Article In Brief
Neurologists rapidly adopted telemedicine practices at the height of the COVID-19 pandemic. But as the public health emergency the federal government declared has receded, advocates for teleneurology question whether flexible licensure and reimbursement models will remain in place to make it more universally sustainable across state lines.
At the beginning of the COVID-19 pandemic in the United States in March and April 2020, neurology departments and practices that had offered minimal, if any, telehealth options for their patients were forced to transition to video and televisits for almost all non-emergency situations nearly overnight.
More than two and a half years later, as the pandemic moves into what might be called a “post-acute” phase, most programs have overcome the initial growing pains of that chaotic early period, with their dropped calls, muted microphones, and turned-off cameras. Indeed, many have adopted integrated telehealth policies that have made patients' lives easier and improved their satisfaction without sacrificing the quality of that care.
Telehealth in neurology is here to stay, experts told Neurology Today, just as it is in the rest of the health care system. But to make the most of this care modality, the flexible, patient- and provider-centric regulatory and reimbursement models that allowed for expanded care during the public health emergency the federal government declared must be adapted to continue once the official “emergency” ends, they said.
Trends in Use
Across the Mayo Clinic enterprise—including its medical centers in Rochester, MN; Phoenix and Scottsdale, AZ; and Jacksonville, FL; and in the Mayo Clinic Health System in Minnesota, Iowa, and Wisconsin—the number of neurology video-to-home telemedicine visits averaged approximately 10,000 a year as of 2022—a 10 percent increase over 2021.
“We have seen no sign that as the height of the pandemic lessens, neurologists and neurology patients are reducing their use of video consultations,” said Bart Demaerschalk, MD, MSc, FRCPC, FAAN, professor of neurology and medical director for digital health research in Mayo's Center for Digital Health. “Neurology acute care telemedicine—including telestroke, teleneurology, and teleneuro-critical care—has also grown by about 16 percent over the past year, reaching approximately 2,500 consultations annually.”
Not every institution has experienced similarly high levels of teleneurology visits after the acute phase of the COVID-19 pandemic. Overall, Atrium Health Wake Forest Baptist Medical Center in North Carolina went from zero to 100 percent telehealth visits within a week in the spring of 2020 but then saw telemedicine consultations decline to about 25 percent of all neurology visits by mid-2021 and reach about 20 percent of all visits by mid-2022. That varies by specialty, said Roy E. Strowd, MD, FAAN, associate professor of neuro-oncology at Atrium Health Wake Forest School of Medicine and co-director of the Comprehensive Tuberous Sclerosis and Neurofibromatosis Clinics.
“In my practice we are still doing about 30 percent or so video visits, give or take, depending on the clinic day,” he said. “For some movement disorders and neuromuscular practices, which are difficult to do with telephone or video consultations, they are almost 100 percent in person. Other subspecialty providers, such as in headache or sleep medicine, may have a much higher percentage of telehealth visits.”
At the Icahn School of Medicine at Mount Sinai in New York, teleneurology visits—both telephonic and video—have also declined since the early days of the pandemic but are still offered in most subspecialties, said Benjamin R. Kummer, MD, director of clinical informatics in neurology and assistant professor of neurology. He noted that the option for a remote visit remains particularly popular for conditions such as headache and multiple sclerosis, where a significant percentage of the patient population is younger and may still be in the workforce and have younger children.
“These are also the groups that were using teleneurology the most prior to COVID, as we had a small pilot of teleneurology at that time, and we chose those divisions initially because we thought the population was younger and would be more tech-forward,” Dr. Kummer said.
Some of the decline in telehealth visits has occurred with the still-evolving state of regulations governing interstate telehealth consultations. Although the federal government has not yet declared the public health emergency over, many states have begun tightening the licensure restrictions eased during the pandemic, allowing doctors to provide telehealth consultations for patients in states where the doctors themselves were not licensed.
As of Sept. 9, 10 states continued to have licensure waivers for interstate telemedicine; 38 states and the District of Columbia no longer had waivers; and 20 states allowed long-term or permanent interstate telemedicine, according to the Federation of State Medical Boards.
“I have patients in South Carolina, West Virginia, and Virginia, and they are driving just across the state line and going to a rest stop parking lot to do video visits from their car,” said Lauren Doyle Strauss, DO, associate professor of pediatric neurology at Atrium Health and chair of the telehealth committee in the department of neurology. “They joke that the rest stops just across the border should have reserved spots for my patients.”
“Many of the patients I see are women who require ‘one-off’ consultations for pregnancy, menopause, and contraceptive and hormonal therapy management via telehealth,” said multiple sclerosis specialist Riley Bove, MD, associate professor of neurology at the University of California, San Francisco Weill Institute for Neurosciences.
“The expansion of coverage and access for interstate telehealth meant that patients could consult with me from all over the country. Although we had an established track record with telemedicine before the onset of the pandemic, we hadn't been able to do these interstate consults previously. Now, for patients in many states, we have had to transition them back to full management with a local neurologist.”
Neurology departments have come a long way in understanding how to use telemedicine resources over the past two years—but it wasn't always easy. Mt. Sinai, for example, hit a few speed bumps in selecting a standard telehealth technology platform.
“Our first vendor gave us a decent audiovisual connection, but there were a lot of technical problems with getting patients' devices to connect to the visit,” Dr. Kummer said. “Then we switched to another platform that allowed features like sharing images and sharing screens with family members but had significantly worse audiovisual quality. As Zoom became a mainstay of everyone's daily lives, we decided to conduct a pilot of Zoom as a primary platform for our televisits in our Alzheimer's center and the general neurology clinic. It was very clear that this was a superior solution, so we've now adopted it as our official telehealth platform.”
Integrating the in-person clinic with the remote clinic can be another challenge. “We've adapted our check-in processes, staffing, visits, and follow-up in a rapid way,” Dr. Strowd said. “But at the same time, we are squeezing telemedicine care into an in-person care delivery model, which to me feels somewhat like a square peg in a round hole.
“For example, the hospitals where I work have a lot of provider work rooms—big open spaces where people sit at individual modules. You can't do a televisit in that space, so we end up using the exam rooms for telemedicine visits. I'll go into one room, and see an in-person patient, then go into the next room and see someone by video, which can sometimes make the flow more difficult.
“Our check-in process is still built around the in-person model, which has a lot of checks and balances and wiggle room in the system to limit delays and maintain timeliness. Because this new approach has been so rapidly implemented, we haven't been able to build a new infrastructure model for telecare delivery. One of the big future needs is not just more infrastructure for patients but changing the systems we work in to accommodate high-quality telemedicine care, should it be funded and supported moving forward.”
Who Chooses Teleneurology?
Several recent studies have assessed the factors that influence patients to choose telehealth visits in neurology over in-person visits.
“In my practice we are still doing about 30 percent or so video visits, give or take, depending on the clinic day. For some movement disorders and neuromuscular practices, which are difficult to do with telephone or video consultations, they are almost 100 percent in person. Other subspecialty providers, such as in headache or sleep medicine, may have a much higher percentage of telehealth visits.”—DR. ROY E. STROWD
“Patients who preferred in-person visits tended to emphasize their confidence, trust, and familiarity with the provider, and that ‘laying on of hands’ in the in-person neurologic exam,” said Dr. Strowd, who co-authored a paper in May in the Journal of Neurology assessing patients' preferences with and response to telemedicine. “For the patients who preferred video visits, they emphasized convenience and support. The ability for people who were working full-time, or who were full-time students, or who had young children, to not have to take time out of a busy schedule to come into the clinic was very important to them.”
That kind of convenience is also valued by patients with conditions that affect their mobility or cognition. “It not only reduces the burden on the patient and family caregiver, but it also gives us a better window into the patient's life and how the environment around them might be influencing their disease and care,” Dr. Strowd said.
“I saw a patient via video visit the other day, and it was the first time I'd seen them in their home. They had been having some difficulty with remaining adherent to their medication regimen, and it became clear to me as I saw them in their home environment that they had too many medications. Patients don't always bring all their medications to in-person visits even when we ask them to; seeing this patient at home allowed me [to gain] an insight into the problem and get them on a better medication regimen.”
“Before COVID, a lot of neurologists inexperienced with telemedicine assumed that you couldn't effectively examine a patient remotely,” Dr. Bove said. “By the time we were six months into the pandemic, everyone had become much more comfortable. We've established that teleneurology is feasible even for patients who may be older and have dexterity or ambulatory or cognitive difficulties.”
Several studies and surveys have found patients are highly satisfied with the care they receive via telehealth, in general, and in neurology. “Looking at our Press Ganey survey data for 2020-2021, we compared nearly 3,000 Mayo Clinic neurology patients who had telemedicine visits and nearly 11,000 who had in-person visits, and the satisfaction ratings were not significantly different,” Dr. Demaerschalk said.
“The ‘overall likelihood to recommend’ top box score for neurology was 88 percent for telemedicine visits and 87 percent for in-person visits, while for neurosurgery it was 88 percent for both telemedicine and in-person visits.”
Some neurologists have been surprised by how much of the neurologic exam can be conducted via video visit. For those who have done it for a while, however, “we've known for a long time there are things you can certainly do remotely to test strength and function,” said Jaime Hatcher-Martin, MD, PhD, FAAN, a neurologist who provides telehealth services in acute care medicine, consults with hospitals and emergency departments that may not have an expert neurologist on site, and provides care for ALS patients in their homes through the teleneurology platform Synapticure.
“You can ask the patient to stand up from a chair with their arms crossed or push up from the chair with their arms, walk on their toes, pick up a gallon of water,” she said. “A lot of our exams in neurology are observational, such as picking up cues for atrophy in the arm and hand muscles and the way the face moves.”
There are limitations, of course. “If there are nuances in the strength exam, you can't test that, nor can you do a really detailed sensory exam unless you have a very astute patient or caregiver who can parse out the details, but that's the exception,” Dr. Hatcher-Martin said. “Reflexes are very difficult to test over telemedicine unless you are working with a telepresenter who is very skilled in eliciting those or they are spontaneously abnormal.”
And while studies and surveys have suggested that patients are generally satisfied with teleneurology and telehealth in general, the question of equivalent quality of care remains unknown.
“We don't yet know whether we are preventing loss of neurologic functions, getting people on the right medications, and providing care in the right way,” Dr. Bove said. “Gold standard randomized controlled trials will be very important there” to test that.
One early signal is that diagnostic accuracy for new patients appears to be very good when clinical assessments take place over a video visit, according to an article published in September in JAMA Network Open by Dr. Demaerschalk and colleagues. The patients had new neurologic problems and were seen first by video and then in person on campus. The researchers then compared the provisional diagnosis from the video visit to the in-person standard reference diagnosis.
“Overall, we were very encouraged to see that diagnostic accuracy was about 81 percent in neurological practice and approximately 88 percent for nervous system conditions in general,” they explained. “And among the small percentage of patients for whom there was not a diagnostic match, this was most likely to occur in neurologic conditions that we know require a detailed, in-person, traditional physical examination; brain imaging; or other neurological studies, such as electromyography nerve conduction studies, to establish a diagnosis. For example, some neuromuscular conditions having to do with the spine, such as neck pain or back pain, were very challenging to diagnose accurately by video alone.”
Reimbursement and Regulation
While telehealth has become a major part of the practice model within many departments of neurology in hospitals and health systems over the past two years, concerns remain about sustainable models for reimbursement. Dr. Strauss said the issue “was a big topic of conversation” at a recent Southern Headache Society regional meeting.
“Particularly in private-practice settings, people are worried that long-term reimbursement models for this type of care will not be equal to that for an in-person visit,” she said. “If compensation doesn't remain stable, practices that have not been able to invest in telehealth to date will not invest in that technology and training going forward. If more practices are not adopting and improving the technology and making this a reliable and accessible option for patients, I can see payers not reimbursing telehealth equally.”
Some payers already are decreasing reimbursement for telephone visits as opposed to video visits, which can pose issues of equity.
“My sense is that video telemedicine is unevenly and inequitably distributed among patients who have access to video and broadband services, who live in environments conducive to those types of visits,” Dr. Strowd said.
In a study of barriers to access to telemedicine published in Neurology: Clinical Practice in 2020, he, Dr. Strauss, and colleagues found that Black male patients who were older and had Medicare or Medicaid as their insurance provider were less likely to have completed a video visit.
“Although we have seen many gains in access to telemedicine over the past two years, the potential barriers and inequities, in my mind, are widening and not narrowing,” Dr. Strowd said. “This worries me a great deal.”
Dr. Strauss, who cares for patients in a heavily rural area in North Carolina that includes the Appalachian region, agreed. “I was recently evaluating [someone with] a Zoster rash, and the video was skipping and buffering. This is a condition that would be great to assess over video, but the investment in fundamental infrastructure and broadband for the region is lacking,” she said. “It will take some tough decisions and state and federal action to help make sure that we respond to challenges like these.”
Dr. Demaerschalk noted that at Mayo, telephone visits are the only area of telehealth that has declined in overall pace since 2020-2021. “They were at their peak within the first three months of the WHO declaration of the pandemic, then declined precipitously before plateauing,” he said. “There is no doubt that telephone consultations will continue to be important, however, particularly for individuals in communities with broadband access issues.”
As a lifeline for the socially vulnerable, audio-only telehealth needs to be preserved, Dr. Kummer said, and “we have to continue to make sure those services continue to be paid at a rate that is palatable for providers.”
“The Centers for Medicare and Medicaid Services needs to set the rules for Medicare and Medicaid to reimburse telehealth-to-home visits and make that permanent before the public health emergency ends,” Dr. Kummer added. “Private payers have already started rescinding some of those payment policies in advance, and that is very troublesome.”
The American Academy of Neurology recently joined the American Telemedicine Association and other organizations to send a letter to Senate Majority Leader Charles Schumer (D-NY) and Minority Leader Mitch McConnell (R-KY), urging the Senate to act to provide certainty for telehealth services beyond the COVID-19 public health emergency, which is set to expire at the end of 2022.
“Virtual care is now a fundamental part of the US health care system, and it will improve patient access to high-quality care and strengthen continuity of care well beyond the COVID-19 pandemic,” they wrote. “While many of the most compelling clinical use cases for virtual care are only now emerging, more communities than ever have experienced the powerful impact telehealth has had in bridging gaps in care.
“Telehealth is helping to address the crisis-level mental health, primary care, and other workforce shortages. Many underserved communities that historically have had limited access to care may now beam in additional support for their workforce as well as top specialists to help save lives and treat critically ill patients. Unfortunately, without statutory certainty for remote care, the hard work of building infrastructure, trust, and relationships with these communities is beginning to stall.”
In July, the House of Representatives passed the Advancing Telehealth Beyond COVID-19 Act (HR 4040), which would extend key telehealth flexibilities until the end of 2024 by a vote of 416-12, but the Senate has not yet taken up the bill. Meanwhile, telehealth flexibilities will remain in place 150 days after termination of the public health emergency.
“If that is not passed and the public health emergency expires, there will be serious implications for our ability to provide teleneurology consultations,” Dr. Demaerschalk said. “It's critical for our patients that we achieve this two-year extension of flexible telehealth regulatory policies, but ultimately it's most important that these be made permanent to ensure continued and uninterrupted access over time.”
No one wants to go backward. “Telemedicine has been normalized as a care delivery model for both patients and providers,” Dr. Strowd said. “Patients and providers have both gained confidence in this model. We've figured out how to lessen the administrative burdens and learned how to personalize and individualize this tool for the right patients.”
“The expansion of coverage and access for interstate telehealth meant that patients could consult with me from all over the country. Although we had an established track record with telemedicine before the onset of the pandemic, we hadn't been able to do these interstate consults previously. Now, for patients in many states, we have had to transition them back to full management with a local neurologist.”—DR. RILEY BOVE
“Telemedicine is 100 percent here to stay, and our job as neurologists is to optimize the ways we can utilize it to care for our patients while at the same time understanding the limitations as well,” Dr. Hatcher-Martin said. “There will always be conditions and situations for which you really need to be seen in person. There's no way to replace what a hands-on exam can do, but as a whole, both the medical community and patients are starting to understand all of the things that telemedicine can offer.”
