Why telemedicine needs to be a permanent part of Medicare [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“While preparing to assist our patients in the emergency rooms and dedicated COVID-19 wards, our clinic continues to triage patient concerns, creates new care plans, and provides a necessary layer of support, reassurance, and education in a chaotic and stressful time. Like all of you, my colleagues and I look forward to resuming our normal lives as once this pandemic is resolved. But, the resolution of this unprecedented public health emergency should not be a reason for CMS to revert back to its old rules. As these first weeks have shown, telemedicine is a valuable, proven, and effective tool for our patients, their families, and our medical community.”

Magdalena Bednarczyk is a geriatric medicine physician.

She shares her story and discusses her KevinMD article, “CMS needs to permanently eliminate barriers preventing routine use of telemedicine.”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Magda Bednarczyk. She’s a geriatrician, and she wrote the KevinMD article “CMS,” that is the Centers for Medicaid and Medicare Services, “needs to permanently eliminate barriers preventing routine use of telemedicine.” Magda, welcome to the show.

Magdalena Bednarczyk: Thank you for having me, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but first off, tell me your story and your journey to where you are today.

Magdalena Bednarczyk: I am an academic geriatrician. I work in a major teaching academic institution in Chicago, Rush University Medical Center. Currently I am the section chief of geriatric medicine within the department of internal medicine. I am also the medical director for our geriatric medicine clinic, Senior Care, and I also serve as the medical director for our Center of Excellence in Aging at Rush.

Kevin Pho: How has the pandemic affected you and your geriatric practice?

Magdalena Bednarczyk: You know, it’s been chaotic, it’s been exciting, and it’s been challenging. There’s definitely been a roller coaster of emotions and patient experiences. I am very fortunate in the fact that I have a wonderful team behind me and working side by side with me. It’s been just like everyone else; it’s been unlike any other experience that we’ve ever encountered in the past. And so relying on each other in a time of crisis and uncertainty, especially when new information is coming down the line so quickly and you have to adjust and pivot and come up with new workflows and address a new crisis, having that team behind you and being able to appreciate each other and trust each other at the same time has really helped get us through the day-to-day chaos.

Kevin Pho: Excellent. And I can’t stress how important it is to have a good team behind you, especially during these times. So let’s get into your KevinMD article, “CMS,” the Centers for Medicare and Medicaid Services, “needs to permanently eliminate barriers preventing routine use of telemedicine.” Now, for those who haven’t read your article, can you walk my audience through your article and share the story of why you decided to write it?

Magdalena Bednarczyk: So it actually sort of gets back to my career over the last 10 years in geriatrics. When I first started out as a geriatrician, I was 100 percent clinical. Especially in the academic center world, you can be fully clinical, you can have time devoted to education or to research, or it can be quite variable with all three included. And so I started out as a full-time clinician working in the outpatient, inpatient, and nursing home settings. After a couple of years, I started getting a little bit frustrated and a little bit burned out. It wasn’t the fact that I didn’t love medicine and I didn’t love my job, but the issue was that I felt like all I did was put out fires, in the sense that I was able to take care of my patients in clinic, and then they ended up in the hospital or the nursing facility, and it always seemed like all hell broke loose. Something went wrong despite our best efforts to take care of these patients.

And so one of the epiphanies that I had at the time, and a lot of us have it, is the fact that, especially as a geriatrician, there’s never going to be enough of us in the workforce. Nationally, there are about 7,500 board-certified geriatricians. The numbers really aren’t increasing, and yet the rates of older adults are increasing. And so even as we try to train future geriatricians, we really have to think about training the entire workforce. I was very fortunate in the fact that I was able to get involved and become part of a grant through the Health Resources and Services Administration for the Geriatrics Workforce Enhancement Program. It was a way to start developing education material so that participants, whether it’s a patient, a caregiver, or another clinician, in a wide variety of multidisciplinary team settings, could learn more about how to better care for older adults.

As I was going through that, the other epiphany I had was, “Great, so I’m now educating potentially all of these new learners, but ultimately what we really need to do is change the health care system,” because combining education with the health care system will be so incredibly powerful, and that’s really the only way to make that change sustainable in the long term. And so, again, thinking about my team members and also being able to be part of that HRSA grant, my group actually became more involved with the Age-Friendly Health Systems movement and designation that’s really been spearheaded by the John A. Hartford Foundation with the Institute for Healthcare Improvement and the American Hospital Association. And so you really started thinking about, again, how do you make that change sustainable for older adults across every health care setting that they’re in?

So when you’re looking at outpatient and inpatient care, and you really start listening to patients and what they really need and what the barriers are, access continues to be a huge issue. So then I started thinking, well, in my role as section chief, what can I do to be able to address that? So then I went back to my leadership team, and I said, “Look, I think it would be really great if we were able to have some sort of a digital center for health medicine for older adults. Why can we not do telemedicine?” And I wasn’t immediately shut down. They said basically, “You know what? Go back, research this a little bit more, talk to other people, come back and tell us what other academic centers are doing, and let’s continue the conversation.”

In the meantime, actually, Rush University Medical Center was building and had built a platform to allow for just very minimal and simple medical problems to be addressed via a telemedicine encounter. My vision was a little bit more comprehensive, and so I started researching it, and all of a sudden I realized this is actually a pretty significant undertaking with significant barriers. In terms of reimbursement, insurance companies, CMS, really weren’t covering it. There were grant opportunities available for setting up a demonstration project, or if you were in a rural health setting or a federally qualified health center, there were options, limited options, but there were some options available for telemedicine. But it really required a lot of extensive effort and setup in order to be able to accomplish this. And so I sort of set it off to the side a little bit, because I started thinking, “Wow, this is a really big undertaking, and I definitely can’t change CMS reimbursement for this.” But it was still in the back of my mind.

And so the more that we started thinking and hearing about COVID, and really what a pandemic was going to do for patients in the outpatient care setting, for more vulnerable older adults, telemedicine very quickly became part of the solution for continuing to care for these patients while trying to minimize and prevent the unnecessary emergency room visits and utilization of the health care system, while we’re trying to figure out how we keep everyone safe at the same time.

And so in March, when it was announced that Medicare was allowing for this coverage, initially they were really changing the reimbursement for video visits. Telephone visits were very much reimbursed at a much lower level. So now there’s this great opportunity, right? We’re able to offer telemedicine. But what’s happening with older adults, right? They’re having issues with technology. While technology has definitely been advancing and we’ve all integrated technology into our daily lives, when we think about patients, especially the patients that we care for at our center, we have a very diverse patient base, but a lot of our patients still come from the West Side of Chicago, where lower socioeconomic status and lower education levels are definitely a significant issue for these patients and become a significant barrier to receiving care, including telemedicine.

When you think about access, who has internet access, who has a smartphone, who is not only knowledgeable but familiar enough with using this kind of technology to be able to use our platform to initiate the telemedicine visit, all of a sudden you’re thinking about all of these other barriers that you need to overcome. And so having a health care system that’s able to provide that platform, and to have behind-the-scenes clinical support staff that’s able to reach out to these patients to teach them how to set it up, how to initiate those visits, to become more familiar, and to troubleshoot any issues that might come up before the visit is scheduled, is a huge time-consuming task.

And so what we were experiencing locally is happening at a national level. We’ve been able to show that telemedicine is effective. It’s not perfect. It should not be utilized in every single situation. The way that I look at it, telemedicine should be an additional tool in your clinical toolbox for helping to augment better care, and there’s still a lot of work that needs to be done. But the first step is, when you’re going back to your leadership and you’re trying to say, “Hey, I want to continue doing this,” the financial side also has to work out. And so when we think about patients in terms of transportation, and caregivers who definitely are also struggling with access and bringing in their loved ones to receive care, this is an alternative. It should not be the only way that you receive care, but if you’re able to include that as part of the options, I just think that this is a win-win situation.

And so I’m really hopeful. In the last couple of days, we’ve seen major articles published about this. The New York Times has written about telemedicine and looked at whether it’s going to continue. There are private insurance companies that are starting to say that they will continue funding telemedicine services. I think it’s a promising step, and I just really hope that it continues and that we don’t turn the clock back.

Kevin Pho: Now, what are you seeing in your practice regarding your geriatric population? Do you find that a lot of your patients still want to come in and see you? In other words, when you tell them that you’re offering virtual visits, how excited are they about taking you up on that offer?

Magdalena Bednarczyk: So it actually varies. Initially, in March and April and at the height of COVID for us in Chicago, there was a lot of fear and reluctance for most patients to come in, and also we were only trying to really see the patients that truly medically needed an in-person visit, and trying to see and manage most of the other problems over the phone or through a video visit. But as we know that our campus has become safer, with our screening procedures and our ability to provide PPE not only to the clinical staff but to patients that are coming in and, for example, don’t have a mask, that we can provide it, that we can screen them for symptoms, the campus is safer. So at this time, I’d probably call the last month and a half, two months, sort of our window of opportunity for bringing in patients.

And part of it is that there’s a trust and a relationship that’s been built in with patients, right? They rely on us to provide them with guidance and to say, “Yes, we think that it’s safe,” and that for you, whether it’s a routine patient care appointment where we should continue to address preventive health issues and chronic care management, versus an acute issue where we’re really trying to prevent an emergency room visit or a hospitalization, you should come and see us. Patients are really starting to want to come back more. There is still that reluctance for some patients, but at this point, we’re seeing increasing numbers of patients wanting to come back. And the reality is also that we don’t know what’s going to happen in the fall and the winter time. And so as we know that right now, again, from a physical distancing standpoint, with visitor restriction and screening, the campus feels safer and is a more controlled environment, in that sense patients feel better about coming back.

Kevin Pho: We’re talking to Magda Bednarczyk. She’s a geriatrician, and she wrote the KevinMD article “CMS needs to permanently eliminate barriers preventing routine use of telemedicine.” I read an article in JAMA Internal Medicine recently that found that only one quarter of geriatric patients had the equipment for virtual visits. Now, what are some of the ways that we can overcome that obstacle in order for telemedicine to really take hold in this population?

Magdalena Bednarczyk: That’s a great question, and that’s actually something that we are looking at, how we can better address. We have seen, either from philanthropy, in terms of donations from the public sector, or even from the federal government, grants that are being offered to allow health care systems to look at how they can improve access for older adults to telemedicine. It’s going to be a multipronged process in order to be able to address that adequately.

So the first thing is, patients need internet and technology access. So whether there are grants that provide free internet services, that can provide a free smartphone, because ultimately, right now, we look at it as almost like a medical necessity, right? If you want to receive your care through a telemedicine encounter, this is necessary in order for that visit to occur, and even for the way that we’re able to monitor some of our patients and their symptoms and their vital signs, we really need that. So first is internet access and technology access.

The second part is, health care institutions have to have the appropriate platform. One of the arguments against widespread use of telemedicine is the increased risk of fraud. And so a secure platform that is able to appropriately track patient encounters and documentation, and show whatever the insurance companies require, including CMS, that this was a true clinical appointment and that patient information is protected, should be developed and promoted.

And then what we need is education. Even for patients, while some might have some knowledge of how to use technology, being able to access the appropriate platforms to initiate those visits requires some coaching. And so that requires an additional level of resource, whether it’s clinical staff that reaches out to the patient or the caregiver before the appointment and troubleshoots the process so that everyone is familiar on the day of the appointment, or someone who initiates that visit and cues the patient to be there when the appointment needs to happen.

And also, it is about planning appropriately. It is also about teaching patients and caregivers that, just like when they come in for a visit in the outpatient setting, where they bring their medications, they have their blood sugar and blood pressure diaries available, and they have their questions written down, we want to prep them to be prepared for that visit so that the time is utilized most efficiently. So those are some just good habits that they can start developing for those visits.

Also, I have to say that the idea of actually being able to see the patient’s home, you know, we talk about home visits, but also from a video perspective, just literally being able to see them on screen, and even their surroundings, can also provide some additional information. Thinking about how to get through those steps so that that visit can be as successful as possible is going to be a big effort. I feel like we’ve really been at a disadvantage over the last decade especially, of not having this become a routine way to receive a part of your care. So there’s a lot of work that needs to be done so that we can catch up. But patients and caregivers are flexible, they’re willing, most of the stuff is. So as long as people continue to be flexible and willing and the resources are there that can make this happen, I think it can be a recipe for success.

Kevin Pho: And my final question: What is your take-home message that you want to share with the KevinMD audience?

Magdalena Bednarczyk: I think telemedicine should continue. I think that it’s a wonderful tool. And again, there’s been so much debate about the use of telemedicine technology. This is not meant to be a replacement. It’s literally meant to augment the care that we’re already providing to our patients, and if we use it appropriately, I think it can be really effective.

Kevin Pho: Wonderful. Thank you so much for sharing your time and insight, and thank you for being on the show.

Magdalena Bednarczyk: Thank you so much for having me, Kevin.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes