It was early March, just before Covid-19 would hammer and ultimately lock down the Garden State, and Jean Boyko of Lavallette was seeing her internist about a burn she’d suffered at her backyard grill a few weeks earlier. She’d been applying an antibiotic ointment to the burn, but instead of healing, it had developed into an itchy rash, and Boyko was concerned.
The doctor took a look, assessed the rash as an allergic reaction, and instructed her to discontinue the ointment. But the rash persisted, so a few weeks later, Boyko called her dermatologist, who was now seeing all of his patients remotely. During a Zoom video call, she showed him the rash, and he told her it was almost certainly an infection, which she could treat with antibiotics.
Sure enough, after several days on the prescribed meds, the rash cleared up. “Ironically,” she says, “going to the doctor in person turned out to be inferior to seeing a specialist by telemed.”
More than half a year into the pandemic, most patients are familiar with the concept of telemedicine (also known as telehealth and virtual care), either because they’ve seen a doctor virtually themselves or know someone who has. According to the management consulting firm McKinsey & Company, as of this past May, nearly half of American patients had experienced at least one telehealth visit in 2020, as opposed to 11 percent in 2019.
Covid-19 didn’t create telemedicine. Some of the first video consults between doctors and patients took place in the early 1960s as part of a program at the University of Nebraska. The concept of widespread virtual care really took hold with the rise of the Internet in the 1990s. But what Covid-19 did create are the ideal conditions in which telemedicine could flourish: a growing fear of contagion; government stay-at-home orders in many states, including New Jersey; and—perhaps most significantly—new laws, in the Garden State and elsewhere, that mandated insurance coverage for televisits.
In March, it was already clear that, without virtual care, there would be no care at all for most non-Covid-19 patients, thanks to the lockdown. So that month, the state Legislature enacted a law requiring that so-called fully insured health plans issued in New Jersey—group health plans created when an employer or other association buys health insurance from a commercial insurance company to cover its employees or members—provide reimbursement for televisits up to the same amount allowed for in-person visits.
Many legislators, including Herb Conaway (D-Delran), himself a physician, felt that “up to” wasn’t good enough, and that the law shouldn’t just apply to fully insured plans. A new bill, cosponsored by Conaway, passed the Assembly Health Committee in June; as of this writing, it hadn’t yet been presented for a vote. If enacted, it would ensure telehealth reimbursement at parity with in-person care for a much wider variety of insurers, including state Medicaid and the State Health Benefits Program (for state employees).
That’s particularly important, notes Conaway, because telemedicine isn’t likely to disappear when the Covid-19 emergency abates. “I think the trajectory for telehealth isn’t going anyplace but upward now that so many people have had experiences with it,” he says. In addition to its necessity during the pandemic, telemedicine is useful, he says, for “people who don’t have mobility, those in rural areas, and those at a distance from their health care providers.”
It’s also incredibly convenient, as anyone who’s had to interrupt a busy day to travel to the doctor (and sometimes languish in the waiting room) can attest. Annie Costa, a resident of West Orange who takes the immunosuppressant medication Enbrel for a chronic autoimmune disorder, needs to see her rheumatologist at Manhattan’s Hospital for Special Surgery every three months to get her prescription renewed. This August, she saw him via Zoom. He couldn’t palpate her fingers to check for pain, so he showed her how to do it herself.
Not only did the televisit save Costa several hours of travel time, it cut her wait time to about two minutes. The consultation was initiated by a call from a medical assistant when the doctor was ready for her. “Unless my symptoms were to get worse,” says Costa, “I would feel very comfortable continuing teledoc appointments for my three-month checkups.”
In fact, in a survey this year of 1,000 patients conducted by Wakefield Research, more than 75 percent of respondents reported they were “very satisfied” or “completely satisfied” with their telemed experiences. Today, patients in New Jersey can access a wide array of medical services via televisit, including pediatric psychiatry, addiction counseling and cancer care.
Since March, for example, patients at Rutgers Cancer Institute of New Jersey and RWJ Barnabas Health have been able to receive at least some of their care virtually. Dr. Michele Blackwood, chief of breast surgery at the institute and northern regional director of breast services for RWJ Barnabas Health, notes that “breast cancer and breast issues are very well suited to telemedicine,” since so much of treatment involves discussion—about options (lumpectomy versus mastectomy, various methods of breast reconstruction versus none at all, etc.), genetic risks and other topics.
In a sign of the times, a growing number of medical schools, including the Hackensack Meridian School of Medicine in Nutley, are offering courses in telemedicine. Virtual care, says Dr. Harpreet Pall, a pediatric gastroenterologist, chair of Hackensack Meridian’s telehealth committee for children’s health and chair of pediatrics at Hackensack Meridian K. Hovnanian Children’s Hospital, “is definitely going to be a very important part of our care-delivery system for the future, so we want to be sure that we’re training doctors on how to be most impactful with it.” The two-week course through the School of Medicine, which covers everything from setting up a remote video operation to maintaining privacy online to conducting a virtual physical exam, is likely to become a part of the standard curriculum. In fact, in June, the American Medical Association officially recommended that telehealth training be a part of all medical curricula.
Patients anticipating or considering a televisit for the first time may feel like they’re at the border of a brave new world without a GPS. To provide one, and to answer the most common questions, we consulted a range of specialists, all of whom are offering both in-person and virtual care.
Do all doctors offer virtual care? And will my doctor continue to offer it after the health emergency?
While most in the medical community agree that virtual care will be part of the medical future, few are willing to guess at the scope of its ultimate role. “It may very well be that the bulk of the service delivery by some of the providers may be mostly telemedicine, with very little in-person care,” says Conaway. That would be a relatively easy transition for some specialties, like psychiatry and psychology, which require little in the way of hands-on care.
Dr. Thomas Zaubler, chair of the department of psychiatry at Morristown Medical Center, cites research indicating that, in terms of results, telepsychiatry is comparable to in-person psychiatric care. And in some cases—treating patients with autism using the therapy known as applied behavior analysis, for instance—it may be superior: “Sometimes for those with developmental disabilities,” Zaubler explains, “there’s significant stress in going to an office for an appointment.”
On the other hand, there are instances—and entire specialties—for which telehealth is not ideal. Although many patients have undergone virtual physical exams during the pandemic—providing information to the doctor on vital signs and other health data like weight, temperature and, if they have the necessary equipment on hand, blood pressure, oxygen saturation and blood sugar—Glen Ridge family physician Dr. Michele Nitti believes that wellness exams and physicals are better conducted in person. “In a physical,” she says, “you’re asking a lot of questions, the answers to which may lead to a need for hands-on examinations.”
Dr. Kaliq Chang, an interventional pain specialist in West Orange, notes that visits to diagnose the source of pain are better done in person and often require testing that can’t be done at home. And in a specialty like OB/GYN, notes Dr. Judith Pinto, a gynecologist in Wayne, “physical exams are almost always a part of the visit.”
Two specialties that lend themselves well to telehealth are dermatology, which relies heavily on visual, rather than hands-on, examination, and gastroenterology, for which a doctor-patient conversation can sometimes provide enough information for a diagnosis. Across many specialties, follow-up visits are well suited to virtual care, often requiring little more than a few questions and perhaps a simple measurement—blood pressure for someone who’s hypertensive, for example, or blood sugar for a diabetic—that can easily be done by the patient. In addition, across an array of specialties, second opinions can frequently be handled remotely.
Like many physicians, Dr. Jonathan Teitelbaum, a pediatric gastroenterologist in Long Branch, says, “Most of us expect that even after the pandemic, we’ll continue to offer some type of telemedicine.” Dr. Manal Youssef-Bessler, an infectious disease specialist in Whippany, says that for stable chronic-care patients, she would probably alternate virtual and in-person visits.
What sort of preparation do virtual visits entail?
Depending on the purpose of your visit, the doctor’s particular specialty, and the equipment you have on hand (scale, thermometer, blood pressure cuff, pulse oximeter, etc.), you’ll likely be asked to take measurements such as weight, temperature, blood pressure, blood oxygen level and blood sugar before you meet with the doctor. If you have access to mobile health (mHealth)—essentially, apps that allow health-related data collection via devices like cell phones, tablets and smart watches—you may also be able to track your own heart rate and perform an electrocardiogram (ECG or EKG), a test that records the heart’s electrical activity. Dr. Mark Pass, a geriatrician in Marlboro, says that, for a televisit, he wants to know “the basics—the same vital signs that I would take in our office: the patient’s weight this morning when they woke up, wearing clothes, because typically they would be dressed in my office; their blood pressure today; their temperature today; and if they have an oxygen sensor, their oxygen level today.” You’ll also be asked to fill out paperwork online in advance of the appointment.
What video platform is my doctor likely to use? What can I do if I don’t have access to technology?
Some doctors use one or more of the widely available video conferencing platforms, including Zoom, Skype and FaceTime, while others have opted for specific medical platforms like Zoom for Healthcare, Doxy.Me or Doximity, all of which are user-friendly and comply with HIPAA (Health Insurance Portability and Accountability Act)—which means, most importantly, that they protect patient privacy. (Because of the Covid-19 emergency, the government has temporarily suspended the mandate that all platforms comply with HIPAA regulations.)
With most medical platforms, says Pass, “the patient gets a text message on their cell phone or an e-mail to their computer or tablet that they just click, and it brings them right to a secure video call.” So you don’t need to be a tech whiz—or even particularly tech proficient—to participate.
Of course, no technology is perfect, and even the best platforms are subject to glitches. “You may have issues with getting a good video or audio signal,” cautions pediatric gastroenterologist Teitelbaum. He notes that a recent storm knocked out power across parts of the Garden State, suspending telehealth for up to a week in some locations.
If you don’t have a computer or cell phone, ask your doctor if the appointment can be conducted via your land line; currently, phone visits are generally reimbursed at the same rate as video visits.
How is my televisit likely to compare to an in-person appointment?
You’ll be asked—and asking—the same questions you would during a traditional appointment and sharing your symptoms with the doctor visually and/or verbally. The major difference, of course, is that you won’t be receiving a hands-on examination—although the doctor may guide you through a limited physical examination, perhaps asking you to touch parts of your body to see if you experience discomfort.
Many practitioners, like Freehold cardiologist Dr. John Checton, say the time they spend in an online visit is comparable to that of a traditional appointment. “A new-patient televisit would typically take 45 minutes to an hour,” Checton notes. “A post-hospital visit would be about 30 minutes, and a follow-up appointment for blood pressure or cholesterol management would be 15 to 20 minutes.”
Parlin resident Robert Rasa saw four different specialists—an endocrinologist, a dermatologist, a rheumatologist and a cardiologist—between April and May. “I actually found that the amount of time they spent with me on my cell phone was very similar to the amount of time that they spent with me in the office,” he says. If a comparable in-person visit would entail a relatively lengthy hands-on exam, of course, you can expect the televisit to be shorter.
In addition, scheduling may be looser with televisits. For instance, Nitti, a family physician, says “Virtual visitis allow us the ability to fit patients into a busy day of scheduled in-office patients, if the virtual patient is flexible with timing—which they usually are as most are working from home. Also, since my staff is not involved, I am able to do after-hours virtual visits, if needed.”
There’s one more significant way in which virtual visits differ from the in-person variety: They invite the doctor into your home. As telemedicine became the norm during the height of the pandemic, many doctors were surprised at how much they could learn from observing a patient’s surroundings. Extreme clutter in the background, says psychiatrist Zaubler, might indicate a hoarding disorder. Dangerous furniture placement can represent a fall hazard, especially to elderly patients or those using walkers. Even something as simple as a bit of shower curtain in the background can be a potential lifesaver. That’s what infectious disease specialist Youssef-Bessler spotted as she was completing a televisit. She asked the patient if she was in a bathroom, and why. “She told me she couldn’t get off the toilet because she was urinating constantly, it burned, and she was feeling very weak,” says Youssef-Bessler. “I sent her to the emergency room, and she ended up admitted with sepsis,” a life-threatening blood infection.
What about the fee? Will it be the same as an in-person visit? And will insurance cover it?
If you’re covered under a fully insured health plan, as defined earlier, your televisits must be reimbursed at the same rate as comparable in-person visits for the duration of the state-declared health emergency, thanks to a March 22 directive from the state’s Department of Banking and Insurance. (If enacted, the legislation cosponsored by Conaway would convert that directive into law.)
In fact, for a televisit—at least under the current law—patients in New Jersey could actually end up paying less, since those fully insured health plans are mandated to cover telehealth services without so-called cost sharing, like copayments or deductibles. Blackwood, the breast surgeon, notes that you’ll likely experience other forms of savings as well: “Patients don’t have to take large chunks of time off work,” she says. And they don’t have to pay for gas, either.
For other types of insurance, like self-funded plans (in which a company itself funds the insurance under which its employees are covered), Medicare, the State Health Benefits Plan and the School Employees Health Benefits Plans, televisits may be reimbursed at different rates. It’s wise to check with your insurer before you connect with the doctor.
Given its advantages, telemedicine is likely to continue to be in demand going forward, with or without a global pandemic to spur its growth. Even before Covid-19 washed over our shores, telehealth was being touted as a boon in a variety of health care arenas. It could, for example, increase access to buprenorphine, a drug that’s been very effective at helping addicts wean themselves off heroin and other opioids, but hasn’t always been easy to get, particularly in rural areas suffering from a severe shortage of providers. It also allows someone with a chronic condition like opioid addiction or HIV to access services with some measure of privacy rather than having to visit a site known for treating these conditions. “Patients seen accessing treatment at a clinic for HIV infection or addiction can feel traumatized,” notes Ann Bagchi, an assistant professor at Rutgers School of Nursing, who has done research on the benefits and challenges of telehealth. “They could avoid that trauma if the services were available remotely.”
Perhaps most significantly, telemedicine holds out the promise of banishing the health care disparities that have long plagued the American medical system and created barriers to care for the elderly, rural residents, Americans of color, the LGBTQ population and those living under or near the poverty line. It could do that, says Bagchi, by lowering or eliminating the cost of transportation to and from a medical appointment and by increasing access to physicians across a wide range of specialties for patients in underserved populations—not just those in rural areas, but also inner-city residents and people with limited mobility.
To do that, telemedicine has to overcome some barriers of its own. The people who could most benefit from virtual care are those most likely to be on the wrong side of the digital divide, lacking access to the technology that makes virtual care possible, either because they can’t afford it, aren’t aware of its full potential, don’t know how to use it, or—in many rural areas and some inner-city neighborhoods—don’t have the broadband access to utilize it.
Without research to determine which populations lack access to telemedicine, Bagchi says, and without investment to help those populations get on board, “telehealth could end up exacerbating disparities.” On the other hand, she notes, if we commit to making the investments necessary to ensure equitable access to, and safe use of, telehealth technologies and services, it could create a more equitable health care system, not to mention one that’s more patient friendly, pandemic or not.
“Covid-19 forced telemedicine on us, if you will,” says Blackwood, “but it’s now a great tool to have in our armamentarium.”
Blackwood believes that virtual care will be with us going forward, an expectation shared by many, if not most, practitioners. They include geriatrician Pass, who believes that patients will continue to demand telemedicine as an option, in his specialty and others. “The horse is out of the barn,” Pass says. “Now that patients and doctors have the ability to communicate virtually, I don’t see how you can ever take that away from them.”
Leslie Garisto Pfaff is a longtime contributor on health, education and other topics.Click here to leave a comment