Michelle Andrews: When to ask for an in-person medical visit instead of a virtual one
“As a consumer, you should do what you feel comfortable doing. And if you really want to be seen in the office, you should make that case.”
— Dr. Joe Kvedar, Harvard Medical School professor and former chairman of the American Telemedicine Association
When the COVID-19 pandemic swept the country in early 2020 and emptied doctors’ offices nationwide, telemedicine was suddenly thrust into the spotlight. Patients and their physicians turned to virtual visits by video or phone rather than risk meeting face-to-face.
During the early months of the pandemic, telehealth visits for care exploded.
“It was a dramatic shift in one or two weeks that we would expect to happen in a decade,” said Dr. Ateev Mehrotra, a professor at Harvard Medical School whose research focuses on telemedicine and other health-care delivery innovations. “It’s great that we served patients, but we did not accumulate the norms and [research] papers that we would normally accumulate so that we can know what works and what doesn’t work.”
Now, three years after the start of the pandemic, we’re still figuring that out. Although telehealth use has moderated, it has found a role in many physician practices, and it is popular with patients.
More than any other field, behavioral health has embraced telehealth. Mental-health conditions accounted for just under two-thirds of telehealth claims in November 2022, according to FairHealth, a nonprofit that manages a large database of private and Medicare insurance claims.
Telehealth appeals to a variety of patients because it allows them to simply log on to their computer and avoid the time and expense of driving, parking, and arranging child care that an in-person visit often requires.
But how do you gauge when to opt for a telehealth visit versus seeing your doctor in person? There are no hard-and-fast rules, but here’s some guidance about when it may make more sense to choose one or the other.
“As a patient, you’re trying to evaluate the physician, to see if you can talk to them and trust them,” said Dr. Russell Kohl, a family physician and board member of the American Academy of Family Physicians. “It’s hard to do that on a telemedicine visit.”
Maybe your insurance has changed and you need a new primary-care doctor or OB-GYN. Or perhaps you have a chronic condition and your doctor has suggested adding a specialist to the team. A face-to-face visit can help you feel comfortable and confident with their participation.
Sometimes an in-person first visit can help doctors evaluate their patients in nontangible ways, too. After a cancer diagnosis, for example, an oncologist might want to examine the site of a biopsy. But just as important, he might want to assess a patient’s emotional state.
“A diagnosis of cancer is an emotional event; it’s a life-changing moment, and a doctor wants to respond to that,” said Dr. Arif Kamal, an oncologist and the chief patient officer at the American Cancer Society. “There are things you can miss unless you’re sitting a foot or two away from the person.”
Once it’s clearer how the patient is coping and responding to treatment, that’s a good time to discuss incorporating telemedicine visits.
If a Physical Exam Seems Necessary
This may seem like a no-brainer, but there are nuances. Increasingly, monitoring equipment that people can keep at home — a blood-pressure cuff, a digital glucometer or stethoscope, a pulse oximeter to measure blood oxygen, or a Doppler monitor that checks a fetus’s heartbeat — may give doctors the information they need, reducing the number of in-person visits required.
Someone’s overall physical health may help tip the scales on whether an in-person exam is needed. A 25-year-old in generally good health is usually a better candidate for telehealth than a 75-year-old with multiple chronic conditions.
But some health complaints typically require an in-person examination, doctors said, such as abdominal pain, severe musculoskeletal pain, or problems related to the eyes and ears.
Abdominal pain could signal trouble with the gallbladder, liver, or appendix, among many other things.
“We wouldn’t know how to evaluate it without an exam,” said Dr. Ryan Mire, an internist who is president of the American College of Physicians.
Unless a doctor does a physical exam, too often children with ear infections receive prescriptions for antibiotics, said Mehrotra, pointing to a study he co-authored comparing prescribing differences between telemedicine visits, urgent care, and primary care visits.
In obstetrics, the pandemic accelerated a gradual shift to fewer in-person prenatal visits. Typically, pregnancy involves 14 in-person visits. Some models now recommend eight or fewer, said Dr. Nathaniel DeNicola, chair of telehealth for the American College of Obstetricians and Gynecologists. A study found no significant differences in rates of cesarean deliveries, preterm birth, birth weight, or admissions to the neonatal intensive care unit between women who received up to a dozen prenatal visits in person and those who received a mix of in-person and virtual visits.
Contraception is another area where less may be more, DeNicola said. Patients can discuss the pros and cons of different options virtually and may need to schedule a visit only if they want an IUD inserted.
If Something Is New, or Changes
When a new symptom crops up, patients should generally schedule an in-person visit. Even if the patient has a chronic condition such as diabetes or heart disease that is under control and care is managed by a familiar physician, sometimes things change. That usually calls for a face-to-face meeting too.
“I tell my patients, ‘If it’s new symptoms or a worsening of existing symptoms, that probably warrants an in-person visit,’” said Dr. David Cho, a cardiologist who chairs the American College of Cardiology’s Health Care Innovation Council. Changes could include chest pain, losing consciousness, shortness of breath, or swollen legs.
When patients are sitting in front of him in the exam room, Cho can listen to their hearts and lungs and do an EKG if someone has chest pain or palpitations. He’ll check their blood pressure, examine their feet to see if they’re retaining fluid, and look at their neck veins to see if they are bulging.
But all that may not be necessary for a patient with heart failure, for example, whose condition is stable, he said. They can check their own weight and blood pressure at home, and a periodic video visit to check in may suffice.
Video check-ins are effective for many people whose chronic conditions are under control, experts said.
When someone is undergoing treatment for cancer, certain pivotal moments will require a face-to-face meeting, said Kamal, of the American Cancer Society.
“The cancer has changed or the treatment has changed,” he said. “If they’re going to stop chemotherapy, they need to be there in person.”
And one clear recommendation holds for almost all situations: Even if a physician or office scheduler suggests a virtual visit, you don’t have to agree to it.
“As a consumer, you should do what you feel comfortable doing,” said Dr. Joe Kvedar, a professor at Harvard Medical School and immediate past board chairman of the American Telemedicine Association. “And if you really want to be seen in the office, you should make that case.”
Michelle Andrews is a Kaiser Health News reporter.
Michelle Andrews: andrews.khn@gmail.com, @mandrews110
Sarah Jane Tribble: It can be telehealth vs. no care
— Photo by Ceibos
Dartmouth-Hitchcock Medical Center, in Lebanon, N.H.
— Photo by Jared C. Benedict
When the COVID-19 pandemic hit, Dr. Corey Siegel was more prepared than most of his peers.
Half of Siegel’s patients — many with private insurance and Medicaid — were already using telehealth, logging onto appointments through phones or computers. “You get to meet their family members; you get to meet their pets,” Siegel said. “You see more into their lives than you do when they come to you.”
Siegel’s Medicare patients weren’t covered for telehealth visits until the pandemic drove Congress and regulators to temporarily pay for remote medical treatment just as they would in-person care.
Siegel, section chief for gastroenterology and hepatology at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., is licensed in three states and many of his Medicare patients were frequently driving two to three hours round trip for appointments, “which isn’t a small feat,” he said.
The $1.7 trillion spending package that Congress passed in December included a two-year extension of key telehealth provisions, such as coverage for Medicare beneficiaries to have phone or video medical appointments at home. But it also signaled political reluctance to make the payment changes permanent, requiring federal regulators to study how Medicare enrollees use telehealth.
The federal extension “basically just kicked the can down the road for two years,” said Julia Harris, associate director for the health program at the Washington, D.C.-based Bipartisan Policy Center think tank. At issue are questions about the value and cost of telehealth, who will benefit from its use, and whether audio and video appointments should continue to be reimbursed at the same rate as face-to-face care.
Before the pandemic, Medicare paid for only narrow uses of remote medicine, such as emergency stroke care provided at hospitals. Medicare also covered telehealth for patients in rural areas but not in their homes — patients were required to travel to a designated site such as a hospital or doctor’s office.
But the pandemic brought a “seismic change in perception” and telehealth “became a household term,” said Kyle Zebley, senior vice president of public policy at the American Telemedicine Association.
The omnibus bill’s provisions include: paying for audio-only and home care; allowing for a variety of doctors and others, such as occupational therapists, to use telehealth; delaying in-person requirements for mental health patients; and continuing existing telehealth services for federally qualified health clinics and rural health clinics.
Telehealth use among Medicare beneficiaries grew from less than 1% before the pandemic to more than 32% in April 2020. By July 2021, the use of remote appointments retreated somewhat, settling at 13% to 17% of claims submitted, according to a fee-for-service claims analysis by McKinsey & Co.
Fears over potential fraud and the cost of expanding telehealth have made politicians hesitant, said Josh LaRosa, vice president at the Wynne Health Group, which focuses on payment and care delivery reform. The report required in the omnibus package “is really going to help to provide more clarity,” LaRosa said.
In a 2021 report, the Government Accountability Office warned that using telehealth could increase spending in Medicare and Medicaid, and historically the Congressional Budget Office has said telehealth could make it easier for people to use more health care, which would lead to more spending.
Dr. Corey Siegel and his colleagues at Dartmouth-Hitchcock Medical Center see remote care as a tool for helping chronically ill patients receive ongoing care and preventing expensive emergency episodes. It “allows patients to not be burdened by their illnesses,” he says. “It’s critical that we keep this going.”
Advocates like Zebley counter that remote care doesn’t necessarily cost more. “If the priority is preventive care and expanding access, that should be taken into account when considering costs,” Zebley said, explaining that increased use of preventative care could drive down more expensive spending.
Siegel and his colleagues at Dartmouth see remote care as a tool for helping chronically ill patients receive ongoing care and preventing expensive emergency episodes. It “allows patients to not be burdened by their illnesses,” he said. “It’s critical that we keep this going.”
Some of Seigel’s work is funded by The Leona M. and Harry B. Helmsley Charitable Trust.
For the past nine months, Dartmouth Health’s telehealth visits plateaued at more than 500 per day. That’s 10% to 15% of all outpatient visits, said Katelyn Darling, director of operations for Dartmouth’s virtual care center.
“Patients like it and they want to continue doing it,” Darling said, adding that doctors — especially psychologists — like telehealth too. If Congress decides not to continue funding for remote at-home visits after 2024, Darling said, she fears patients will have to drive again for appointments that could have been handled remotely.
The same fears are worrying leaders at Sanford Health, which provides services across the Upper Midwest.
“We absolutely need those provisions to become permanent,” said Brad Schipper, president of virtual care at Sanford, which has health plan members, hospitals, clinics, and other facilities in the Dakotas, Iowa, and Minnesota. In addition to the provisions, Sanford is closely watching whether physicians will continue to get paid for providing care across state lines.
During the pandemic, licensing requirements in states were often relaxed to enable doctors to practice in other states and many of those requirements are set to expire at the end of the public-health emergency.
Licensing requirements were not addressed in the omnibus, and to ensure telehealth access, states need to allow physicians to treat patients across state lines, said Dr. Jeremy Cauwels, Sanford Health’s chief physician. This has been particularly important in providing mental health care, he said; virtual visits now account for about 20% of Sanford’s appointments.
Sanford is based in Sioux Falls, S.D., and Cauwels recalled one case in which a patient lived four hours from the closest child-adolescent psychiatrist and was “on the wrong side of the border.” Because of the current licensing waivers, Cauwels said, the patient’s wait for an appointment was cut from several weeks to six days.
“We were able to get that kid seen without Mom taking a day off to drive back and forth, without a six-week delay, and we were able to do all the things virtually for that family,” Cauwels said.
Psychiatrist Dr. Sara Gibson has used telehealth for decades in rural Apache County, Arizona. “There are some people who have no access to care without telehealth,” she said. “That has to be added into the equation.”
Gibson, who is also medical director for Little Colorado Behavioral Health Centers in Arizona, said one key question for policymakers as they look ahead is not whether telehealth is better than face-to-face. It’s “telehealth vs. no care,” she said.
Sarah Jane Tribble is a Kaiser Health News reporter.