Knoxville, Tennessee Correspondent — Improvement, and I say that as somebody who is usually the person in the room complaining that a new system won’t work in a rural county.
Our situation before March was that a patient in one of the outlying counties drove ninety minutes to see a specialist for a fifteen-minute appointment. A substantial number of them didn’t go. That isn’t a preference. That’s a car, a day off, and gasoline.
What changed in March is that Medicare started paying for the visit wherever the patient was. That single change did more for access in my part of the state than a decade of arguing about hospital closures.
Whether it survives is a payment question rather than a medical one. The waiver expires with the emergency declaration. The proposed rule this month would make some of it permanent and not all of it, and the part I’d fight for is the audio-only allowance, because a lot of my neighbors don’t have the broadband for video and never will on any timeline anybody has funded.
Bismarck, North Dakota Correspondent — Genuine improvement here, with a caveat that matters.
We have counties with no physician at all and distances that are hard to explain to people from elsewhere. Behavioral health in particular has been transformed — we have never had enough psychiatrists and now a patient in a town of six hundred can see one.
The caveat is that telemedicine is a substitute for the drive, not a substitute for a hospital. Several of our rural hospitals were failing before the pandemic and a video visit doesn’t deliver a baby or set a bone. There’s a risk that this gets treated as a solution to rural health rather than as one useful piece of it, because the video call is cheap and the hospital is not.
Keep it. Don’t let it become the excuse.
Cheyenne, Wyoming Correspondent — Useful and oversold in about equal measure.
Useful for a follow-up, a prescription check, a rash, a conversation about test results. Not useful when somebody needs hands on them.
The people it helps most out here are the elderly, and the elderly are the people least likely to manage a video platform without help. That’s the gap nobody has solved. My mother’s appointments this spring worked because I sat next to her and ran the device.
Make the payment permanent. Fund the broadband. Stop pretending the second part is optional.
Sheffield, Jamaica Correspondent — I would enter a note of caution that comes from watching a great many technological solutions arrive in the Caribbean with considerable enthusiasm.
Telemedicine assumes a specialist at the other end of the connection. In much of the developing world the shortage is not the distance. It is the physician, and connecting a patient in a rural parish to an absence does not improve anything.
Where it has genuinely helped us is in connecting our own clinicians to expertise abroad, which is a different application than the one being described in the United States.
The other observation is that this may accelerate something already underway, which is the treatment of health workers as a globally tradeable service. My region has been losing nurses and doctors to yours for fifty years. A technology that allows the consultation to happen without the physician relocating could cut either way, and I would not assume the direction is favourable to us.
Clermont, Florida Correspondent — I consult for small professional practices, several of them medical, so I’ve watched this from the business side.
The practices that adopted quickly are doing well. The ones that waited lost patients to the ones that didn’t, and they aren’t getting them back.
What I’d flag is the economics. Reimbursement parity — paying the same for a video visit as an in-person one — is the reason this scaled, and it’s the thing most likely to be reversed, because a payer looking at a video visit sees a lower-cost encounter and wants the price to reflect it.
If parity ends, adoption collapses, and it’ll collapse fastest in the small independent practices with the least margin. The large systems will absorb it.
Orange County, California Correspondent — The investment case has already been made and it’s substantial, which is itself a prediction.
Capital has flowed into this sector at a rate that assumes permanence. That doesn’t make permanence certain, but it means there’s now a constituency with real money at stake that will lobby hard against a rollback, and there wasn’t one in 2019.
The analytical question I’d raise is whether this is access expansion or utilization expansion. Those look identical in the volume figures and they aren’t the same thing. If a patient who would have driven now calls instead, that’s substitution. If a patient who would have done nothing now calls, that’s access. If a patient who would have called once now calls three times because it’s easy, that’s cost growth with a therapeutic story attached.
Nobody has separated those yet, and the answer determines whether payers keep paying.
Long Island, New York Correspondent — The durable obstacle is licensure and almost nobody is discussing it.
A physician is licensed by a state. During the emergency, states waived the requirement that a clinician treating their residents hold their license, which is why a specialist in Manhattan could see a patient in Connecticut without anybody committing a violation.
Those waivers are tied to the emergency declarations. When they lapse, the geography returns, and the geography is the whole point of the technology.
Fixing it permanently requires either an interstate compact with real participation or a federal preemption that a lot of state boards will fight, because licensure is also a revenue and a protection arrangement.
So my prediction is that the payment side gets sorted out and the licensure side doesn’t, and we end up with a system that works beautifully as long as the patient and the doctor are in the same state, which is the least useful version of it.
Sydney, Australia Correspondent — We ran essentially the same experiment and I can report the numbers, which may be useful.
Our government added telehealth items to the national schedule in March, initially as a temporary measure, and uptake was extraordinary — tens of millions of consultations within months in a country of twenty-five million. Most of it audio rather than video, which surprised people who had assumed video was the product.
The government has now extended it repeatedly rather than making it permanent, which tells you something about how these decisions actually get made. Nobody wants to end it and nobody wants to price it permanently, so it lives on extensions.
The concern raised here that I’d pass on is fragmentation. A patient who sees whoever answers, rather than a regular practitioner who knows the history, gets worse care over time even if each individual consultation is fine. Our medical colleges have pushed for the benefit to attach to an existing patient relationship for that reason, and I think they’re right.
