COVID-19 Pandemic Previews Telemedicine’s Future: Chronic Disease Management

By Mark Stephan, MD, Chief Medical Officer, Equality Health
Twitter: @equalityhealth

In the grip of the COVID-19 pandemic that has already infected more than one million Americans, it’s difficult to think too distantly into the future. Right now providers are concerned about the health and wellbeing of their patients, many of whom have avoided care over the past several months. However, thanks to a rapid expansion of telehealth, health consequences of social distancing and quarantine may be mitigated to some degree. Telehealth has emerged as a lifeline of sorts, maintaining the physician-patient relationship (albeit with some notable changes) while reducing the risk of coronavirus infection at an in-office visit.

In this, we can catch a glimpse of telemedicine’s post-pandemic future – a tool to be used by clinicians to improve management (and self-management) of chronic conditions. Because so much of managing chronic diseases involves monitoring functional status, patient education, development of treatment plans and discussing disease trajectory, elements which require limited or no (re)examinations, telemedicine represents an ideal means of accomplishing these tasks.

A telehealth progress report
Telemedicine has been around for decades in the U.S., primarily used in the beginning as a mechanism for delivering care to rural and underserved populations. While telemedicine’s adoption certainly expanded in the intervening, pre-COVID years, the medium had yet to really establish itself. For example a 2019 report from Definitive Healthcare showed that only about one-third of inpatient hospitals and 45% of outpatient facilities provided telemedicine services.

Our experience within the Equality Health Network shows that medical practices fall into a wide spectrum of telemedicine adoption, with some physicians very interested in the technology’s potential, and many wary about the impact on practice operations. But even in the latter group, practices decisively pivoted to telehealth soon after the national emergency was declared. All told, independent physician practices in our network have since conducted more than 7,500 telehealth visits for patients of all ages and needs.

The formula behind this high volume in such a short time span: training, support and rallying practice staff. There is no getting around that telemedicine disrupts many established office workflows. Modifications and tweaks will be needed, from scheduling visits to conducting them to post-encounter documentation. But the benefits of integrating telehealth into the practice are worth the leap–especially if using the technology to better manage the underlying conditions that make people especially vulnerable during the COVID-19 pandemic.

Using telemedicine for chronic disease management
We now know that people with chronic conditions such as chronic obstructive pulmonary disease (COPD), diabetes and chronic kidney disease are at greater risk of developing severe illnesses related to COVID-19.

Chronic diseases affect approximately 133 million Americans, which represents more than 40% of the total population of the nation, according to the National Health Council. Many of these people are understandably nervous at the prospect of acquiring a life-threatening virus at a medical facility, leading them to put off needed care maintenance.

This is where telemedicine has an important role to play, not only during the pandemic, but after the outbreak subsides. Millions of patients with chronic illnesses need help managing their conditions, but not necessarily in the provider’s office. Once a patient has had an initial in-person examination, clinical diagnosis and plan of care established with a provider, telemedicine could actually become the preferred option for chronic disease management – barring any significant changes in health status.

For example, the challenges faced by most chronic diabetes patients in controlling their conditions primarily involve health behavior changes. For both diabetes patients and physicians, these conversations about goals, sugar levels, barriers to improvement, exercise, weight loss and the like can be productive virtually, without requiring the inconvenience and potential safety compromises of an office visit.

Absent significant changes to the diabetic patient’s blood sugar levels, these virtual visits can continue for months. Should the patient’s blood sugar levels show a departure from the norm, she may be referred by her provider to undergo lab tests, obtained at a laboratory draw site or the office at the time of the patient’s choosing.

For many other chronic diseases, as well as behavioral healthcare issues, the scenario is the same. Management of these conditions is accomplished primarily through discussion and shared-decision-making, which make them ideal candidates for telemedicine.

Permanently removing the roadblocks
The COVID-19 pandemic has only further justified why the U.S. healthcare system must continue its transition from fee-for-service reimbursement to value-based, advanced models of payment.

In the former, providers are paid for seeing more patients and doing more procedures, while consultations have generally been undervalued in reimbursement. Because of this disparity, ambulatory clinicians have been hesitant to shift substantially to virtual consultations, which has historically hindered telehealth growth and adoption.

In contrast, under a value-based system such as capitation, providers are incentivized to focus more on preventive care today that will help avoid costly complications tomorrow. For telemedicine to truly take off for chronic disease management, the U.S. healthcare system must boost investment in these types of alternative payment models. Doing so will clear the path toward a healthier post-pandemic future.