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To its advocates, telemedicine is the perfect remedy for a pandemic.
They see it as the ideal way to literally bridge the gap between providing the sick with treatment for coronavirus as well as other ailments — and the long-term need to keep doctors and nurses physically apart from potentially infectious patients.
Yet even as some long-standing obstacles to telemedicine fall rapidly, others remain stubbornly in place.
While the Trump administration this week lifted national restrictions on the use of telemedicine by Medicare, the new policy did not apply to care provided by community health centers, which serve 81,000 elderly residents in Pennsylvania.
And Pennsylvania remains one of perhaps only 10 states that does not require private insurers to cover telehealth programs.
Legislation to do that has been hung up in large part due to opposition from foes of abortion, wary such programs would offer women “morning after” drugs by phone. The insurance industry has also raised questions about the measure in the past, though a trade group leader said Wednesday it now supports current legislation.
In this region, at least two leading hospital systems — Jefferson Health and Penn Medicine — suggest those seeking help for coronavirus contact the systems’ telehealth programs.
When people do call in, however, each program demands that they pay a $49 fee.
"That’s ridiculous. That’s a huge barrier,” said Mariana Chilton, a professor of public health at Drexel University “A lot of people who are poor don’t have credit cards.”
With the pandemic as a driver, telemedicine is having a moment now.
On Tuesday, federal officials dropped restrictions that had limited Medicare telehealth programs largely to rural areas. Medicare, the vast health-care program for the nation’s elderly, said Tuesday that the relaxed rules would stay in effect as long as the pandemic lasts. Coverage is to be retroactive to March 6, the date Congress passed and President Trump signed an emergency $8.3 billion anti-virus spending bill.
In Pennsylvania, Gov. Tom Wolf, on the same day as the federal Medicare decision, removed the state’s restrictions on using telemedicine in Medicaid, the state-directed government insurer for low-income patients. Wolf’s Human Services agency even said telemedicine was now the “preferred” method of delivering health care.
Dr. Judd Hollander, who directs Jefferson Health’s JeffConnect program, said Wednesday that the number of people seeking help through the program has gone up 20-fold since the virus surfaced. Just on Tuesday, he said JeffConnect teams of physicians and staff provided medical guidance remotely to 1,200 people.
The growth has been strong, too, at Penn Medicine’s OnDemand program, which only opened up to the public recently. The number of OnDemand patients assisted daily has more than tripled since the pandemic broke, the hospital says.
Until coronavirus, Jefferson’s Hollander said, no insurer would pay for JeffConnect charges. Since then, he said, “Everyone has changed or is changing” — and covering the telemedicine bills. (Samuel Marshall, president of the Insurance Federation of Pennsylvania, a trade group for insurers, said he was surprised to hear that, saying he thought most plans had been paying for telehealth coverage.)
Under telehealth programs, people talk with their doctors and staff by phone or online by Skype and share medical information via internet.
Crucially, said Kathy Wimberley, director of the federally funded Midatlantic Telehealth Resource Center, this can spare people from visiting doctors in their medical offices or making trips to emergency rooms and hospitals.
Telehealth program, she said, can help stem the spread of the virus and also address long-standing medical issues. “We are also hearing from all over the country that people are afraid to go to their heath-care providers for their normal services,” Wimberly said.
As the pandemic grows, she said, “one of the major concerns is, Are we going to overload the system? We really want to save the emergency rooms and the bed space for the people who are seriously ill.”
The help goes two ways, she noted. Unless contact is minimized, she said, “health-care workers get sick as well. And then they get taken out of commission.”
Cheri Rinehart , president of the Pennsylvania Association of Community Health Centers, said she welcomed Trump’s decision to permit telemedicine for Medicare patients, of which there are 1.6 million in Pennsylvania, or one out of every eight residents.
“It is a very sweeping change and an important one in responding to the epidemic and something that was advocated long before COVID-19,” she said, using the term for the respiratory disease caused by coronavirus. “It was just a very difficult one to get through government."
That said, Rinehart said she was distressed that the Medicare change left untouched patients served though the state’s more than 300 community health centers. There are more than 60 such facilities in Philadelphia, including seven medical centers operated by the city Department of Public Health, and 11 in the four Pennsylvania counties surrounding the city.
At the centers, she said, staffer faced a troubling dilemma — they could prepare to reach out by telephone to low-income patients, but not elderly ones. As she put it, “They are operationalizing for Medicaid, but can’t do it for Medicare.”
James Garrow, spokesperson for the Philadelphia Public Health Department, said the city is providing telemedical help to seniors anyway.
“The city health centers are already implementing telephonic ‘virtual visits’ for our Medicare patients since older adults are at increased risk for COVID-19 complications,” he said in a statement Wednesday. “We are hopeful that rules will be changed to allow reimbursement for these Medicare visits.”
Government-paid insurance aside, Pennsylvania can also find it difficult to obtain coverage for telemedicine in the private insurance market.
Unlike most other states, including New Jersey, Pennsylvania has not adopted a so-called telehealth parity law requiring insurers to cover all medical procedures that can be provided by phone if they cover them in the hospital.
In Harrisburg, a bill to require telemedicine coverage overwhelmingly passed the state Senate in the last two sessions, but has run into trouble in the lower chamber. At a hearing in 2018, Marshall, of the Insurance Federation, said his group opposed the mandate “in its current form,” saying it would force insurers to treat equally all hospital telemedicine programs. “They’re not all exactly the same," he said then. "Some have much better telemedicine programs than others.”
On Wednesday, Marshall said his group supports a newer measure to mandate coverage that passed the state Senate in October by a 47-1 vote.
However, the bill was amended in the state House to forbid telemedicine programs from offering patients a drug that can end pregnancies up to 10 weeks.
State Rep. Kathy Rapp, cochair of the House Pro-Life Caucus, said Wednesday that restrictions made sense.
“I think it’s a huge risk for women to receive abortion through telemedicine, to be told to go home and expel or abort their child on their own without being in a facility,” she said. “I just don’t believe this is a good way to practice medicine.”
Dr. Hollander, the emergency-medicine specialist who heads JeffConnect, has lobbied in Harrisburg for an insurer mandate.
“Pennsylvania,” he said Wednesday, “is one of the few [states] that have not gotten their act together on that. Without some legislative fix, it leaves it to each insurance payer to do what it wants to do.”
As for JeffConnect’s $49 fee, Hollander said he hoped insured patients could be reimbursed by their health plans.
As for those without insurance or even a credit card, he noted that Jefferson Health provided care for the poor at emergency and urgent-care facilities. At the same time, he said Jefferson alone could not subsidize care. “Unfortunately, that is a problem we cannot solve,” he said.