The recent outbreak of the novel Coronavirus (COVID‐19) has swept across the United
States and is present in every US state and every major metropolitan area. As national,
state, and local governments have begun implementing policies aimed at preventing
the transmission and spread of COVID‐19, changes in health care delivery have inevitably
emerged. During this extraordinary time, health care systems and providers are seeking
alternative delivery methods to ensure their patients’ needs are met. Among the many
approaches to continue providing needed care in the wake of physical distancing, telemedicine,
defined as the use of technology to deliver clinical care remotely, remains a promising
yet underutilized method. The purpose of this commentary is to explore the use of
telemedicine in reaching underserved patients.
Telemedicine and Medically Underserved Populations
In response to COVID‐19, Medicare and Medicaid programs have begun expanding coverage
and reimbursement of telemedicine services to promote care of beneficiaries using
a variety of virtual communication methods.
1
Many private payers have made similar provisions. While definitions of the various
telemedicine modalities are lacking in consistency, generally telehealth is defined
as use of real‐time interactive audio and video in order to deliver care at a distance.
Conversely, virtual visits are telephonic (audio only), and E‐visits make use of written
communication, typically via an online patient portal.
The basic technical requirements for telehealth are a broadband connection, an application
for the video, technology support, and a device capable of handling the technology.
2
When functioning as designed, telemedicine offers a convenient and effective form
of clinical care.
3
Unfortunately, if one or more of these components is missing, the entire system will
not function and alternatives must be explored. In many cases, although health care
organizations will pay the upfront costs for telehealth technology and make this available
to their patients at no additional cost, a lack of broadband access for patients can
effectively stymie full telehealth capabilities.
4
According to the Federal Communications Commission (FCC), there are approximately
24 million Americans who lack access to broadband, defined as Internet connections
supporting sufficient download (25 megabits per second) and upload (3 megabits per
second) speeds.
4
Nearly one‐third of Americans in rural areas lack broadband, and disparities are greater
among people of lower socioeconomic status and people on tribal lands.
4
Older adults are also at a disadvantage: just 51% of Americans 65 and older have broadband
at home, only 42% have a cellular phone, and even fewer have a “smart phone” capable
of streaming video.
5
The patient population we serve at our clinic represents a microcosm of clinical panels
across the United States. We serve a mixed rural‐suburban population, with a large
concentration of patients who are older adults or have substance use disorder, low
income, low levels of formal education, or who have some combination of all of these
factors. The majority of patients we serve rely on insurance coverage through Medicare
or Medicaid.
For many of our patients, full access to telemedicine, particularly the video capabilities
required of telehealth, is not feasible. A substantial proportion rely on landline
telephone service, use prepaid cellular phones with limited data plans, use mobile
carriers with narrow data coverage, or have limited broadband access, a problem exacerbated
by high Internet usage due to, for instance, virtual schooling requirements for their
children. We have encountered these challenges frequently when we contact our patients
whose visits have been converted from in‐person to telemedicine, but then cannot launch
the video for a telehealth platform or cannot take a phone call because they lack
cellular reception during the time slotted for the visit. Our experience has been
that even well‐resourced patients often run into issues with wireless coverage, making
video connection a persistent challenge under seemingly ideal circumstances.
Additional barriers unrelated to technological compatibility exist as well. For example,
older patients are often less familiar and therefore less comfortable with video‐based
technology. Cognitive and sensory impairments are also prevalent, and these barriers
frustrate our ability to provide seamless care via video visit.
6
,
7
We find that many of these patients opt for a phone call or a home visit over pursuing
telehealth when scheduling their appointments. Furthermore, our ability to perform
remote monitoring which may otherwise guide clinical decision‐making for Medicare
patients is limited. For example, Part B coverage of blood pressure monitoring devices
remains confined to a limited subset of the population. Finally, some patients of
any age group may experience a significant amount of stress at the prospect of a telehealth
visit: one patient shared that she had spent all night cleaning her house before our
care team could see into her private home.
Given these challenges, and despite our best efforts, many of our remote visits, including
those which are originally scheduled as video‐enabled telehealth visits, end up as
audio‐only virtual visits. Until very recently, the clinical revenue generated by
these audio‐only encounters was significantly less than would likely be required to
maintain clinic solvency. Preliminary data from our practice suggest that reimbursement
rates for telehealth mirror those of regular in‐office clinic visits, whereas telephone
and patient‐initiated, asynchronous communications through an online portal known
as E‐visits tend to reimburse at much lower rates, typically less than half that of
full reimbursement. Nationally, Medicare reimbursement for telemedicine visits varies
considerably (see Table 1). For telehealth visits, reimbursement rates from Centers
for Medicare & Medicaid Services (CMS) range from approximately $46 for a 10‐minute
visit to approximately $110 for a 25‐ to 30‐minute visit.
8
In contrast, for virtual visits and E‐visits, average rates have ranged from approximately
$15 for a 5‐ to 10‐minute visit to approximately $41 for a 21‐ to 30‐minute visit.
8
Hence, telehealth visits yield more than twice the reimbursement for providers as
compared to telephone calls or E‐visits of comparable duration.
Table 1
Medicare Reimbursement for Telemedicine Visits Stratified by Encounter Type, April
2020
Description
HCPCS Code
Time
National Nonfacility Rate
NC Nonfacility Rate
TelePHONE encounters (audio only)
Virtual check‐in
G2012
5‐10 min
$14.80
Telephone E/M (physicians)
99441
5‐10 min
$14.44
99442
11‐20 min
$28.15
99443
21‐30 min
$41.14
Telephone (nonphysicians)
98966
5‐10 min
$14.44
98967
11‐20 min
$28.15
98968
21‐30 min
$41.14
E‐Visits (online using patient portal)
Est Pt, online digital E/M (physicians)
99421
5‐10 min
$15.52
99422
11‐20 min
$31.04
99423
21‐30 min
$50.16
Est Pt, online digital E/M (nonphysicians)
G2061
5‐10 min
$12.27
G2062
11‐20 min
$21.65
G2063
21‐30 min
$33.92
TeleHEALTH encounters (includes video)
New Pt, outpatient E/M, Level 1
99201
10 min
$46.56
$44.20
New Pt, outpatient E/M, Level 2
99202
20 min
$77.23
$73.61
New Pt, outpatient E/M, Level 3
99203
30 min
$109.35
$104.47
New Pt, outpatient E/M, Level 4
99204
45 min
$167.09
$160.16
New Pt, outpatient E/M, Level 5
99205
60 min
$211.12
$202.61
Est Pt, outpatient E/M, Level 2
99212
10 min
$46.19
$43.86
Est Pt, outpatient E/M, Level 3
99213
15 min
$76.15
$72.77
Est Pt, outpatient E/M, Level 4
99214
25 min
$110.43
$105.81
Est Pt, outpatient E/M, Level 5
99215
40 min
$148.33
$142.34
Initial annual wellness visit
G0438
n/a
$172.87
$166.10
Subsequent annual wellness visit
G0439
n/a
$117.29
$112.31
John Wiley & Sons, Ltd.
This article is being made freely available through PubMed Central as part of the
COVID-19 public health emergency response. It can be used for unrestricted research
re-use and analysis in any form or by any means with acknowledgement of the original
source, for the duration of the public health emergency.
Thankfully, some payers have announced their intent to address this discrepancy by
raising the reimbursement rate for virtual visits. NC Medicaid, for example, has recognized
the challenges that vulnerable populations and their providers encounter and, consequently,
has updated its fee schedule for audio‐only encounters to allow enhanced reimbursement,
albeit still lower than rates allowed for telehealth visits.
9
Unfortunately, certain types of encounters, such as Annual Wellness Visits for Medicare
beneficiaries, are still required to be conducted via telehealth, eliminating our
ability to continue providing these for many older adults.
Discussion
COVID‐19 is changing how we deliver health care. We are in an unprecedented time of
intense learning and development. More medical practitioners than ever are providing
care remotely, and similarly, more patients are seeking their care through remote
methods. Although many patients will return to the clinic once the pandemic has subsided,
it is likely that telemedicine will continue to play a prominent role, especially
since: (1) telemedicine visits have frequently proven to be useful and convenient
for patients and providers alike; (2) challenges related to the startup and sustainability
of these services will have been overcome by many practices; and (3) we may see a
resurgence of COVID‐19 and need to enact distancing measures again in the future.
Although reimbursement appears to be on its way to aligning with patient needs, access
barriers remain. To improve access to telemedicine, state‐level initiatives can aid
with bridging gaps. Some states have made efforts to promote better access to broadband
through a number of mechanisms, including direct funding through grant programs, income
tax credits, and infrastructure coordination.
4
Unfortunately, not all states have these mechanisms in place and these efforts will
not solve all telemedicine challenges—particularly for older patients who have cognitive
or sensory impairments.
Providers will continue to meet their patients’ needs to the best of their ability,
during and after the pandemic. The use of telemedicine may be especially helpful in
this endeavor for those who have transportation, distance, or mobility challenges.
We have seen this for our rural patients who are enthusiastic about eliminating their
considerable travel times and the costs associated with them. In order to ensure its
success, particularly for patients who stand to reap the greatest benefit and the
providers who serve them, policymakers will need to be aware of the possible unintended
consequences of certain rules for medically underserved populations, and ensure that
financial incentives are aligned with care needs and adequate resources are available.