It’s 3 a.m. on a Sunday and an intensivist – a physician steeped in critical care medicine – is tracking the vital signs of a patient in the emergency room of a community hospital hundreds of miles away. She calls the ED doc on the overnight shift and tells him the patient is hypotensive and needs a central line inserted so he can get meds to restore his normal blood pressure. Using a video connection, the nurse practitioner watches as a nursing assistant places the line and titrates the right drugs, all the while assessing whether this patient needs to be admitted or sent home.
This is a routine night for a physician working for my company, which was formed by doctors who wanted to escape medicine delivered in 15-minute increments while lashed to electronic records systems, and who enjoy being able to work from a home office. Unlike most telehealth services, ours involves specialists licensed to practice in their service area, who establish relationships with staff and who can order tests and treatment.
Until the pandemic struck, telehealth was seen as a service mainly for rural hospitals, which need help from urban medical centers for specialty care such as stroke. COVID-19 revealed the depth of need for virtual care for almost any condition everywhere. A new report from the U.S. Department of Health and Human Services found that the lifting of most restrictions during the public health emergency led to telehealth visits jumping 63-fold from approximately 840,000 in 2019 to 52.7 million in 2020, mostly in urban areas. Visits to behavioral health specialists showed the largest increase in telehealth in 2020, accounting for a third of all visits.
Although CMS recently announced some easing of the restrictions on the remote treatment of mental health disorders, any permanent expansion of general telehealth services is going to be a subject of intense debate on how much face-to-face care is essential. The key question for me is whether telehealth can help solve some existential crises that are plaguing the healthcare industry today, including spiraling costs and operating losses, labor shortages and poor care outcomes. Much of this predated COVID, but the pandemic sprayed fuel on the fire.
According to new data, hospital operating margins fell 12% from September to October 2021 and by 31% compared to pre-pandemic levels. Labor costs rose 15% in October compared to 2019, but the number of actual workers fell by more than 4%, suggesting higher salaries, not staffing levels, are to blame.
We don’t yet know the full extent of the departure of nurses and physicians burned out by COVID care or simply retiring early to do something less stressful, but the anecdotal evidence is piling up. Just one small state, Mississippi, lost 2,000 nurses in 2021.
Despite the increase in telehealth visits during the pandemic, total utilization of all Medicare clinician visits declined about 11% in 2020, leaving what will be lasting effects of delayed cancer care and other serious conditions.
Advances in quality that required so much time, energy and effort over the past decade have been wiped out by labor shortages and a sicker populace. A CDC analysis1 of infection rates by quarter in 2020 compared with 2019 found that healthcare-acquired infections had skyrocketed in the pandemic. Given the nature of COVID care, it is especially disheartening to discover that ventilator-associated infections rose 45%.
Payers are noticing. Last summer the National Alliance of Purchaser Coalitions, an employer group, released results of a survey2 showing that six in 10 employers are considering or already engaged in value-based design approaches. CMS is aiming to have all providers who accept Medicare payment participating fully in programs that reimburse based on quality and efficiency metrics by 2025.
Value-based payment models have ushered in a new acceptance of telemedicine3, which is no longer deemed to be of lower quality than in-person visits. “It is clear now that telemedicine delivers enormous clinical quality, financial value and efficiencies,” David Snow, chairman and CEO of Cedar Gate Technologies, a healthcare IT company, told the journal Patient Safety & Quality Healthcare.
For most hospitals, including some in urban areas, there is a lack of specialists all the time, but even more so overnight and on weekends. With mental health issues out of control today, it is especially concerning that 50% of U.S. counties do not have a psychiatrist and 50% of all psychiatrists are 60 or over.
Perhaps the most powerful case for high-quality telehealth is in patient transfers – the seams in patient flow that often are bottlenecks to cost-effective care. Images of patients lined up on gurneys in hospital hallways are now commonplace. Delaying transfers to ICUs carries enormous risk for patients4, while leaving patients in EDs5 without treatment negatively impacts the safety, timeliness and quality of care.
Telehealth carries the hope of better quality of care for people regardless of where they are. As my colleagues and I have found, if you can offer physicians the opportunity to do this good work from home on their own schedules, you can go a long way toward restoring their faith in medicine, maybe even re-finding the joy they had coming out of training.
This is why many hospitals can’t find good doctors, but here I am staring at a stack of CVs on my desk from physicians who interned at places such as Harvard, NYU, Vanderbilt and Yale and seek a better work/life balance. For us, there is no labor shortage.
Dr. Scurlock graduated Magna Cum Laude from Texas A&M with a degree in Chemistry. He completed his Medical School education at the University of Texas and an Anesthesiology Residency at Baylor College of Medicine, in which he was elected Chief Resident followed by a Critical Care Fellowship at Harvard Medical School. In 2010, he completed an MBA from the Johnson Business School at Cornell in Management and Leadership. He is the author of over 70 peer-reviewed publications with articles in the New England Journal of Medicine and Circulation.