by Cathy Cassata

• In March, the Centers for Medicare & Medicaid Services began allowing Medicare beneficiaries to receive care via telehealth. 
• Telemedicine is best served when it occurs between you and a doctor you already have a relationship with.
• To help keep patients with chronic conditions out of the emergency room, and to leave room for those with COVID-19, many physicians are conducting telehealth.

With more and more Americans abiding by stay-at-home orders in their states, many are turning to telemedicine to connect with their physicians.

However, up until a few weeks ago, most Medicare recipients weren’t able to use telehealth, unless they wanted to pay out of pocket for their care.

As of March 6, under President Trump’s emergency declaration, the Centers for Medicare & Medicaid Services (CMS) broadened access to Medicare telehealth servicesso beneficiaries can receive a wider range of services from their doctors virtually.

CMS stated: “The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans — particularly those at high-risk of complications from the virus that causes the disease COVID-19 — are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.”

Dr. Susan Wehry, chief of geriatrics at the University of New England College of Osteopathic Medicine, says older adults take to telehealth well.

Early in her career, she used telehealth while working in rural Alaska. She talked over the telephone with patients who couldn’t travel the distance to receive on-site treatment.

“People often wonder whether older adults are comfortable using this kind of technology, but in my experience, they are very much so. They are grateful, oftentimes, not to have to travel to see their doctors,” Wehry told Healthline.

She says ideally telemedicine is a great tool for those who have an established relationship with a physician and who don’t otherwise have access to care.

“The way it works best is that a doctor sees a person face to face once, they do a physical exam, and ask the patient how they feel about telemedicine, and then have telehealth sessions from there,” she said.

However, with the emergence of COVID-19, Wehry acknowledges there’s an urgency to expand the use of technology to help those in need of routine care, and to keep vulnerable people with mild symptoms in their homes while maintaining access to the care they need.

“[Medicare] is now waiving their audit of telemedicine practices, so if providers do this for a new patient, Medicare won’t know. It’s not as if they condone it, but during a crisis they are saying they are not going to intervene,” Wehry said.

This means doctors can reach across state lines and offer telehealth services to new patients they’ve never treated.

Medicare recipients receive care across states
In response to the pandemic, Dr. John Hopkins founded the nonprofit Medicare Telehealth Hotline, which offers a free resource for Medicare recipients to gain access to a doctor nationally.

“Our goal is not to take away the patient-doctor relationship. If your doctor is available, keep that relationship. We are here when [your doctor is] not,” Hopkins told Healthline.

For the past 5 years, Hopkins has provided primary care services to older adults in his Philadelphia practice, CCS Healthcare. Before that, he was an emergency medicine doctor.

“What I saw was a revolving door in the ER of older patients who could have received care in another venue rather than going to the hospital, so I started a company that [offers] comprehensive primary care and psychiatric care for the at-risk elderly,” he said.

Hopkins started using telemedicine in his practice from the get-go, despite not getting reimbursed from Medicare for it.

“I truly believed that it would decrease trips to the hospital, and it did. We service primarily senior living communities, nonskilled and skilled, and when someone uses our telemedicine service, they stay in their community 85 percent of the time. We’re only sending out 15 percent of our urgent telemedicine calls to the hospital and treating the other patients in place,” he said.

During the pandemic, Hopkins says he hopes his nonprofit can help keep older adults out of emergency departments across the nation.

“We have an expertise that not a lot of people do, and we want to do a public service. If Florida is getting slammed with COVID, it’s unlikely a doctor from Nevada is getting on a plane and going to volunteer his time, but it’s very likely that they will sit at their computer and help patients in Florida, where you have increased demand,” he said.

Anyone who has Medicare and who’s 65 or older can receive access through the hotline without paying a copay. Hopkins gets paid by billing Medicare for the telehealth consultation. He calls his service a “virtual urgent care for the Medicare population.”

When a patient calls in, they get placed into a virtual waiting room. Hopkins calls the patient or caregiver back and takes the patient’s medical history over the phone, including medications they take, allergies, current diagnoses, and any recent surgeries.

Then he sends them a link if they have the ability to video chat. They click on the link and join him or a colleague in a virtual exam room.

“My team is all emergency medicine trained. In emergency medicine, we don’t have the luxury of being prepared for everything that walks in the door. The same thing for our practice in geriatrics now. We’re experts at getting people through complicated and challenging situations and giving them outside-the-box alternatives to the standard medical system and care,” Hopkins said.

He recently treated a woman in Florida for a finger infection and a bus driver in Alabama who reported symptoms of COVID-19 exacerbation.

Hopkins says some of the communities he serves have COVID-19 outbreaks. He’s beginning to treat 10 people in one community.

“[Many] are 85 and above and… fairly sick but don’t want to go to the hospital because they don’t want to die alone, and we are putting them on hospice and giving them medications and more support and trying keep them hydrated. Ultimately, they don’t want to leave their home if the alternative is they are going to go to the hospital and be isolated away from their friends and family,” Hopkins said.

Difficulties with telehealth
While Wehry agrees that freeing up the ER is a legitimate example of a coordinated system of care, she says this type of care is still best done with an established physician-patient relationship when possible.

“Emergency medicine is for a very specific targeted acute problem where you have the person right before you. You can see them, touch them, examine them, draw labs on them. You can do what you need to do to know everything instantly. In some ways, you don’t need to know the patient to take care of the acute problem,” she said.

However, Wehry says one of the difficulties with emergency medicine is what happens afterward, particularly with older adults.

“The real issue for people who are isolated at home are their chronic conditions. Eighty percent of visits to the ER by older adults are for completely preventable conditions and more often than not related to the adverse effects of drugs, so applying an emergency medicine acute care model, which is a great model in the emergency room, to a population for whom their main problems are chronic may not be the best solution,” Wehry said.

She also cautions older adults about receiving prescriptions for hydroxychloroquine through telehealth.

On March 28, the Food and Drug Administration (FDA) issued an Emergency Use AuthorizationTrusted Source for use of oral formulations of chloroquine phosphate and hydroxychloroquine sulfate to be prescribed by doctors for hospitalized adult and adolescent patients.

“When there is a crisis, it’s quite understandable that we’d think hydroxychloroquine has promise and conduct some studies. Those studies are underway, and it may turn out to be a drug that’s helpful with treatment for some people, but the downside to prescribing drugs to patients you’ve never seen across states lines is that all drugs have side effects, and this particular drug can cause certain heart arrhythmias,” Wehry said.

Because many older adults have comorbid medical conditions, she says treating them with a drug not proven to help COVID-19 comes with risks.

“The more we can get people to think about the pros and cons of telehealth and the ways to improve it, as well as build in protections against potential harm, the better we’ll be able to expand the service now and after the pandemic,” Wehry said.