If you’ve been to the doctor lately, you might not have actually been to the doctor’s office. Instead, doctors and other medical professionals have been coming to you virtually since stay-at-home orders began in March due to the coronavirus pandemic.
Telemedicine has been available to people for some years, but mostly it was used to connect a patient in one clinic to a specialty doctor in a different clinic.
Insurance companies also would not pay the same rate for a telehealth visit as an in-person visit, which made it financially unfeasible for doctors to use regularly.
When Gov. Greg Abbott declared a state of emergency, his declaration waived certain regulations and required state-regulated insurance plans to pay the same amount for telemedicine visits as in-person visits. The Texas Medical Board also allowed for the medical community to use telemedicine, including by phone only, to see patients.
"The governor’s office was really quick and responsive," says Dr. Debra Patt, executive vice president for public policy and strategic initiatives at Texas Oncology.
Abbott’s order covered 120 days, which was to be over in mid-July. The Texas Department of Insurance announced Wednesday that it has been extended another 60 days to Sept. 12, the department said in an email. Some advocates are pushing for the parity provision to be made permanent.
The state order only covers insurance plans regulated by the state, such as Medicaid and state plans bought through heathcare.gov. That only covers about 20% of all of Texans’ insurance plans. Plans covered by Medicare and state employee plans follow federal guidelines, which also expanded telehealth usage and added payment parity. Private or employer-subsidized plans also follow federal guidelines, but there have been no guarantees.
"Insurance is such a patchwork," says Dr. Jeffrey Kane, pediatric neurologist and the founder of Child Neurology Consultants of Austin. "Blue Cross is not one thing. Some are regulated at state rules, some are national contracts and have to follow federal rules. It’s very difficult to keep track."
Doctors’ offices have been receiving notifications from insurance companies of end dates to the parity provision, but mostly they then get another notice that the provision has been extended.
"They give us a deadline that they are going to stop paying for it, and then two days before they extend another month," Kane says. "It's created a lot of chaos."
Instead of having to switch patients’ appointments from virtual to in-person to virtual again, Kane says his practice has opted to go ahead and extend its telehealth offerings through the end of the summer and eat the cost if it has to during this time, rather than creating confusion for the families.
Of course, if a patient’s case requires a physical examination or it’s a new patient, he is seeing people in his offices.
"If they are stable and we know them, we would be happy to give them a choice," he says.
The difference in what insurance would pay before the temporary parity provisions were put in place, though, could prevent that choice. Insurance might pay as little as 10 cents for a virtual visit for every $1 it pays for an in-person visit, Kane said. There is a push to improve that — including from consumer groups, medical boards and doctor organizations — which might move it to a little less than 50 cents on the dollar, he said.
His office staff would have to check with each individual’s insurance plan to see what’s covered and at what rates.
Kane's office was exploring offering telehealth when the pandemic began and quickly got up to speed.
"Our families love it," he says. "It has taught me a lesson in terms of how difficult it is for some of our families to get into their visits."
Patt says Texas Oncology has been using telehealth in a variety of ways, including initial visits. She is able to look at their scans, show them on a shared screen and then discuss their options. Then before the surgery, she does the physical exam.
It’s also been helpful in counseling patients on the next steps. Currently, patients’ families cannot typically be in the doctors’ offices.
"If they are dying of their cancer, can you imagine doing that with that doctor and being alone without being able to bring in family to a difficult discussion?" Patt says.
She believes the need will continue as doctors’ offices have had to reduce capacity inside the building because of disease transmission concerns but still need to see patients.
"I think the genie is out of the bottle," she says. "It’s not anyone’s goal to be as restrictive as we have been."
VidHealth, which began as an Austin-based staffing company for psychiatrists, created a telehealth platform for doctors to see patients in rural communities and now has become a provider of telemedicine platforms for doctors’ practices throughout the country.
Its platform and servers went from hosting hundreds a month to 1,000 a day.
Founder Bo Claypool has been dealing with insurance companies on this matter since before COVID-19. "The overuse of outpatient services scares them," he says.
He does think that even in the case of behavioral health, if someone uses multiple telehealth visits a week paid at the same rate as an office visit, it still will be less expensive than hospitalization and could prevent the need for hospitalization.
He thinks parity will continue to be extended while insurance companies figure out new rates. Their clients (the patients) are going to demand access to this kind of care now, he says.
Claypool, who did his graduate work in epidemiology, says he doesn’t see COVID-19 disappearing anytime soon, but he would like to see the silver lining that it has helped more people discover telehealth.
For the insurance companies, he says, "This is a massive benefit and opportunity for them," he says. "They will save money in a big way."