The Case for Expanding Emergency Telehealth Services

by Aditi U. Joshi, MD, MSC, FACEP

Telehealth and tel-emergency care isn’t new, not in its purest definition of using technology to connect two people for a medical encounter. While it already existed in aerospace, military, and rural areas, it has become more widespread due to the COVID-19 pandemic.

Almost everyone has now had experience with this modality, including its use in emergency care. However, not all are convinced that this is something that we should be doing. In a decade working in this space, there is little I haven’t heard about the cons of using telehealth. I will not claim that telehealth is good for everything: there will always be a need for in-person emergency care. However, technology has been part of almost all other parts of our lives. Recognizing and planning for its utility in emergency medicine is a more efficient use of time. Telehealth does have some broad advantage—namely access, efficiency, and potential costs.

In terms of access, it removes the geography requirements to see patients where they are, whether at home, on an ambulance, at another hospital, or in rural areas. It allows for specialist consultations for our colleagues in rural areas where there are fewer specialists available. Research in tele-stroke has demonstrated that there is less time to tissue plasminogen activator (tPA) and decreased morbidity with clinician-to-clinician telehealth use.¹ This access to specialists also brings a type of continuing medical education (CME), as one must be there during the virtual consultation and witness the specialist working, which improves outcomes and efficiency.

It also increases access for patient populations that may have a hard time leaving home, whether it is due to caregiving, disability, or having childcare responsibilities. Emergency physicians appreciate that these limitations lead to a delay in seeking care from the traditional brick and mortar of health care facilities. With telehealth, patients can at least get a visit to determine if they need to see a physician in-person or if they can safely follow up later. The utility is huge—we can educate, see, train, and be part of a collaborative team from a distance.

Telehealth also has the potential to improve efficiency and decrease costs as a triage measure to ensure all patients are at the right level of care. Tele-triage programs have been used to triage and begin a workup within EDs already; this can potentially be extended to triaging at home, with EMS, home care facilities, and other places that funnel into the ED.² Tele-triage can help alleviate some of the burden on EDs, especially when patients could be seen in an outpatient setting. For patients who have already had an ED workup, newer programs are using telehealth for virtual observation units, keeping ED and hospital beds open and allowing patients to recover in their home. As we see better personal health and monitoring devices, this care model has the potential to grow. The burden on EDs has only grown, and one solution is to use tele-emergency care more efficiently to decrease this only growing issue.

There is, of course, work to be done to be able to realize the full potential of tele-emergency care. There must be quality standards, workflows, thoughtful design, and program planning. We also require a comprehensive training and education program that needs to begin in undergraduate medical education (UME) to ensure we have a new generation of physicians who understand how their future practice is going to be affected. Reimbursement must also be codified and kept in law for this practice to be financially feasible.

Much of this is happening. CMS has extended its regulations consistently since the pandemic. The AAMC has set standards for what is required for telehealth education. There are courses to improve digital physical exam and empathy skills. Within EM, ACEP has an active telehealth section that works on advocating and working with other organizations to define and understand the needs of EM physicians in this future practice. Every year more research, programs, and colleagues become involved in telehealth, attesting attests to its expanding worth and utility.

It may seem overwhelming that telehealth will increase the scope of emergency medicine. However, emergency physicians are no strangers to change or innovation. This specialty has always been involved in the community as the front door of the hospital and the connection to all the front-line services. Emergency physicians are innovators, educators, advocates, leaders, researchers, as well as clinicians. All we must do is recognize this as our future practice and incorporate technology and telehealth safely and effectively within emergency medicine.

Emergency Telehealth Creates Reimbursement Challenges

by James L. Shoemaker, JR., MD, FACEP, and David A. McKenzie, CAE

The expanded use of telehealth services from the emergency department (ED) during the public health emergency (PHE) has proven to be an efficient and effective way to expand access to patients who might not otherwise have been able to safely or timely obtain that level of care during the COVID-19 pandemic. ACEP sees the use of telehealth as one avenue to step outside the four walls of the ED to expand the breadth of our specialty and deliverables to our patients. This falls firmly within ACEP’s strategic plan.

U.S. Centers for Medicare & Medicaid Services (CMS) has covered telehealth services from the ED using ED E/M CPT levels 99281–99285 during the PHE, but may not continue to do so, at least at the higher intensity levels of ED E/M services described by CPT codes 99284 and 99285. It’s important to note that CMS reimbursement for levels 99281–85 is the same for in-person and remote visits, as CMS rules do not allow for rate changes based on these differences. These relative value unit (RVU) valuations are the building blocks for health care insurers, and they also cannot alter them. It’s the parity in these codes for reimbursement that makes the reimbursement for telehealth a complex and multifaceted issue.

ACEP has successfully argued—and CMS has agreed—that upper-level ED services (99284–85) are more intense than those furnished in an office-based setting. Emergency physicians are usually caring for many patients simultaneously, instituting care and medical decision making for multiple patients many times per hour. As a result, the RVUs and resulting payments are higher for ED services provided in the ED setting. It is essential that ACEP be able to continue to emphasize the intensity of our ED services, or we’ll have to face a grim reality of time-based compensation that would negatively impact our revenue. Emergency medicine is an outlier in our RVU valuation because our levels are intensity-based rather than time-based because there isn’t a good way to accurately record time for a physician juggling multiple patients in the chaotic environment of the ED.

CMS is on record as believing the higher intensity of upper-level ED services (99284–5) do not lend themselves to being furnished via telehealth. This makes it difficult for ACEP to advocate for parity in payments for ED services furnished via telehealth with those for in-person services after the PHE ends. If we argue to CMS that upper-level ED visits are not too intense for telehealth use, we risk lowering the future values of all ED services. Parity would not be advantageous should that occur. CMS and the members of the RBRVS committee that set RVU valuation at the RUC would certainly question our rationale for parity when telehealth visits seldom, if ever, have the complexity of a dozen patients and varying acuities coupled with the continual interruptions of the ED setting.

The ACEP CPT team has worked for years to get the ED E/M codes (99281-99285) added to Appendix P of the CPT code set, meaning they could be paid when furnished via telehealth. So far, those attempts have been unsuccessful because ED codes are considered more intense than office visits. Further attempts could upend the valuations we have successfully defended and increased over the past two decades.

There is clearly a need for telehealth delivery in and from a variety of geographic locations, but careful considerations need to be made if we should include 99284 and 99285 in the telehealth codes for reimbursement. These two codes represent most ED services provided in any setting, and we cannot jeopardize a possible reduction in value, especially when there are so many other potential cuts to ED payments on the horizon. This becomes even more essential as the documentation guidelines change in January 2023 and we find a new distribution of ED codes submitted for reimbursement. Many ED visits may “level up” based on those changes, and 99284 may become the most important code in our family to preserve and protect.

We must acknowledge that telehealth service is not exactly comparable to in-person visits. There is no boarding or unanticipated influx of patients with telehealth. The individual patient may be similar, but the environmental circumstances are different. There is some concern of established telehealth entities siphoning off the well-reimbursing patients, making the economics of delivering in-person care more tenuous. Similarly, expansion could lead to a single emergency physician supervising multiple non-physician clinicians in various locations in ways that could radically alter the emergency medicine workforce.

Lastly, the facility fee for a telehealth visit does not incur the same direct expenses as an in-person visit. The current construct of payments for the originating site (where the patient is) and distant site (where the emergency physician is) needs to be explored for fair payment of resources used in the in-person versus telehealth visit. The practice expense component of telehealth services must be the subject of considerable cost effectiveness research.

There is no easy answer to telehealth reimbursement, and ACEP’s RUC and CPT teams will need to continually assess risk and benefit of our strategies to benefit the whole of our specialty and our patients.

Does Telehealth Amplify Social and Economic Inequality?

by Ahra Cho, MD, MBA, and Tony Bai, MD

The COVID-19 pandemic provided a nidus for growth in telehealth. Through necessity and adaptation, primary care physicians and certain specialties embraced the contactless convenience of virtual appointments with patients in need. While there is no question technology will continue to enrich the practice of medicine, there are many issues that need to be addressed in order to make telehealth safe and effective for both patients and physicians. These shortcomings are particularly evident in the application to emergency medicine.

Possibly the most concerning aspect of telehealth as it relates to our specialty is social and economic inequality. While advocates argue that telehealth would expand access to care by allowing patients increased flexibility in interfacing with clinicians, particularly patients in rural areas without constant access to care, there is genuine concern that underserved populations will be functionally impeded from accessing this service.³ This can happen both at the system and individual patient level as telehealth relies on the existing infrastructure of participants in question.

From a health systems level, telehealth systems will depend on robust information technology (IT) systems and consistent staffing. These factors put rural hospitals caring for the underserved at a disadvantage, as they are more likely to suffer deficiencies of both. Under-resourced hospital systems already struggle with high volumes of underinsured patients and lack of access to resources, including physicians and ancillary staff. Without significant increases in funding, the decision to invest in telehealth systems will require health care expenditures to be drastically reduced in other areas, particularly in-person health services and preventative care, exacerbating the access issues in already struggling communities.

At the patient level, the success of telehealth and its flexibility will depend on the patients’ baseline level of digital literacy, as well as consistent access to a computer, internet, data services, and time. These resources are not guaranteed with underserved populations and risk further alienating low-income patients. While access and use of technology, cellular phones, and wireless services seem ubiquitous particularly in urban areas, the Pew center estimates that up to 16 percent of Americans are not digitally literate, with this rate much higher among Black and Hispanic adults, and roughly a quarter of adults with household incomes below $30,000 annually don’t own a smartphone.⁴ Given that the poverty rates for Black and Hispanic Americans are more than double that of non-Hispanic whites, plus the education gap that already exists along income levels, telehealth services risk disproportionately benefiting a narrow demographic while hurting low-income patients, particularly from minority backgrounds.

Even setting aside the issue of social justice, it is unclear if telemedicine can offer patients high quality care. Physicians spend years in training learning how to hone their clinical gestalt by observing patients in person and differentiating between sick and healthy patients. For instance, on oral boards, physicians are rewarded points for asking in the first 30 seconds what the patient looks, feels, and smells like, in recognition of the key information that comes from assessing the patient in real time. In telemedicine, with the loss of the softer aspects of patient encounters such as body language and non-verbal cues, a key factor in the clinician’s history and assessment will be lost. Even if systems can find ways to collect information to address this deficit, the concern on how to complete the medical workup, with simple orders such as EKGs, imaging, or even administering crucial medications cannot be ignored. For telehealth systems to be effective, they must be limited to patients with low acuity, urgent care level complaints who don‘t need further workup, or be within a larger health care system that would allow patients quick transfer for in-person evaluations. In the current health ecosystem, where health literacy and health care access levels vary across geographic and income levels, it is unclear if telehealth systems will be useful for a majority of ED patients who will need further evaluation in person.

Lastly, while cost savings are often touted as a reason for expansion of telehealth programs, it is unclear if services would indeed lower costs. Theoretically, the expansion of telehealth programs could prevent unnecessary ED visits by freeing up scarce resources and allowing physicians to focus on critical illnesses, but it is also possible that telehealth could increase costs due to high costs of implementation and supplier-induced demand driving greater patient utilization. Successful implementation and maintenance of telemedicine depend on pre-existing technology infrastructure, including working IT systems, internet access, and staffing. The costs associated with necessary investments, maintenance, as well as hours of clinical time necessary (and possibly lost) in staff training and upkeep of standards of practice, may be significant. Furthermore, telehealth systems may simply lower the barrier for patients to seek care for visits and lead to greater inefficiencies. For instance, the rise of urgent care centers focusing on lower-acuity visits have not reduced health care costs or ED volumes. As many of our patients do not know how to appropriately self-triage or the appropriate time to seek care, telehealth systems may simply attract patients from urgent care visits, or even raise ED volumes by encouraging patients who would’ve never sought care at all to seek care, leading to a situation where patients are evaluated three times: in telehealth, the ED, and in their primary care offices, further overburdening an already strained system.

As exciting as it is to embrace new technologies and continue to push the frontiers of health care delivery, clinicians and health care systems need to consider emergency telehealth’s possible pitfalls in order to better design an equitable and safe telehealth system for both patients and clinicians.

Dr. Joshi is current councillor and past chair of ACEP’s Emergency Telehealth Section. She is the former medical director of the telehealth program at Thomas Jefferson University Hospital. She works in telehealth and digital health consulting and is writing a book on telemedicine.

Dr. Shoemaker is ACEP’s Board liaison to the ACEP Reimbursement Committee. He serves as ACEP‘s alternate RUC representative at the AMA where RVU valuation for the House of Medicine is proposed for CMS.

Mr. McKenzie is ACEP’s reimbursement director. He represents emergency medicine during the AMA RUC and CPT processes.

Dr. Cho

Drs. Cho and Bai are assistant vice chairs of EMRA‘s Technology, Telehealth, and Informatics Committee. Dr. Cho is a resident at Icahn School of Medicine at Mount Sinai, and Dr. Bai is a resident at the University of Wisconsin.

References

1. Richard JV, Mehrotra A, Schwamm LH, et al. Improving population access to stroke expertise via telestroke: hospitals to target and the potential clinical benefit. J Am Heart Assoc. 2022;11(8):e025559.
2. Joshi AU, Randolph FT, Chang AM, et al. Impact of emergency department tele‐intake on … – Wiley Online Library. Wiley Online Library. https://onlinelibrary.wiley.com/doi/10.1111/acem.13890. Accessed November 18, 2022.
3. Adepoju OE, Chae M, Ojinnaka CO, Shetty S, Angelocci, T. Utilization gaps during the COVID-19 pandemic: Racial and ethnic disparities in telemedicine uptake in federally qualified health center clinics. Journal of General Internal Medicine. 2022;37(5):1191–1197.
4. Mamedova S, Pawlowski E. A description of U.S. adults who are not digitally literate. Stats in Brief. US Department of Education website. https://nces.ed.gov/pubs2018/2018161.pdf. Published May 2018. Accessed November 30, 2022.