Article In Brief
Neurologists with expertise in telemedicine and medical economics discuss how the COVID-19 pandemic will lead to changes in health care delivery, medical licensure, payment parity, and the neurology exam.
Just a few months ago, a telehealth neurology practice was considered a rarity, relegated largely to a handful of private practitioners seeking flexible employment from telemedicine corporations, and to academic stroke centers delivering care to patients at smaller, regional hospitals. Today, it has become the norm, with almost every practicing neurologist in the nation now set up to deliver care virtually. Sweeping changes in insurance reimbursement, regulatory mandates, state and federal legislation, and a remarkable spirit of cooperation have led many experts to predict that medical practice, as we once knew it, will be no more.
Neurology Today asked several telemedicine and medical economics experts to consider the role of the coronavirus pandemic as the catalyst to health care delivery reform, and to share their vision of neurology practice in five years to come. What follows are their propitious predictions as a tonic for these dystopian times.
“We are in the midst of the greatest social transformation of American medicine in a century; the way we cared for patients fundamentally shifted from clinics to telemedicine in a matter of a month,” said E. Ray Dorsey, MD, MBA, the David M. Levy professor of neurology and director of the Center for Health + Technology at the University of Rochester Medical Center.
Dr. Dorsey estimates that the number of telemedicine visits has increased from 100- to even 1000-fold in some medical centers and accounted for the majority of the outpatient visits in neurology at centers across the country during the first few months of the pandemic.
Doctors Without State Borders
“In five years, the reach of specialists may extend far beyond state borders, and the notion that all health care is local may become quaint,” Dr. Dorsey predicted. “The future holds immense possibilities, including the compelling notion that neurological care will be increasingly available to anyone anywhere,” he added.
Many patients will question the need to return to a clinic after realizing the advantages of convenience and flexibility for the first time, Dr. Dorsey said. He also envisions that more frequent, shorter visits, from a wide range of clinicians—dieticians to occupational therapists to pharmacists—are more likely.
So too will medical credentialing requirements change. Bruce H. Cohen, MD, FAAN, director of the NeuroDevelopmental Science Center and interim vice-president and medical director of the Research Institute at Akron Children's Hospital, noted that the 2020 HHS 1135 waiver allowed state medical boards and departments of health to waive the need for a medical license at the site of service temporarily. Until that time, it had been both costly and cumbersome for physicians to apply for multiple state licenses routinely.
“But over the next five years it is likely that physicians will carry an active license in the state in which they see patients face-to-face, and a restricted license or other valid credential for telemedicine services only which requires a minimal background check,” Dr. Cohen predicted. “Moreover, the advent of block chain credentialing services will make obtaining those additional state licenses as easy as sharing a private key with the licensing agency,” he said. “Every credentialing statement will become the property of the physician and need only be authenticated once,” he explained. “The blockchain technology would also allow all state requirements for ongoing licensure to be pushed to the doctor in real time and intrastate reciprocity for educational requirements would be commonplace,” he added.
The ease of acquiring medical licenses will allow neurologists to expand their employment choices. For the last two decades we have seen an era of hospital system branding, but the rapid shift to telemedicine services, if sustained after the pandemic, provides a new opportunity for neurologists to start branding themselves.
“Those general neurologists or subspecialty neurologists who prefer a telemedicine practice or mix of telemedicine and hands-on work will be able to fill their clinics with patients across the country, and those with subspecialty expertise will be highly sought after as patients with rare diseases or complicated courses will seek second opinions as well as ongoing care with the nation's leading experts in their conditions,” Dr. Cohen said.
“One can envision employment arrangements at several institutions in various locations in the United States,” Dr. Cohen continued. “Neurologists will compete for appointments at preferred institutions in any location in the country, and neurologists may be able to provide care from miles away, even from other countries,” he concluded.
The pandemic period motivated regulators to allow payment parity regardless of the visit site. “It will not take long for insurers to permanently eliminate originating site of service rules as they are too burdensome and only in their removal can telehealth truly advance,” predicted David E. Evans, MBA, chair of the AAN Health Policy Subcommittee.
“Telehealth has been shown to be cost-effective, efficient, and equal in therapeutic value to face-to-face encounters, and quality studies will reveal that its value is commensurate with face-to-face visits, and in some cases, superior in better addressing the social determinants of health,” Evans continued. “Moreover, health disparity and access to care, a concern that applies to those with limited technology and mobility, will be addressed through acceptance of audio-only visits with reasonable reimbursement to effectively promote access to care and reduce disparities,” he added.
With payment parity in place, it will be cost-feasible to employ telehealth broadly. Evans envisions that the process of valuing a televisit vs. an in-person visit will be an arduous process for the RVS Update Committee (RUC), which is tasked with establishing RVU values for CPT codes, but ultimately, the value proposition will drive appropriate valuation.
“The rapid shift to telemedicine as a result of COVID-19 may disrupt the dominant payment model of fee-for-service, in that the practice expense for ambulatory care is reduced,” Dr. Cohen suggested. According to Dr. Cohen, who serves as the AAN's CPT advisor, although this may cause an initial financial blow to hospital systems that rely on these fees, ultimately the cost of medical care is reduced and value-based models of care can become more attractive to health systems and their patients.
“The individual neurologist may benefit by having more choices and added variety to their work, which could include seeing both local patients and those living remotely,” Dr. Cohen predicted. “Health systems—with the aid of a change in antitrust rules—will need to cooperate on care that is now thought of as downstream revenue, such as routine laboratory and radiology services.”
Personalized Patient Apps
“Patient smartphone apps and accessories will help with all aspects of the teleneurology encounter, including history, physical exam, medical decision-making, and treatment,” said Neil A. Busis, MD, FAAN, associate chair of Technology and Innovation in the department of neurology at NYU Langone Health. He believes that patients will record relevant aspects of their clinical course at home and share it with their physician before or during the encounter. The information will accommodate patient preferences to take the form of a text, audio, or video format.
“Using sensors either built into the smartphones or as accessories, patients will be able to monitor and share physiologic parameters such as temperature, blood pressure, pulse, pulse oximetry, weight, movement, and tremors,” Dr. Busis said.
Patients who have wearable or implanted cardiac or brain devices will be able to send prolonged electrocardiogram or electroencephalogram recordings to their physicians, he continued.
“The tele-neurology exam will be amplified by apps that will be able to assess visual fields, visual acuity and color vision. A camera accessory with supporting apps will enable visualization and photography of ophthalmic structures, and similarly, auditory accessories and apps will enable hearing to be tested. Remote physiological monitoring and virtual house calls will revolutionize chronic care management,” Dr. Busis said.
“With appropriate security and privacy measures in place, the data from these apps will be used for machine learning and artificial intelligence to increase our ability to diagnose and treat,” he added.
Remote Programming of Devices
Bryan T. Klassen, MD, assistant professor of neurology at the Mayo Clinic in Rochester, MN, said that the deep brain stimulation (DBS) device companies do not currently have an on-label way to remotely manipulate neurostimulator settings directly. However, all of the devices are able to store alternative settings as well as stimulation amplitude ranges which the patients can manipulate with a patient remote control that they take home with them.
“A ‘work around’ solution utilized during the quarantine was to provide a bit more liberal ranges and additional settings based on what we think might be necessary over time and then scheduling video follow-ups during which the situation is assessed, an alternative program potentially chosen, or instructions regarding adjusting the range given.”
“The patient can be talked through applying those changes under video supervision if needed,” he explained.
Dr. Klassen suspects that all of the device companies are interested in rolling out additional functionality surrounding remote programming. “Regulatory, licensure and billing issues will need to be sorted out, however, within five years I think much of this will be in place. I would imagine many patients could have their device settings optimized over a remote clinical encounter with the clinician monitoring by video and manipulating parameters remotely,” he said.
As a movement disorders provider, Dr. Klassen thinks it would be ideal if adjustments of infusion therapy, (currently this is only available for Duopa, a carbidopa/levodopa enteral suspension), could also be delivered remotely. “There is less of an obvious path for this right now, though one could imagine a similar scenario where a patient is seen over video, infusion rates assessed, and adjustments made remotely as needed,” he said. “Currently, with Duopa adjustments, we have the same option of programming more liberal ranges into the patient's pump and talking them through adjusting their settings over video,” he added.
“The other thing that could conceivably be offered remotely down the line would be diagnostics in the form of remote kinematic analysis,” he added. “A clinician may perform an initial evaluation over video and then could send out a wrist-worn accelerometer or other motion-sensing device which collects data over time to either further characterize movement phenomenology or potentially to classify different motor states,” Dr. Klassen envisioned.
Registries for Quality of Care
“The Axon registry as a quality improvement registry will be a tool that allows us to compare the quality of care and outcomes when patients are cared for face-to-face vs via telemedicine,” said Sarah M. Benish, MD, FAAN, chair of the Registry Subcommittee, explaining that it will help demonstrate when and where telemedicine works and when office care is needed.
“It will be able to streamline visits and allow for patients to help populate their own charts thus decreasing the burden of chart keeping while still prioritizing meaningful outcomes for neurological patients,” she predicted. Questionnaires will be sent to the patient prior to the appointment and will be given to the provider ahead of time, allowing for the integration of patient reported outcomes, she added.
“These can ensure neurologists are helping improve patients' quality of care and outcomes of treatments and allows for a more streamlined appointment than having to go through a repetitive rooming process, endless completion of identical forms etc,” she said.