Urologists Adapt to Telemedicine Amid Pandemic

Kerry Dooley Young

July 03, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

After the temporary measure to increase the use of telehealth was implemented, Juan Andino, MD, from Michigan Medicine in Ann Arbor, saw a change in his urology practice.

Telemedicine visits allow him to go over the next steps for handling medical conditions with his patients and the people who support them, because family members can easily join the appointments.

"It's been nice to be able to share information," Andino told Medscape Medical News. "Everyone is on the same page when the visit ends, which obviously isn't always possible when someone comes to the clinic."

In March, the Centers for Medicare & Medicaid Services (CMS) announced that it would pay for telemedicine services "at the same rate as regular, in-person visits" as part of the federal response to the pandemic. It later waived the video requirement for certain telephone evaluation and management services.

The number of medical visits across specialties conducted by video leapt from 444 in February to 6800 in March at Michigan Medicine, according to a blog post. And in April, more than 20,000 medical appointments were handled by video visit.

Telemedicine works in urology because for many conditions — such as erectile dysfunction and infertility — treatment choices are informed by discussions with patients about symptoms and results from lab tests and imaging, Andino explained.

He is a representative for the Alliance for Connected Care, an umbrella group that advocates for the increased use of telemedicine. Members of the alliance include a mix of medical societies — such as the American Urological Association (AUA), the American Academy of Family Physicians, the American Nurses Association, and the National Association of Accountable Care Organizations — and tech companies, such as Amazon and Intel.

Andino said the CMS will likely reverse some of its temporary telemedicine policies at some point and prohibit the use of tools that do not guard patient privacy, like FaceTime.

In March, the Office for Civil Rights at the Department of Health and Human Services (HHS) said it would exercise discretion in cases of inadvertent breaches of HIPAA privacy rules when clinicians were using technology in good faith to serve patients.

"That would make a lot of sense to roll back because patient privacy and confidentiality are extremely important," said Andino, who was pressing for more use of telehealth in urology before the pandemic. "As we move forward, we have to make sure we are doing this correctly for patients and that we are protecting their information."

Before March, some commercial insurers had moved ahead with payment policies supporting telemedicine, but Medicare had largely limited its use to rural areas and places with shortages of health professionals, and required patients to drive to a site near their home to connect with a physician.

This approach requires a significant investment in resources. For example, staff must be trained to deliver medical care remotely in a way that is approved by the CMS.

And it can be a challenge to partner with a distant site. "Most practices and hospitals were not inclined to invest in identifying a clinic or other remote location defined by CMS to which a patient could drive and do a teleconference," Andino said.

Now the doctor is getting paid for what he or she did for free for decades.

Urologists have long provided a form of telemedicine — phone consultations — without being paid for it, said Neil Baum, MD, a urologist in New Orleans.

"They gave advice, they called in prescriptions. They didn't get paid for it and they didn't document it in the chart, but they were legally responsible for it. That's crazy," said Baum, who is medical advisor for the Denver-based Vanguard Communications Group and an advocate for telemedicine reimbursement. "Now the doctor is getting paid for what he or she did for free for decades."

This marks a major shift in attitude for the CMS, he noted. In fact, at this time, Medicare officials are not seeking to discount telehealth services; there is parity between face-to-face visits and virtual visits.

"They are not saying, 'the patient didn't come in so you didn't need to have staff. You didn't need to have bricks and mortar, so we're going to cut the reimbursement by 50%,' or some ridiculous figure like that," Baum said.

Instead, the new approach reflects the time physicians spend preparing before these telehealth visits to get up to speed on their patients and the time they spend on follow-up.

"It takes 5 minutes to look at the chart, to look at the electronic record. You usually need 15 minutes for the virtual visit and then, when you are done, you have to check the record, send notes to the referring physician, send prescriptions to the pharmacy," Baum said. "Now you get paid for all of that at the same level you would if you were doing this in the office."

The potential for fraud has long been cited as a concern in discussions about expanding government payments for telehealth.

In fact, 96% of Medicaid telemedicine payments were insufficiently documented or otherwise fell short of requirements, according to an audit of 100 payments in South Carolina from 2014 to 2017 conducted by the HHS Office of Inspector General (OIG).

For 95 of the payments, clinicians had made documentation errors, such as failing to note start and stop times. For two payments, the visits were in-office consultations, not telemedicine services. Only three payments were allowable.

More Flexibility

Still, the OIG has made it easier to use telemedicine to provide care during the official national COVID-19 emergency.

On March 17, for example, the OIG began to allow physicians to reduce or waive cost-sharing obligations, such as coinsurance and deductibles, in connection with telehealth during the national emergency. In normal times, according to the policy statement, such reductions and waivers could trigger the federal antikickback statute.

Governors and state legislatures also have been busy removing obstacles to telemedicine. In March, for example, officials in California directed insurers to set reimbursement rates for telemedicine to mirror those for office visits. All new state rules made to accommodate telemedicine are being tracked on the website of the National Telehealth Policy Resource Center.

As patients get more experience with this approach to care, the CMS will face pressure to maintain this more convenient option, said Aaron Spitz, MD, from Orange County Urology Associates in Laguna Hills, California, who has served as cochair of AUA Telehealth Task Force.

"If I were in CMS' shoes, I would allow it," Spitz told Medscape Medical News.

But for urologists, a drive toward telemedicine could be a financial concern if the CMS moves to lower payments for these services as the COVID-19 crisis ebbs, he said, noting that the CMS might reconsider its payments for telemedicine in terms of relative value units (RVUs).

"Will they still pay RVUs in parity with office visits? That is something that I have my doubts about," Spitz said. The CMS could try to argue that practice expenses are lower when physicians provide telehealth, but this is not true.

"It's not as if we have no overhead on the days when we do telemedicine," he explained. "We have to pay the same rent and the same employee wages and benefits and supplies, more or less, to be adequately stocked and staffed to blend in-office and telemedicine patients. You still have to have in-person access for these patients."

It is likely that many urologists have taken a financial hit while providing telemedicine during the pandemic, even with Medicare paying at parity levels. Their revenue is derived from a blend of evaluation and management services, procedures, and diagnostics. Urologists might steer clear of telemedicine in the future if they see a drop in income, Spitz said.

"For urologists to adopt an increasingly telemedical practice, already there is a financial threat to that," he said. "Even if the patients love it, if the providers find it to be punitive, you could have a failure to launch."

But Medicare could "pay doctors substantially more to provide telemedicine and still save the system a significant amount of money," he said.

For example, he explained, the fairly routine urine analyses done on patients as part of an office visit could, at times, detect bacteria in a patient not showing signs of an infection. In many cases, the patient does not need treatment, but might end up getting an antibiotic anyway, adding at least the cost of the drug.

And "some of the patients who are treated will develop allergic reactions or even C difficile intestinal infections," Spitz said, triggering "an additional cascade of utilization and costs."

Reconsidering Workflows

Video technology needs to improve to make it easier for patients to connect to their physicians' offices, said Steven Schlossberg, MD, vice president and chief medical information officer for John Muir Health in Walnut Creek, California. Schlossberg has been active for many years in the AUA, and has been looking at how the CMS can pay for the new technologies adopted by physicians.

With telemedicine, there might be a need to reconsider workflows that are now more conducive to office visits.

For example, a conversation about Physician's Orders for Life-Sustaining Treatment is very personal, and includes a discussion of "what life-sustaining treatments you would want if something bad happened," Schlossberg said. "How do you do that in a virtual world? And how would you get the right documentation?"

But with increased ease of payments for telemedicine, urologists and other physicians will have more reason to consider the kind of services that can be done remotely, he said. Postoperative visits, for example, could be handled this way if physicians have the right technology.

And a hybrid approach — a mix of telehealth and office visits — could allow for more frequent contact in cases where this may be helpful, such as palliative care, he explained. In his work for the AUA over the years, Schlossberg has studied how the CMS makes its payment decisions and has served on the RVS update committee of the American Medical Association, which helps set Medicare payment rates.

He said he expects the CMS to work out potential coding issues and other hurdles that will allow a continued increase in remote medical care.

"Telehealth is here to stay," Schlossberg said.

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