April 30th, 2020
Story

Illustration by iStock/rashadashurov

By Fran Kritz

Since mid-March, Kyle Knierim, MD, a family physician with UCHealth, is much more likely to be interacting with patients on his smartphone or computer screen than seeing patients in an exam room.

The physician’s technology devices have become a critical part of his medical practice since the spread of COVID-19, the disease caused by the novel coronavirus, drastically reduced the number of in-person patient visits for the safety of both patients and providers. That prompted UCHealth’s clinics, like so many other medical practices across the state and country, to recommend that many patients see their physicians through telemedicine visits via smartphone, tablet or computer.

Expanded Medicaid rules for telehealth visits released in March by Health First Colorado, the state Medicaid program managed by the Colorado Department of Health Care Policy and Financing (HCPF), made such visits available to even more people in the state. Providers were previously reimbursed by Medicaid for visits over a computer screen, but the types of covered telehealth consultations have been significantly broadened.

“Functionally, from a provider’s perspective, the biggest change was that Health First made live chats and phone calls equivalent to in-person visits,” said Knierim, who also heads the department of practice innovation at the University of Colorado School of Medicine. “Expanding it to phone really reduced the technological barriers for our Medicaid patients.”

In February, the 13 UCHealth primary care clinics conducted about 80 virtual visits, according to Knierim. While overall visits have been down in the wake of the coronavirus outbreak, the number of telehealth visits increased to more than 3,000 in March. And as of late April, upwards of 20% of the virtual visits at the clinics were by patients covered by Medicaid. “We’re seeing that number go up each week,” said Knierim.

Reducing barriers to care for Medicaid clients in the state as the outbreak unfolds has been critical, said John Thomas, PhD, MSSW, director of telehealth at Children’s Hospital Colorado. Internet access (and, in particular, high-speed broadband access) needed for video chats is still lacking in some parts of the state, especially in rural Colorado communities. As of November 2019, 13% of the state lacked broadband access, according to the Governor’s Office of Information Technology, including areas with high percentages of Health First Colorado enrollees.

Expanding telemedicine access within Health First Colorado “improves access to care, protects our providers who are on the front line caring for Coloradans and reduces the demand for provider personal protective equipment which is in short supply,” said Kim Bimestefer, HCPF’s executive director, in a statement. “Telemedicine will prove to be one of the most effective means of improving access to care while mitigating coronavirus spread.”

Lisa Latts, MD, Health First Colorado’s chief medical officer, said the Governor’s Office of Information Technology is looking at how to both expand internet access to more rural areas as well as increase speed in order to allow for video chats—a feature also crucial for online classes while schools are closed.

Knierim says live-chatting has become very popular with his Medicaid clients, especially parents who are grateful for a quick reply. “I can’t say we won’t need to bring a patient in or even refer to an ER if something is serious, but often we can assess the situation and even suggest an over-the-counter product they may already have at home, providing peace of mind while they continue to stay safe inside,” said Knierim.

Francesca Maes, 60, had her first-ever teleheath visit in early April. The Thornton, Colo. resident has severe asthma and disabilities that impact her mobility. When she recently began experiencing symptoms, she thought it might be COVID-19, and she reached out to her primary care physician, based at National Jewish Health in Denver—a two-hour trip for Maes by public transportation.

Maes asked about a telehealth visit, and the new Medicaid rules made the process simple—and even able to overcome some glitches. Previously, telehealth visits had to be on secure platforms. But with the COVID-19 pandemic putting so many people in need of easy access to health care providers, Health First Colorado made the decision to allow access off-platform.

In Maes’ case, the visit was over Zoom, the popular videoconference software. The audio failed to connect, but the expanded Medicaid rules meant the doctor could see Maes by Zoom and speak with her simultaneously by calling her cell phone. Within a few minutes of the visit starting, the National Jewish Health provider had sent a prescription order to Maes's pharmacy, replenishing one medication Maes had run out of and also adding a new one.

“I liked the visit,” said Maes. “They could hear my breathing and they could see me coughing, and could make an assessment—I thought it was a thorough exam.” Maes said displaying her symptoms over phone and video was “just what I would do in front of them if I had to go in, but much less stressful.” She still has headaches, but has chosen not to get tested for COVID-19.

While physicians and clinic directors say many of the telehealth visits are generally not specific to COVID-19, “patients are so anxious, and so questions about the virus pop up during almost all encounters,” said Thomas of Children’s Hospital Colorado.

In addition to adding telephone use for telehealth visits, Health First Colorado is also allowing federally qualified health centers and rural clinics to be able to bill for those services as if it were an in-person visit, and at the same rates. They’ve also expanded the telehealth services that can be covered, to now include physical therapy, occupational therapy, home health, hospice and pediatric behavioral therapy.

When it comes to telehealth and Medicaid, “we’ve seen 100 years of progress” since March, Latts said.

Health care practices are continuing to work on interpretation services for the telehealth visits. Pamela Valenza, MD, chief health officer at Clínica Tepeyac in Denver, says all clinical staff speak both English and Spanish, and for patients who speak other languages they are able to provide interpreter services by phone. The UCHealth clinics currently have Spanish language and ASL interpreters, and will soon be able to add other languages.

Informing Health First clients of the new telehealth options for assessments and evaluations has been a priority. Examples have included website banners, emails, patient-portal messages and even phone trees, said Knierim. At Clínica Tepeyac, which calls itself “a gateway to health for the underserved,” website information about the clinic’s expanded virtual visits explain that “anyone who can use technology like Skype or Facebook can use telemedicine.”

Valenza says administrative staff at Clínica Tepeyac are contacting all patients ahead of a scheduled appointment, to let them know that the clinic is still open, and for those that are eligible (based on their medical needs) giving the option to convert their visit to a telehealth visit instead through the clinic’s new telehealth platform.

Not every visit can be accomplished via telehealth, though. For example, the American Academy of Pediatrics is recommending that in-person visits continue for newborns and early childhood immunizations, so practices are working to separate healthy children from those who have COVID-like symptoms. During a phone meeting of the Medical Services Board in March to discuss the emergency Medicaid rules on telemedicine, Christine Fraley, MD, a member of the board and a pediatrician with Pediatric Partners of the Southwest in Durango, said her practice, which has 9,000 patients, was using an empty school clinic for well-child visits.

“Our schedulers and scheduling algorithms have scripts and prompts to promote virtual visits first—in some cases, virtual only, depending on the complaint,” says Knierim. And ahead of a video visit, staff is “troubleshooting a lot of the technology barriers” with patients, explaining what to click, for example, to join a Zoom visit.

Knierim says the clinic has discussed providing tablets or other technology to Medicaid clients who don’t have computer access, especially if the COVID-19 crisis goes on for much longer. “We’re also looking for access to self-care devices like home pulse oximeters,” he added, “so that people can monitor for COVID severity by themselves without having to come in. That’s difficult because of [equipment] shortages.”

While telehealth experts and practitioners say they are glad that Medicaid clients have been able to use a range of technology to access their health care providers during the current crisis, they hope at least some privacy protections will be restored once the COVID-19 pandemic has abated.

“You have to put some of those things back into place,” said Thomas of Children’s Hospital Colorado. “Patients have to feel confident that information about them will be kept private—for example, behavioral health information to keep patients from feeling vulnerable. You absolutely need privacy protection for the patient, and there are ways to do it that aren’t cumbersome.” At Clínica Tepeyac, for example, patients use a secure portal in part so that the telehealth visits can continue seamlessly if the emergency rules are changed when the pandemic ends.

As with every other state, the Medicaid waiver for expanded telehealth visits is officially only allowed for the duration of the COVID-19 crisis. Yet health care policy experts expect at least some of the expansion to remain once the crisis has passed.

“I hope we can learn from this, and I know that people are starting to think about what is working when it comes to patient safety, satisfaction and experience, both for care teams as well as for patients,” said Susan Mathieu, the Medicaid policy director at the Eugene S. Farley, Jr. Health Policy Center at the University of Colorado School of Medicine. Among the benefits Mathieu hopes remain after the crisis are phone calls as reimbursable visits and ramped-up comfort with the technology among patients.

Knierim says he’s really glad to see his patients during this anxious time, and video visits come with added benefits.

“I had a scheduled visit with a patient recently and I saw her husband, who’s also one of my patients who I haven’t seen in over a year, walking around in the background,” said Knierim. “There are pieces of the tele-visits that build a stronger relationship with the care team and the patient. I appreciate it.”

Fran Kritz
Health care and health policy writer
Washington, DC