Telehealth may finally shift health care to be patient-centered
The COVID-19 pandemic has ushered in a new era of telehealth for primary care, and patient-centered care is now easier than ever. This has been the model promoted as early as 1967 by the American Academy of Pediatrics. The idea is that the patient and not the physician or the hospital is at the center of a wheel. Each health provider in the care team, including preventive, acute, and chronic care, is at the end of a spoke in the wheel. Each provider contributes to the care of the patient, but the patient is the ultimate decision-maker. Data shows that chronic medical conditions are managed better in this model.
Why isn’t patient-centered care just standard of care? One of the major barriers is how we have traditionally paid for health care: Under the fee-for-service model, the provider only received payment for a procedure or visit. But patient-centered care requires many time-consuming duties that are not patient visits, such as reviewing the medical record, reading and responding to email and phone calls, and monitoring tests. Under the fee for service model, those activities were not compensated.
The transition from fee-for-service to a more integrated form of patient compensation has been much too slow. As a result, physicians have been incentivized to fill their schedule with office visits. Many of these visits are not needed; they benefit physicians and the health care facility more than patients. Now that telehealth visits are being reimbursed at close to or equal to what office visits were, we can come closer to putting the patient at the center
A few years ago, at my hospital, the department of general medicine switched from fee-for-service to a “panel-based” model to compensate their primary care physicians. That means primary care physicians are now paid a fee per patient rather than per visit or procedure. My job is to manage my panel of patients and not to fill my schedule. For example, I get paid the same whether I manage a patient’s diabetes via the phone or in person. If I get an email from a patient with a question about their glucose monitoring regimen, it’s part of my job to answer. Under fee-for-service, I might spend 30 minutes answering that email without any compensation.
The old system incentivized my staff to call that patient into the office for a visit they may not really need just so I could get paid. Now, the incentive is to make contact based on patients’ preference and clinical need rather than physician need. With the panel management model, the financial interest of physicians is aligned with the patient’s health: the incentive is on what is necessary, not just what is doable.
We needed telemedicine before COVID, but the virus made it clear just how much and how quickly. Due to overwhelming need and demand, many of the old barriers to reimbursement have been lowered or eliminated. CMS and commercial insurance companies have issued policy changes expanding coverage and access so patients can get their care while staying at home. Health care systems have rapidly expanded the technological infrastructure to integrate telehealth with electronic health records. Additionally, many states are waiving in-state licensure requirements, allowing patients to “see” providers out of state. With this change, providers in Boston are now able to practice telemedicine for those who live outside Massachusetts and get paid at the same rate.
Telehealth won’t eliminate every barrier to patient-centered care. Many physicians are still skeptical about changes. They were trained in an era when the physician alone cared for the patient — some fear to lose the unique patient-doctor bond when other team members are involved in the care. The team approach requires patients to trust other physicians besides their own and be comfortable sharing sensitive and personal information with team members. As an ‘old school’ primary care physician in practice for 25 years, I was a late adapter to team care and telehealth. But I was always a proponent of patient-centered care. Now I see how interconnected they are.
As medical care is now more complex and fragmented, I have come to realize that team care is the best way to care for our patients because they have better access to us. For example, they can see a nurse practitioner instead of me with shorter waiting times. Furthermore, a nurse, social worker, case manager, mental health ‘coach’ or collaborator can more effectively educate patients, provide access to behavioral health services, and give tips on self-management support. I see physicians in my practice draws on the expertise of a variety of provider-team members. In sum, everyone gets more of what they need.
The recent changes in regulations in telehealth reimbursement need to be made permanent. Physicians should not be financially penalized for doing what is best for the patient. The old fee for service model is clearly not working: despite leading the world in medical expenditure, we are at the bottom on many health measures when compared with other advanced countries.
Our health care system, led by Centers by Medicare and Medicaid Services, needs to instead incentivize quality, improved outcomes, and patient satisfaction. Paying for telehealth and promoting non-face to face visits is one small step in practicing patient-centered care. Putting our patients first should not only be a slogan but a true mandate.
Li Tso, M.D. is a primary care physician at Mass General Hospital, assistant professor of medicine at Harvard Medical School.
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