Telehealth Became a Lifeline for Older Americans. But It Still Has Glitches.
Ben Forsyth had doubts about telehealth.
When the coronavirus pandemic hit New York, he was wary of trekking by subway from Brooklyn to see his palliative care doctor at Mount Sinai Hospital in Manhattan. The prospect of entering a hospital and sitting in a waiting room troubled him, too.
But when his doctor, Helen Fernandez, suggested a video visit to monitor his chronic kidney disease and other conditions, “I wasn’t sure how it would work,” said Dr. Forsyth, 87, a retired internist and university administrator. “Would I feel listened to? Would she be able to elicit information to help with my care?”
Still, he logged on through Mount Sinai’s patient portal (“I wouldn’t say it was completely user-friendly”) on his laptop — and quickly became a convert.
He’s had four video appointments with Dr. Fernandez since, along with two in-person visits once he was fully vaccinated. He consulted her remotely when he wintered in Florida; he has also seen his cardiologist and his sleep specialist through telehealth.
Telehealth, also called telemedicine, refers to providing care remotely using technology such as video and phone calls, monitoring devices and patient portals.
“It should be part of the options that people have,” said Dr. Forsyth.
For now, it will be. In March 2020, Medicare greatly expanded coverage for telehealth, giving older Americans and others access to more health care options during the pandemic. Telehealth use promptly soared to nearly 52.7 million Medicare visits last year from 840,000 in 2019, according to a new federal report.
Last month, Medicare announced that it would extend most telehealth coverage through 2023, to allow time to “evaluate whether the services should be permanently added” to its coverage. It had already made certain telehealth services permanent.
This represents enormous change for telehealth. Before Covid, Medicare coverage for telehealth “simply wasn’t very available,” said Tricia Neuman, the executive director of the Program on Medicare Policy at Kaiser Family Foundation. Traditional Medicare permitted telehealth only in rural areas, for a narrow range of services. (Medicare Advantage plans had more flexibility.) Even then, patients had to travel to a clinic or hospital to do video calls if, for instance, they needed to consult with a specialist far away. They couldn’t receive telehealth at home, nor could they receive care over the phone.
Doctors or physician assistants could provide telehealth and get reimbursed, but not physical therapists or nurse practitioners, and they had to have previously seen the patient in person.
Then “the floodgates really opened at the beginning of the pandemic,” said Gretchen Jacobson, the vice president for Medicare at The Commonwealth Fund, which supports research to improve Medicare.
Medicare removed the geographic barriers, so that patients across the country could receive telehealth in their homes.
One hundred and forty additional remote services became eligible for coverage because of the move, as did more kinds of providers. Practitioners no longer needed a previous relationship with the patient and did not need to work in the same state as the person receiving care. If health care professionals lacked digital platforms that complied with federal privacy laws, Medicare allowed them to use widely available apps like FaceTime or Skype. It allowed coverage for audio-only phone visits, too.
And it raised reimbursement amounts so that providers were not paid less for telehealth than for in-person visits, eliminating a critical disincentive.
Now, it’s hard to imagine health care without the “tele-.” Nearly a quarter of U.S. adults over 65 have had a video visit during the pandemic, a Mount Sinai study found.
“They’re most likely to need frequent medical care,” said Julia Frydman, the study’s lead author. Seniors also may face mobility problems that make office visits daunting, and with less effective immune systems, they’re at higher risk for Covid-19. Using telehealth, “they wouldn’t have to travel back and forth and be exposed to a deadly disease,” she said.
Dr. Frydman discovered that another benefit of telehealth was learning more about her patients’ home environments. One older telehealth patient proudly told her about tending the greenery she noticed behind him. Then, over several months, she saw that his house plants were wilting and dying. “It prompted me to ask about his mood, his energy,” she said, and his answers revealed a previously unsuspected problem.
In her palliative care practice at Mount Sinai, Dr. Frydman has found that of course, telehealth has limits. “You sometimes want to see patients walk into the room,” she said. “Has their gait changed? How do they get in and out of a chair?”
That’s what soured Marcia Weiser, 83, on telehealth. “It’s better than nothing, but I don’t see that it’s optimal,” said Ms. Weiser, a retired calculus teacher on Manhattan’s Lower East Side. Many of her health issues, like joint pain and cholesterol monitoring, require “something hands-on, or a blood test or a urine test or an eye test,” she said. “I can’t get that on a computer.”
While telehealth may not be for everyone, studies have shown that both patients and doctors broadly support it. After 2023, when the current Medicare extension ends, “the core question for policymakers will not be whether to allow telehealth, but how to make it efficient, effective and equitable, available to everyone,” said Dr. Jacobson.
Researchers are still investigating whether patients using the virtual services fare as well as they do with in-person care, though one review of clinical trials using video teleconferencing found largely similar results.
Analysts are also tracking whether video and phone visits replace in-person appointments or are additional, unnecessarily boosting Medicare spending. Whether telehealth is more prone to fraud than in-person care is unclear, too.
Improving equity in telehealth poses another challenge, since access to digital devices and the internet varies significantly between different groups.
JB Lockhart, 69, a self-described telehealth partisan in Lake Oswego, Ore., began video visits with her primary care doctor even before the pandemic. “I live on my computer,” she said.
But a Kaiser Family Foundation survey in the fall of 2020 found that a quarter of Medicare beneficiaries over age 75 had no access to the internet. A little over half owned a computer or smartphone, a much lower proportion than among those 65 to 74.
The Pew Research Center reported this year that over a third of adults over 65 never used video to talk to other people during the pandemic. Only 45 percent used a social media site. About a third lacked home broadband.
Among the Medicare population last year, Black and rural beneficiaries used telehealth less often than whites and urban dwellers, the federal report showed. Dr. Frydman’s national study also noted geographic differences, and found that beneficiaries with lower education and those living alone also used telehealth less.
“We need to be really careful that telemedicine doesn’t worsen health disparities,” said Dr. Frydman.
Several recent federal initiatives will help make broadband more available. The largest appropriation, in the infrastructure bill President Biden signed last month, directs $65 billion to improve internet access in rural areas and tribal communities, and for low- income families.
Along with improved internet access, older Americans may need coaching to use the technology, and web designers may need to make telehealth platforms simpler to use. An analysis of electronic health records at Mount Sinai, for instance, found that during New York City’s initial Covid surge, only 53 percent of patients in the geriatrics practice had activated their patient portal, which is necessary for telehealth via video.
Health systems trying to reach older patients might heed Dr. Forsyth, who offered a marketing tip. “Telemedicine sounds so cold and technical,” he said. “If it were called an ‘electronic house call,’ people could feel more comfortable.”