Primary care providers in New York City, one of the U.S. epicenters of the COVID-19 crisis, were some of the first to feel the brunt of the disease's effects. With patients afraid to seek care in person and social distancing necessitating as little face-to-face contact as possible, many clinicians pivoted to telehealth – some with more success than others. 

"It made sense that all eyes were on the hospitals, because they were overwhelmed with sick patients," said Dr. Donna R. Shelley, a professor in the Department of Policy and Public Health Management at the New York University School of Global Public Health. "But primary care doctors are the front line of healthcare in this country, and their patients still needed care." 

In partnership with the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems, the research team surveyed hundreds of area primary care providers from April to July about the impact of COVID-19 on their practices.

Their findings, published this past week in Health Affairs, demonstrate the positive impact that temporary federal changes to telehealth-related regulations have had on virtual care adoption. At the same time, the researchers noted, several hurdles remain for primary care providers when it comes to integrating telemedicine.

Avni Gupta, a PhD student in the Department of Public Health Policy and Management at NYU School of Global Public Health and the lead author of the paper, told Healthcare IT News that before the surveys, "there was a lot of anecdotal information about several challenges" clinicians were facing.

"The pandemic has served as a natural experiment to investigate what else ... we need to implement telehealth effectively into primary care," Gupta added.

Overall, the respondents' recommendations for policymakers fell into five general categories:

• Harmonize the reimbursement criteria
• Create billing codes or payment models for the additional work required to offer telehealth
• Provide coverage for at-home monitoring devices
• Incentivize the development and access to patient- and provider-centered technology
• Review, revise and communicate telehealth malpractice policies

The lack of clarity about reimbursement practices has been a common theme for many regarding telehealth. Just over half of survey respondents said that "uncertain reimbursements" were a barrier to using telehealth, and more than a third said they didn't know whether they'd been reimbursed for virtual care.

"The confusion that is currently prevailing in terms of telehealth needs to be addressed," said Gupta. "All these variables that determine payment – that doesn't help."

"When we talk about independent primary care practices who do not have a lot of wriggle room or resources," Gupta added, it may not be realistic to "expect them to read through all these documents and know the details of every insurer."

"We let 1,000 flowers bloom," said Shelley, with regard to different insurance plans. "My health insurance may have coverage for telemedicine, and yours may not." If the U.S. Centers for Medicare and Medicaid Policy were to address these policy issues in a consistent way, she predicted, commercial insurers would likely follow suit.

Gupta and Shelley also noted the foundational work that goes into setting up telehealth, for which providers may not be reimbursed.

"We had a provider respond [whose] staff spent two hours with a patient trying to help them get online. They didn't get reimbursed for that time," said Shelley. "There are always hidden costs to any activity and any change."

"There's an infrastructure investment" involved with virtual care, "including getting people Internet," Shelley continued. "Maybe the practices have to swallow that costs themselves. But when you're one doctor with one nurse and maybe one receptionist," that cost can be difficult to take on – or even prohibitive.

Ultimately, said the researchers, any approach to telehealth needs to consider the needs of patients and of providers.  

"One of the issues has been for the providers who have low-income, or non-English-speaking patients who are really preferring telephone to video," said Shelley – and the future with regard to audio-only telehealth reimbursement is still unclear. 

"Some of these questions have ramifications for health disparities," she continued, noting the continued lack of nationwide broadband access and a potential digital divide among race, age and income lines.

"The provider- and patient-centered lens is really important to focus on," Shelley added. "Both providers and patients are going to need to access this point of care."

Kat Jercich is senior editor of Healthcare IT News.
Twitter: @kjercich
Email: kjercich@himss.org
Healthcare IT News is a HIMSS Media publication.