tv The Communicators Dr. Joseph Kvedar American Telemedicine Association CSPAN December 25, 2020 10:38pm-11:10pm EST
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>> this week on "the communicators," a discussion about a growing form of telecommunications and that is , telemedicine. joining us are dr. joseph kvedar of the american telemedicine association and harvard medical school, along with our guest reporter, kimberly leonard of "business insider." dr. kvedar, how long has telemedicine been around and what has been the growth or use of it in the past couple months? dr. kvedar: it has been around since the early 1920's, there was a picture in one of the magazines, not popular science, it had a different name back then, it shows a family huddled around a radio having a visit with a doctor on the other side. the concept has been around for a while.
the late 1960's is when it got going, and it puttered around for the next several decades and a couple months ago when we told everyone in the u.s. that they had to stay in their home and we as clinicians had to take care of them, it blossomed overnight. >> how can it be used today? kvedar: it can be used in a -- dr. kvedar: it can be used in a number of ways. the best uses, mental health is the number one use and god knows it is a growing need, so that is wonderful. a lot of urgent-care type things such as sore throats, ear aches, virtual urgent care, then chronic illness has been, follow-up visits for patients with diseases like hypertension, diabetes, heart failure, and the like handily done. are very during the pandemic, we did everything this way. i'm a dermatologist, we did a whole lot of dermatology this way. i think where we are headed is some kind of hybrid.
most people are pretty confident that we will continue to have telehealth as part of our care going forward. and there are a lot of reasons for that, perhaps we can get into some of them later. but most of those things, and then, even more. what i would finish on is saying, not everything. and really the conversation you , need to have is with your doctor, and for us as clinicians to be able to think through the , information we need to make either a diagnosis or change of care plan. and if we can do that without touching the patient, then we can do it via telehealth. peter let's bring kimberly : leonard of business insider into this conversation to explore some of those issues. kimberly: dr., thank you so much for being available for this interview. for those who are not that familiar, my understanding is
that the trump administration had to make a lot of changes to rules to allow telehealth to be used in more doctors offices. can you tell us what some of those changes were for those who might not be familiar? dr. kvedar: the other day, i testified in front of a senate panel and i was informed that there are 31 to be exact but i can only brush the highlights. the biggest one is that the federal government and both private payers came on board with this, other clinicians, the same amount of reimbursement for telehealth patients as they would if someone came in the office. that was a critical one. a second one was allowing us as clinicians to see our patients wherever they were. medicare viewed to limit it to people in rural or shortage areas. that went away. so i can be where i am now, my home, and you can be where you are and begin have a visit and
that would count and we could go for that. the second tier of regulatory relaxation was in the area of of technology and hipaa, a privacy program. and it went away overnight. they could use zoom, google hangouts, skype to do these calls. you could use a telephone. and we could talk about whether that is a good idea or not. but the third area was licensure and 39 out of 50 states have , loosened their licensure requirements so you can practice across state lines. i am in the boston area. if you happen to come visit me, let's say you live in new hampshire, which is about a half hour drive north, and you came and visited me in the office and , we wanted to do a follow-up while you were in your home, we could not do that before, because i was not licensed in the state of new hampshire. but now we can, because of these relaxations.
those three areas are the highlights. kimberly: this week, president trump said that he thought a lot of the telemedicine changes that the administration had made might become permanent. we have heard administrator verma from the centers of medicare and medicaid services say the same. if you were to look at the landscape, which are the most important factors that need to remain in a post-pandemic america? dr. kvedar: thank you for asking. when i mentioned i testified in front of the senate health committee, there was a strong bipartisan support for this. so we are very hopeful. but to be specific, to answer your question, number one is what we call the originating site concept. that i should be able to care for you wherever you are, not just in a health profession shortage area or a rural area. so that is number on our list. being, second one
federally-qualified health centers and rural health centers should be able to be reimbursed for providing these services, that was not the case before. and importantly, that the secretary of health and human services should be able to decide which services are reimbursable or not as part of their mandate. so those are three areas that are important. but were many others, are trying to be sis synced -- succinct. kimberly: it sounds as though some changes might be able to happen through rulemaking but others will probably require legislation. is that right? dr. kvedar: i believe so. the originating site rule that i mentioned was a statutory rule, and as i understand it, that would have to be a new statute to change that. peter: congress usually does not move this quickly. these things are happening pretty fast, hard to they, these rules changes?
dr. kvedar: this is a bit of a new world for me. i have not been rightly involved with government before, but i was impressed when i was on the hill. i was in the same room testifying in front of them, how committed the senators were to move as fast as possible. we have a term that we have -- term that we have telemedicine cliff. is, this ist means not an abstract notion, i am back seeing patients in the office at 40% of our previous volume and when we get a little bit more cranked up, we will be at 75% and be bones go higher than that. so in order for us to meet the demand, we have to have telehealth embedded in our workflows. that, and an't do public health emergency goes away and there is no way to fix
some of these regulatory restrictions, we will be in trouble and our patients will be in more trouble. as a dermatologist, how do you diagnose via camera? dr. kvedar: the way we do it, it turns out -- this is research that i did 30 years ago -- but your smartphone camera is adequate at taking good quality images. when we do this, we have our patients submit those images over the portal, which is secure, and they wind up in my in my electronic records, and then we can do a video call or phone call to review the images. for dermatology, a single lesion or rash, this is a great thing. a lot of my patients have had skin cancer, they need a skin check, that has to be done in the office. that is why this idea of a hybrid environment is the way we are going with this and it is , critical that we are able to do both.
peter: kimberly d. leonard.ly kimberly: my understanding is -- this is from talking to hospital ceos and doctors -- the amount of care they have offered through telemedicine has increased so drastically in the past few months. and for a lot of hospitals, it is something they wanted to do for a long time and have planned to rollout in the next two years, and instead ended up doing it in two months. what percentage would you say of doctors visits are happening over telehealth, and what are some of the biggest lessons that have come out of this? anything unexpected with the volume we have seen of telemedicine business? dr. kvedar: thank you for that. one thing i will say, i am not always proud to be in my profession. sometimes we miss things as a profession, but this is one where i am incredibly proud, because doctors who were previously skeptical or thought of this as a carry city or i'm too busy, i can't get involved,
everyone jumped in and we have not had a bad patient outcome. it has just been extraordinary. of course, patients have always loved this, patients that are really -- when you can give patients what i call a medical triad of access, quality, inconvenience, everyone is happy. and everyone knows it. the patient knows it, the doctor knows it, so i say that is the biggest surprise, that it went so well. where i work in boston, the delivery system is called mass general brigham we did 1600 , virtual encounters in february and we are now up to 16,000 a , week. so it has gone pretty smoothly. and everyone i talk to, other delivery systems, other health care providers are experiencing similar growth. about how we are going to settle out.
because we went from only seeing people in the office, overnight to only seeing people virtually, essentially. except for emergencies. we know that that is not right either. it is too early to tell, but most people, between 30% and 50% of their activities will be virtual going forward. we will see how that turns out. some people have said 70%. i think that is a little aggressive, but between 30% and 50%. and it does depend on your specialty. ophthalmologists can do little this way, you have to go to the office because of all the gadgets that they need to make the diagnosis of your eye condition. kimberly: one thing i'm curious about is for people who might be uncomfortable using the technology, maybe because they are not used to it, or they might live in a part of the country weather is not good high-speed internet. how do you get around those obstacles to make sure that this can be something that patients can use or try or have that as an option for them?
dr. kvedar: thank you for that. one pleasant surprise from this, and there have been a few, but one was that health plans and the government started paying us for telephone interactions with patients. up until the pandemic, that was never done. it was always felt like, they would say, if you call your patient after a visit, it is bundled in with a fee for the visit. and now, that is not the case. the reason i bring that up is for our patients that are in , areas where they don't have broadband or for those patients that can't afford a tablet or smartphone, the telephone works. and there has been a lot of research to show that a lot can be done. not everything, there are things that we miss if we don't have good video, especially, as i alluded to before with mental health, but there is a lot that can be done. in my case, if you send me a few
images, i am comfortable calling you to talk about the results in begin formulate a care plan well on the telephone. so telephone is an anchor point to solving the problem. of course we would love it -- , this is me speaking as an ata official -- we would love it if broadband, we would love it if the government put a stimulus funds into creating more broadband penetration. that would be great for everyone, not just for health care, but for all kinds of things. so broadband would be great. telephone visits are good. finally, one of the things we all own is making these interactions more patient-friendly. god knows some of the software is hard. some people have trouble downloading an app, etc. we have to find ways to make it so that it is very easy. there is one platform that has the workflow that you send the patient a text message when you are ready for the visit, they click on the text and open the video and they are chatting with you. we have to find ways to make it
easy, like that. peter: at the beginning of this discussion, you mentioned that hipaa has gone out the window. could you expand on that a little bit? dr. kvedar: well, yeah. sorry i did not actually need it , that way. but yes for the pandemic, the , federal government relaxed the requirements that your video platforms had to be hipaa compliant, so that we could use any number of things, and doctors did not have to -- before, to get something in, you had to hire an i.t. consultant , and do an rfp and they made it , difficult for people. hipaa is a great thing because we care about patient privacy and we take that very seriously but if you are in a practice , with two or three doctors and have to go through all of that, before, it was an excuse not to get involved. so the federal government in their wisdom was trying to let people overcome that in a time
when, as i said before the only , way we could provide care to you was to do this by telehealth. as we see the pandemic start to wane and we get back to some level of in-person care, i think we will probably see that they will reinstate hipaa, and i think that is a good thing. because for vendors to supply us with videoconferencing and other types of patient engagement technologies, they should be willing to hold door information as a patient secure, that should be part of their bargain and they should be able to do that. and if they can't do that we , probably should not be using the technology. kimberly: how can patients be confident that their health information, when done under video or over the phone, can be confidential? i think of instances where a physician might take a call from a patient when they are in a public place such as a grocery store, or if the information were to get hacked somehow as a patient is having a conversation, how can you make
sure that patients can feel comfortable and know that their information is secure and won't be leaked for everyone to see? dr. kvedar: everyone is concerned about that, and we are certainly concerned about that at ata. number one, it turns out that even though we allowed these various non-hipaa compliant platforms, most of them are secure. for instance skype is secure, , whatsapp is secure, many of them are secure. so i think the likelihood -- and this is important for patients, people watching this -- the likelihood that you would get your information compromised during a video call is low. it is very small. could it happen? yes. it is very unlikely. so that is one thing. and as we move forward, we will get back to a state of normalcy
where we are to many that those , technologies are secure before we use them, so we are headed in that direction, i'm sure. with regards to your question about the clinician and making sure that the clinician is in a private place, we are training people as fast as we can. one of the other activities i'm involved with is the association of american medical colleges, creating training competencies for medical students so we can teach them a number of things about being a good telehealth provider. and one of them is keeping your video chat private from the point of view of where you have it. so we are getting that word out as fast as we can. peoplere aren't too many who are foolish enough to take it in a public place. so i think we are on the way to that. peter are you getting resistance
: from physicians at all? dr. kvedar: maybe a little. i don't know if it is surprising or not. because the one thing that -- you get into sort of a public health emergency like this and people's true stripes come out. as i said, everyone really came to the party, jumped in with both feet, use whatever analogy you like, and participated. so very little resistance. i think honestly, if you were to ask me in january and said, here scenario, i would have said there would have been more, but there is not because people want to take care of our patients because that is our calling. that is a good thing. again, there are some specialties where they need to do a procedure, they need to use equipment, and they just can't do this. so for them, that is not resistance, that is just quality of care. kimberly: post pandemic, should telehealth visits be paid the same amount as a brick and
mortar, in-person visit? is that something you are advocating for specifically? dr. kvedar: it is a complicated answer. it is a highly nuanced, actually. i'm going to try to break it down without sounding too nerdy. but clinician compensation comes in three buckets. complexity of thinking, time spent with a patient, and practice expense. and we would argue that the complex the of thinking and time -- that the complexity of thinking and time spent is what it is no matter what vehicle we are using to care for you and should always be compensated for the service in the same way. it is possible -- and this is -- has not been proven, but we will find that the practice expense might be less and there may be a way to differentiate payments. it is possible.
officialspecific or ata policy is is for the federal government, we believe that these things should be compensated for at parity. health plans will want to payers as they , always do, and we do not feel like it is our place to get in the way of that. kimberly: we have heard from different health insurers when telehealth became more prominent, a lot of them said they would provide telehealth and no co-pay to patients. as a reporter at business insider i have heard from , patients who have gotten these surprise medical bills from telehealth visits. they understood them to be included in their benefits but , ended up with that surprise bill. how do you prevent something like that from happening and make sure that patients know what exactly their benefits are supposed to cover? dr. kvedar: we would all probably benefit from more trans
parity -- transparency in our industry. it is difficult sometimes to communicate the nuances of their plans and various coverage determinations to plan members. i would say that during this time, i'm not really making excuse for anyone but we have thrown a lot at our health plan colleagues, we have thrown a lot at them and said, please pay for all of this. they are reading intimate -- they are reading intimate as best they can. it is a long-winded way of saying cut them a break. any member has the opportunity to go back and question any of that. we all do. but it has been a tough time for everyone and i think they are weeding through it in a careful way. some of those things may have slipped through the cracks. kimberly: you think it is more about speed bumps than- dr. kvedar: i do.
this is another thing i would not have predicted but i have talked to a lot of health plans, not universally, but a lot of the ones are on board with continuing this. there is a belief -- it is only a belief -- i should not say that because there is some data to support it, but there is a belief that if we can keep people healthy, we can lower costs by keeping them out of the emergency room. we will actually say premium dollars. host: dr. kvedar is a practicing dermatologist. kimberly leonard covers health care for business insider. dr. kvedar, is there a chance that these sessions could start to be recorded, thus increasing the privacy concerns? dr. kvedar: well, now, as we are currently doing this and as we alluded to earlier, there are
people using every kind of platform and some of those allow you to press the record button for sure. we strongly advise clinicians never to do that. it does not make any sense. unless, perhaps, you are recording part of a neurology exam for the record or something like that. patients will have the option during that as well. i don't think that should be part of our future but right now, it could happen. kimberly: what if a patient wants that recording to be able to listen back and say -- particularly during maybe a visit with a psychologist, they want to listen back and try to embed it in their brains and re-hear the advice they received, is that permitted if the patient wants that information and wants to record it? dr. kvedar: i believe it is. i would have to double check but i believe that is permitted. i'm not sure if that is best practice going forward, but i believe it is ok.
host: have there been liability concerns with this? dr. kvedar: thanks for asking. there always has been. but there has been very little case log, almost none. all of our malpractice carriers, even before the pandemic, recovering physicians from a malpractice perspective. like any other malpractice conversation or any other negligence conversation, common sense is important and i sat at -- i had said at another point in this interview that doctors need to decide what they need to make a decision and if they can get that information. if they can't, they should not make the decision. if you have to come into a brick-and-mortar facility to get something done, that is the best way to get your care. we have to be thoughtful and we can't be sloppy.
and we are getting to a point quickly where we no longer have to say the only way you can get care is by this, and it will even out and people will start to say, no i would rather you come in for x, but it is ok that we do y by telemedicine. as we do more and more of that, the liability concerns will naturally ease. host: how will 5g advance or change telemedicine? dr. kvedar: 5g will be amazing. i have to say that i was underwhelmed by 4g, so i am a bit of a skeptic, but if it works as advertised, it should be an amazing thing. how many of us, and i am guessing people watching, most of you have probably been on failed zoom calls during this crisis. bandwidth is restricted, and we found out just how restricted it
is, and one of the things with 5g is it will be more elastic. if i can use that term. that is the main thing. not only faster, but more available. if we are going to do more and more video-based communications, not just in health care, but in business, people saying that we are going to be virtual, then we need that bandwidth to be able to get it all done. kimberly: how do we prevent cases of fraud and abuse of the technology? i would think it would be fairly easy for some physicians to bill for visits that they did not conduct. does there need to be new legislation or guardrails passed by the trump administration to prevent those kind of scenarios? dr. kvedar: we are committed to a world where there is minimal fraud. we will advocate for that.
with that background, i would say two things. one is another principle i have lived by for almost 30 years of doing this is that we should not hold telemedicine to a higher standard than in person care. we know that there unfortunately is plenty of fraud in the offices around. if fraud means people randomly sending bills for things they did not do, there is no difference here except we may be even better off, because as you know, software is time stamped and date stamped when you are having a conversation with a patient. at my delivery system, we have zoom embedded. we can track whether people are actually having those video calls as part of our system. we can be pretty we are not -- we can be pretty
sure that we are not committing any fraud in that regard. systems that allow us to record not necessarily the content, but to record that the visit happened. you could envision a future where this type of care shows us, or results in less fraud than in person care, because you can't always document that someone came to the office. host: unfortunately, we are out of time. joseph kvedar is president of the american telemedicine association. harvard medical school professor. kimberly leonard covers health care for "business insider." thank you for being on the program. >> you are watching c-span. your unfiltered view of government. c-span was created by america's cable television companies in 1979. today we are brought to you by these television companies who provide c-span to viewers as a public service. ♪
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