to here, number-crunching analysts that support healthcare administrators and policy-makers tend to look at healthcare service delivery as a numbers game. This often leads to decisions that look good on paper, and make sense from a “numbers” perspective, but have huge unintended consequences for the quality of service being delivered, the access to those services, and on the tools and methods available to the clinicians providing those services. This has already led to a healthcare system that sees patients as numbers on a spreadsheet, instead of unique individuals with unique factors and situations affecting their health and well-being. It also leads to healthcare providers being seen as cogs in a machine (or workers on a conveyor belt), doing their part to provide a standardized “service” and trying to do it at the lowest cost.
In an environment like that, it’s easy to see the allure of offering “virtual” healthcare services that can, decrease cost, increase access, and potentially increase profitability.
Hidden Dangers That Lurk in the Arguments for Telehealth
Now let’s come back to the original question: what are some potential dangers with the mass-adoption of telehealth? There are a few problems I see with this movement into and rapid adoption of telehealth. Those problems don’t exist in the evidence for, cost of, or potential benefits of virtual healthcare delivery. As I said before, I believe that telehealth can be a great tool for decreasing cost, improving clinical outcomes, and increasing access to healthcare services.
The dangers I see stem from the arguments being used to push and advocate for the widespread adoption of telehealth, and the ramifications could actually lead to decreased coverage of necessary services in the days ahead (and after this crisis is over). While these current times call for novel service delivery methods, exploration of new technologies, and the ability to provide services while limiting person-to-person contact, we as clinicians and healthcare providers need to be aware of the potential dangers in the way we advocate for these virtual service delivery methods. I mainly refer to the arguments being made that virtual medicine or telehealth is “just as good” or “comparable” as in-person healthcare delivery.
Below, I outline 3 potential negative consequences of this line of thinking when it comes to the long-term access, cost, and coverage of healthcare services.
1. Virtual Can Not Replace In-Person
While it may seem logical that providing healthcare services virtual in a “face-to-face” manner can be the same as doing so in a clinic or other “traditional” service delivery method, it’s simply not true. I do not believe that virtual assessments or treatments can universally be comparable to in-person visits. There is often too much at play, tissues that must be palpated, or physical assessments that must be completed in order to get a true picture of what’s going on with a given patient or client.
Take, for example, patients or clients with chronic musculoskeletal pain. Can you really make the argument that assessment or treatment provided through a screen is comparable, or could take the place, of in-person, physical assessment or treatment? Now, I come from a clinical background of orthopedics rehabilitation & pain management before moving into consulting, so allow me to explore this further through my lens. I’ve seen many patients, each with a diagnosis of “shoulder pain”, “shoulder impingement”, or “rotator cuff dysfunction”. At first glance, you can clearly observe the decreased range of motion (ROM), inappropriate or compensatory motor patterns, and even functional limitations caused by these diagnoses. And, a trained clinician would be able to observe those via webcam in a virtual setting.
Now, the problem comes when it’s time to determine what is actually causing the limitation, pain, or compensatory motor pattern. How do you adequately assess that? By physically touching the patient or client. By palpating the muscles in the area, completing provocative tests/assessments, and completing other physical assessments. No matter how you try, you simply cannot replace that with a video conference or a web-based assessment.
2. Hidden Dangers with Payers & Regulators
If there’s one thing that is certain within healthcare, at least from a provider or clinician standpoint, it’s that third-party payers and regulators constantly change policies and reimbursement rates. Usually, this results in providers being paid less for the services or treatments they provide. Payers and policy-makers justify this by documenting rationale that their reimbursement structures incentivize the most efficient treatments or services for a given diagnosis. As I’ve written about here, that aim is not always met (as can be noted by time-based reimbursement schemes). All that is to say that, if given the opportunity to deny, limit coverage, or decrease the reimbursement of a given service or treatment, you can almost be assured that that will occur.
Now, given the current pandemic situation we find ourselves in, many clinicians and patients are trying to limit person-to-person contact. This has led to clinics either closing or severely limiting the number of patients or clients they see in a given day, and that has led to 1) even lower access to services and 2) decreasing revenue for healthcare clinics —to the point where financial solvency is being threatened. This has cause many providers to seek out ways to offer telehealth services as a way to continue to provide some access to care as well as replace some of the lost revenue from decreased patient volume.
With this heavy push for Telehealth coverage by third-party payers, clinicians are unwittingly opening themselves up to the vulnerability of giving these payers the ability to select which service delivery method will be covered, which won’t be, and which will be discouraged. While Telehealth may offer improvements, advantages, and positive outcomes, we must ensure that the argument is not made that it can, in any way, replace in-person or person-to-person healthcare delivery. If that argument gains traction, we could easily find ourselves in a situation where many “in-person” services are not covered or denied by third-party payers or policy-makers. And that would decrease access and potential worsen clinical outcomes in the long term.
3. Commoditization of Healthcare Services
Along the same lines as reimbursement, is the idea of the value that clinicians bring to the table. Clinicians already have a difficult time clearly communicating the value that we bring to any situation or diagnosis. Sometimes this stems from a lack of self-confidence, sometimes from other reasons. Whatever the reason, clinicians often take a passive approach to communicating their value. They believe that, if they’re skilled, their value will be apparent. While this may work some of the time, it can’t be relied upon as an effective method for conveying your worth.
So now, we’ve got this virus that forces clinics to close, patients to cancel, or otherwise limits face-to-face interactions between clinicians and patients or clients. Within this environment, a question arises: what is the value that a clinician delivers and how is it best or most effectively delivered. What some have argued —and I would fall into this camp— is that a clinician’s true value is most effectively delivered through interpersonal interactions between themselves and their patients. While this can be partially accomplished through virtual means, video conferencing, and e-visits, again, nothing can quite replace the effectiveness of in-person interactions. The nuances of body language, facial expressions, even breathing patterns and micro expressions all become lost through pixilation and lag time.
In addition, to imply that a clinician’s value can somehow also be delivered through virtual programs and software as standalone means, opens the door to the argument that clinicians don’t actually provide much true and tangible value anyways. It has the potential to commoditize healthcare services, discounting the skills, knowledge, and expertise that clinicians possess in their given area of specialization. And again, in a world were clinicians must constantly demonstrate their true value, making the argument that virtual or telehealth services can replace in-person interactions undermines the idea that clinicians bring unique value to the clients and patients they serve.
At the end of the day, we find ourselves in unprecedented times. Globally, social interaction and person-to-person contact has been limited or prevented by policies and regulations aimed at curbing the spread of a novel virus. I, for one, am positive that the times we are currently living through will be in the history books our children and grandchildren will read in school. That being said, this situation forces us to take a look at healthcare service delivery and develop ways to ensure access to quality healthcare in light of the current environment.
Surely, telehealth and virtual/digital health have a role to play. These methods have been shown to provide positive clinical outcomes, increase access, and decrease cost. However, as clinicians and providers, we must retain that these methods of service delivery can not adequately replace in-person interactions or physical assessments/treatments. We must argue that, while these methods are great adjuncts to traditional treatment, or even appropriate tools in the toolbox, the value that clinicians deliver is most effectively done so through in-person interpersonal interactions. After all, healthcare is a human experience, not simply billable units on a spreadsheet.
Again, my main concern is not that telehealth is ineffective or that the evidence doesn’t support it. I think it’s being shown to be effective in certain situations. My concern lies in the way we advocate for it and how it may ultimately lead to decreased access to care, coverage of in-person services, and the like. I think we need to be very careful not to make the argument that telehealth is “just as good” as in-person therapy, as if telehealth and in-person therapy are two different methods of providing the same service. We need to make the argument that telehelth and in-person therapy are not the same service and that they are both tools that should be in our toolbox, as opposed to two interchangeable methods.
What are your thoughts on Telehealth? Do you think it will have a net positive, negative, or neutral affect on healthcare delivery? Share your thoughts in the comments below!
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Rafael E. Salazar II, MHS, OTR/L (Rafi) is the Principal Owner of Rehab U Practice Solutions. He has experience in a variety of rehab settings, working with patients recovering from a variety of injuries and surgeries. He worked as the lead clinician in an outpatient specialty clinic at his local VA Medical center, where he worked on projects to improve patient & employee engagement and experience throughout the organization. He also has experience as an adjunct faculty instructor at Augusta University’s Occupational Therapy Program, as a Licensed Board Member on the GA State OT Board, has served on several committees for the national OT Board (NBCOT), and as a consultant working for the State of Georgia’s DBHDD. He is also on the Board of Directors for NBCOT. He works to help healthcare clinics and organizations deliver uniquely impactful patient experiences by improving service delivery through training & advisement and through courses & training programs.
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