Anna Webber needed to get the results of a recent biopsy, but she didn’t want to risk going to the doctor’s office.
Then, they called to ask if she would like to see her doctor via telemedicine – the practice of using telecommunication devices to provide health care services remotely.
“I was so relieved,” she said. “I didn’t have to travel to go get the results of my biopsy. The results were good, in itself, so that was good. But the experience … it was just amazing.”
Webber’s experience echoes that of many across the nation who don’t want to leave home and risk exposure to the novel coronavirus while sitting in a waiting area or exam room.
On March 19, following guidance by the Center for Medicare and Medicaid Services (CMS), the Texas Medical Board temporarily relaxed the rules around telemedicine and established an emergency order that requires health insurers to pay the same rate for telemedicine services as in-person visits.
As a result, a greater number of health care providers are making adjustments to the way they practice social distancing while also practicing medicine. Non-emergent procedures and surgeries also have been delayed at the direction of the federal government.
While there are many telemedicine software platforms out there, the nation’s largest virtual-care provider, Teladoc Health, is reporting a sudden surge in the use of its platform to over 100,000 appointments weekly.
Innovations in telemedicine have been widespread since the 1950s and 1960s, but Texas is one place where it really got its foothold in 1993. The rising costs and operational challenges involved in providing health care to prisoners were addressed when the Legislature passed new laws to offer them telemedicine.
Soon after, entrepreneurs and physicians from San Antonio played a major role in bringing telemedicine into the mainstream, said Michael Gorton, an entrepreneur who graduated from John Jay High School and now lives in Dallas.
Gorton partnered with physicians in Galveston, one of whom is a graduate of Thomas Jefferson High School, and, working with a local family practice physician to test the concept, turned their paper-napkin idea into a business known today as Teladoc Health, a publicly-traded company based in New York City that had total revenues of about $700 million in 2019.
But until very recently, the adoption of telemedicine among private physician practices has been curbed by a number of factors, including how health insurance companies reimburse providers for the service and safeguards around privacy.
Ogechika Alozie, an infectious disease specialist in El Paso, who serves on the Texas Medical Association’s telemedicine task force, has been using the technology for three years to care for HIV-positive patients, he said. The task force works to help Texas medical groups find resources for implementing telehealth technology, licensing, training, and payment.
In Alozie’s practice, the physicians began using telemedicine only for patients who pay out of pocket because insurance companies were not paying the same amount for a telemedicine visit as an in-person visit. “It didn’t make sense from a financial standpoint to do telemedicine then because you didn’t get the same amount of money,” he said.
But the efficiency of telemedicine meant Alozie could see more patients in a day, which was also a time-saver for the patients. Now with the pandemic, he’s expanding the use of telemedicine and recommends others get on board quickly, he said.
Telemedicine gives doctors the ability to keep in touch with their patients and “continue to [foster] that patient-physician relationship and the best care possible,” he said. “And I truly believe that coming out of this pandemic, whenever it happens, the physician and the medical groups that are able to continue that relationship and that care will be able to reboot themselves [faster].”
James Jackson, a San Antonio gastroenterologist, has been practicing medicine since 2000, seeing patients for a variety of ailments from heartburn to celiac disease. The practice is about half procedural medicine, such as colonoscopies, and the other half clinical – seeing patients in the office.
Jackson began using telemedicine via Doxy.me three weeks ago when his 24-physician group closed its Stone Oak and Boerne clinics. Learning to use the system was “incredibly simple,” he said, but so far the number of patients he’s seeing is low.
“We’re driven by referrals from primary care doctors, so as the primary care doctors aren’t busy because patients just don’t want to come in or just are valuing their time doing other things, then the referrals to us dry up,” he said. “Normally, there would be a wait to come see me. Now there’s no wait at all.”
That translates to a real economic impact as people don’t seek health care, he said, either because they are reluctant to go to the doctor or they are concerned about costs as the economy crashes. In fact, appointments are so few, 70 percent of the staff is furloughed. Thus, despite the fact that CMS is paying for telemedicine visits, and private insurers will likely follow suit, he said, it isn’t enough.
“In my opinion, the practice of medicine as we know it will change from this, and my practice will change,” Jackson said. In any case, “this is about relationships between doctors and patients and we’ll do what it takes to forge the relationship forward and learn together about the way it’s going to best work.”
WellMed, the San Antonio-based network of clinics focused on senior health care, began piloting telemedicine last fall. But when COVID-19 began to spread across the United States, the company compressed a year-long implementation plan into three weeks, said Charles Van Duyne, associate chief medical information officer and medical director for the company’s telemedicine program.
Since then, WellMed has increased the number of physicians and support staff using telemedicine from 60 or 80 to about 2,500, seeing 50 patients a day in San Antonio for chronic care needs not related to coronavirus. WellMed also eliminated patient co-pays for telemedicine visits during the crisis.
“It’s been a little bumpy, to be honest with you, with the rollout because we’ve had to do so much so quickly,” Van Duyne said. “But overall I think it’s beginning to take hold. … Seniors are much more tech-savvy than we give them credit for.”
Jon Larson, a San Antonio emergency medicine doctor licensed in 32 states, who is also senior medical director of the text-based telemedicine platform HeyDoctor, has been practicing telemedicine for 10 years, at first using Teladoc.
Now that telemedicine is in the spotlight, he said, the number of patients he’s serving has doubled in the past month. He sees 30 to 50 patients a day, coordinating their care using a messaging platform, no video.
“I often say, in the next five to 10 years, telemedicine is just going to be considered medicine at that point,” Larson said, and it may be one solution to a looming physician shortage and even physician burnout.
In the meantime, patients hoping to avoid exposure to COVID-19 by complying with stay-home orders, social distancing, and sanitation guidelines, are also avoiding doctor’s offices whenever possible.
Michele Koch was recently referred by her nephrologist to a urologist for treatment of large kidney stones. The urologist said she had to appear in person for the first visit. When she arrived at the office, a sign on the door directed those with a fever or cough not to enter.
“They had clearly removed many of the chairs in the waiting room, but they weren’t six feet apart,” she said, so she wiped down a chair before sitting to wait and used her own pen to fill out paperwork. She was anxious to avoid germs.
But none of the nurses were wearing masks or gloves, and when a worker handed her a urine sample cup with her bare hands, “at that point, I was crying,” she said.
When it comes to people who are too concerned to visit the doctor for fear of exposing themselves to the virus, local physician Jeffrey Rosenbloom said that issue, too, worries him.
“It’s scary because people are still sick,” said Rosenbloom, an ear, nose, and throat doctor who treats everything from allergies and ear infections to swallowing problems and neck masses – often through minor procedures or major surgeries.
But, “nobody is seeing patients,” he said. “So the real story is what’s going on with these sick people? Where are they? Are they getting sicker?”
Rosenbloom also wonders what will happen if people who are laid off from their jobs lose their health insurance. “It’s like a compound fracture,” he said.
For now, his group of six physicians is relying on telemedicine to try and see some patients, but struggling to examine their throats by video, unable to perform in-house hearing tests, and limited to only a handful of patients a day versus the 20 to 30 they usually see. The front door to the office is locked, and they are performing only essential procedures.
“There are a lot of limits to telemedicine – not just the fact that it’s not reimbursable,” Rosenbloom said. “A surgical specialty usually requires you to see something or feel something.”
Anna Webber also recently had a second telemedicine visit – with her family practice doctor this time. “He said this would be the way to go for a while, until we are able to get back to what we consider normal,” she said.