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State Loosens Telehealth Rules As Providers Ramp Up Services

Telemedicine visit with Kaiser Permanente. | COURTESY OF KAISER PERMANENTE NORTHWEST
March 25, 2020

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As they cancel non-urgent office visits and surgeries to cope with the coronavirus, Oregon medical providers - from primary care doctors to physical therapists and mental health counselors - are rapidly shifting to telemedicine.

The number of video and audio visits is rising in Oregon, both among providers at large hospitals in the Portland area and in sparsely populated regions of the state, where providers are few. Telemedicine protects patients by keeping them out of waiting rooms and allows providers to work without wearing eyewear and face masks, minimizing their risk of exposure to the virus.

But there have been bureaucratic and financial obstacles to telehealth consultations. Insurers have set low reimbursement rates, limited the types of visits allowed and prescribed how they are conducted, banning some technology platforms. 

On Tuesday, state officials lifted many of those obstacles. The state Department of Consumer and Business affairs, which regulates the commercial insurance industry, and the Oregon Health Authority, which oversees Medicaid, said they were loosening telehealth regulations while the COVID-19 outbreak rages. 

The agencies ordered insurers, including coordinated care organizations that administer Medicaid, to support telehealth options on all platforms, which includes video, audio, email and text. 

“The state expects health plans of all types to provide increased access to health care services through telehealth delivery platforms and to encourage patients to use telehealth delivery options to limit the amount of in-person health care services they seek,” they said in a joint announcement.

The agencies told insurance plans to cover in-network telehealth services, including for behavioral health and substance abuse. They said providers can use the visits for all types of health care -- not just for suspected COVID-19 cases -- and that services should be reimbursed at a rate equivalent to an in-person visit to ensure that providers don’t suffer a loss of income by foregoing face-to-face consultations. The announcement said the state was waiving restrictions on where patients could be served, who could be served and the location of providers, allowing them to conduct visits from their home. The guidelines also indicated that patients will not face higher co-pays for a telehealth consultation than they would for an office visit.

The announcement follows similar decisions by Medicare, which only allowed limited telemedicine consultations in the past. Now Medicare will pay for telehealth visits, including when the patient is at home, conducted by a range of providers, including doctors, physician assistants, nurse practitioners, clinical psychologists and licensed clinical social workers.

These new rules could broaden the reach of telehealth at a time when coronavirus cases and deaths are on the rise -- Oregon had 266 cases and 10 deaths as of Wednesday -- and the state has ordered residents to stay home as much as possible.

Portland-Area Hospital Ramp Up Services

Already, Kaiser Permanente, Legacy Health and Oregon Health & Science University have stepped up their telemedicine programs.

By Friday, OHSU said it expected to have 1,000 licensed health care professionals, including oncologists and behavioral health specialists, available for telehealth consultations, a five-fold increase since January. OHSU conducted 345 remote visits in January. That number reached 1,600 consultations by this past Monday, the university said. OHSU is also expanding services at Hillsboro Medical Center, formerly Tuality Community Hospital, and Adventist Health Portland.

Portland-based Legacy Health did not provide numbers but said in a statement that Legacy and GoHealth urgent care centers have seen a “substantial increase in the use of virtual visits.” The company said it is rallying more physicians to expand telemedicine visits to more patients. A Providence Health & Services spokesman said the company's online and phone behavioral health consults are "popular."

Kaiser Permanente Northwest has a dedicated group of physicians who only offer telehealth consultations through a regional call center while other providers slip them into their day, conducting phone and video consultations and email exchanges. The company also has an online screening tool. The program is a well-oiled machine, said Dr. Stella Dantas, associate medical director of ambulatory and convenient care at Kaiser Permanente Northwest. 

“We knew it was the wave of the future,” Dantas said. “We started our virtual care about four or five years ago.”

Since March 12, Kaiser Permanente’s video and phone primary care visits in Oregon and Southwest Washington have skyrocketed. They now constitute 92% of all primary care visits, up from 32%. Video and phone specialty care visits have risen, too, from 24% to 76%, the company said. 

Use of the company’s online screener has jumped as well -- by 500% to 300 consultations a day over the past 26 days. In the screener, patients type in their symptoms, temperature or other data and receive a diagnosis and even a prescription, when appropriate.

Telehealth helps to keep the burden off the health care system at a crucial time when lives are at risk, Dantas said.

“We want safety for our patients, and we want safety for our employees,” Dantas said. “If you do not need a face-to-face appointment, if you do not need an in-person exam, then (the visit) should be offered virtually.”

Telehealth visits are appropriate for a wide range of conditions, from postpartum check-ups to primary care consultations to dermatological diagnoses and urology appointments. But they’re not a solution for many other conditions. The visits are especially useful for triaging flu or COVID-19 patients. 

“It’s not going to change their outcome,” Dantas said. “If they need a higher level of care, we are directing them to where they can get that care.”

Community Health Centers Face Challenges

As Portland-area hospitals scale up their existing telemedicine systems, many community health centers that serve low-income and elderly patients are just getting started. 

There are 32 community health centers in Oregon, all represented by the Oregon Primary Care Association. They stretch from Enterprise in northeastern Oregon to Klamath Falls near the California border and Bandon, on the southern coast.

Reliant on state and federal tax dollars, they offer physical and mental health care along with dental services for patients on Medicare and Medicaid and those who are underinsured or uninsured.

Their model has focused on trying to get people into the center or reaching them through mobile units, said Danielle Sobel, the primary care association’s policy director.

The centers have offered virtual visits in the past, but these were strictly limited. Both Medicaid and Medicare required that a patient go to an originating site, like the center, to qualify for reimbursement, Sobel said.

But both the Oregon Health Plan and Medicare have loosened that rule, allowing providers to conduct visits from home and even allow phone visits. 

“Those were not billable in the past,” Sobel said.

The centers were quick to adapt, she said.

“Our clinics very quickly pivoted to that (telehealth) model to protect their staff and their patients and take care of the patients,” Sobel said.

But not all patients have computers, and some don’t have smartphones. And some areas, for example around Enterprise, have poor broadband access. So the centers have set up WiFi stations. One example is Winding Waters Clinic in Enterprise. It now has a WiFi station in the parking lot of a school.

“Every single one of our (centers) is figuring out how to operationalize (telehealth),” Sobel said. “We’re getting really creative. Health centers are good at that.”

No one knows how long these extraordinary measures will last. But health care leaders said loosening the rules makes it easier for them to provide care.

You can reach Lynne Terry at [email protected] or via Twitter @LynnePDX.