Patient Satisfaction With Telemedicine
A 2017 comprehensive literature review by Kruse et al9 explored patient satisfaction factors in studies that used patient satisfaction to measure telemedicine’s effectiveness or efficiency. The researchers found that positive factors accounted for 62% of patient satisfaction, including improved outcome, preferred modality, ease of use, improved communication, low cost, and decreased travel time.
Since the COVID-19 pandemic, patient and provider satisfaction with telemedicine has increased. A prospective, bicentric study conducted at 2 academic hospitals asked patients to rate their satisfaction with a telemedicine visit through a survey after the encounter.10 The results showed that 83.8% of the patients were satisfied with the encounter, and 89.5% felt the provider addressed their problem during the visit. Only 10% reported increased stress because of the telemedicine encounter. Patients older than 65 years of age had a similar level of satisfaction as younger patients. Gender, age, and reason for the encounter did not significantly alter the findings.
Barriers to Care
Potential barriers to telemedicine’s full implementation include limitations in current electronic medical records and telemedicine platforms. The patient’s access to technology and the available internet infrastructure at the provider and the patient location are also limitations. Other barriers include portability of professional licenses, malpractice insurance, privacy concerns with healthcare information, reimbursement, legal/regulatory problems, provider acceptance, organizational acceptance, remote site commitment, and overall implementation cost.11 Greater access to health care and reduced healthcare delivery cost are just a few of the advantages of using this technology. Delivering healthcare education to areas that were not accessible previously will help reduce healthcare provider disparities in care while allowing providers the resources to keep their skills and knowledge up to date.
This technology also alleviates barriers to healthcare delivery in rural areas. Additionally, many patients in urban settings prefer telemedicine’s convenience; it eliminates the burden and cost of transportation and time off work. Providers report that incorporating telemedicine into traditional healthcare practice is a valuable tool for improving patient care and decreasing healthcare disparties.12
Seniors and Technology
Contrary to the myth that seniors do not want or cannot use technology, a 2017 study by Pew Research Center found that two-thirds of seniors engage online.13 The study showed that 67% of seniors use the internet, and 51% have broadband connectivity at home. Smartphone, social media, and tablet use by seniors increase to 32% and 34%, respectfully, between 2000 and 2016.13
In a 2019 study by Pew Research, 91% of seniors had a cell phone, with 53% owning smartphones.14 The study divided seniors into “Baby Boomers” (born 1946-1964) and “Silent Generation” (born 1945 and earlier) and found a significant difference in technology use between the 2 generations, with 67% of Boomers and 30% of the Silent Generation using smartphones.15 The Silent Generation may have less access to broadband service, tablet ownership, or social media use and are less likely to use technology secondary to lack of confidence and physical challenges.
Current Procedural Terminology (CPT) has evolved since the pandemic began. The codes specific to COVID-19 are unique codes used for documentation and reimbursement of vaccinations and other related COVID-19 procedures.16 Multiple medical specialties joined primary care and mental health practices in offering telemedicine during the pandemic including psychiatry, internal medicine, pediatrics, geriatrics, neurology, urology, allergy and immunology, endocrinology, infectious disease, occupational therapy, dermatology, urgent care, emergency medicine, and radiology.17
Before the pandemic, commercial insurance reimbursement depended on the type of telehealth, and reimbursement of the visit depended on meeting the same standards of care as for in-person appointments.18 However, at the beginning of the pandemic, commercial insurance increased reimbursement to in-person visit levels.19 Some private insurance carriers are starting to reduce their reimbursement rates to prepandemic levels.
According to the Centers for Medicare and Medicaid Services (CMS), the rules for coverage of Medicaid telemedicine services and CPT codes and modifiers are state-specific.20 The state can pick the CPT codes or modifiers they wish to identify, track, allow reimbursement, and decide which specialties and diagnoses they will cover. Reimbursement must satisfy federal law and include provider fees, facility fees, technical support, transmission charges, and additional fees. Most medical practitioners can provide Medicare telemedicine services, including physicians, NPs, PAs, clinical nurse specialists, and psychologists, but each state can decide which providers will be reimbursed or excluded.
CMS also administers Medicare services.21 Before the pandemic, Medicare telemedicine services were restrictive on covered diagnoses and patient settings. The rules stated the patient must live in a county outside of a metropolitan area or in a rural professional shortage area. The visits were often at facilities where a healthcare provider would assist with vital signs and other portions of the encounter. Providers could be at any site if they participate in Federal telemedicine demonstrated projects. Medicare also restricted diagnoses used with telemedicine services. Examples of approved diagnoses include consultations, diabetes, psychotherapy, and end-stage renal disease.22 Since July 1, 2019, Medicare has covered substance use disorder-prevention visits.22 Although legislation has passed in Washington, DC, to increase telemedicine options, Medicare still had restrictions that impact care access for seniors and the disabled.
In response to the pandemic, CMS quickly relaxed rules and enacted payment parity for telemedicine encounters, raising the reimbursement to match in-person visits.19 Commercial insurance carriers followed by similarly increasing reimbursement. The Drug Enforcement Agency changed regulations to allow all providers to prescribe controlled substances II to V via telecommunication, although state prescribing regulations of these medications remained.23 There is currently a temporary reversal of the rules surrounding the patient’s location, allowing in-home telemedicine visits for patients receiving Medicare and most patients receiving Medicaid, although interstate regulations remained in place.19 For telemedicine to thrive in a post-pandemic era, the temporary rules regarding reimbursement and providers’ ability to fully care for the patient in any setting must be made permanent.
The Defense Health Agency’s Tricare health program states that telemedicine services are available to provide clinical consultations and office visits when appropriate and medically necessary, including clinical consultation, office visits, telemental health visits, and services for end-stage renal disease.24 Because of the pandemic, Tricare temporarily relaxed their telemedicine visit rules.25 TriWest and the other affiliated insurances for veterans have varied in their insurance coverage both before and during the pandemic.