Telehealth Local Gets Its Coming Out Party

EVERY GENERATION SEEMS TO HAVE AN EVENT from their early years seared into their collective psyche.

Mine was the explosion of the Space Shuttle Challenger in 1986. I remember an eerie calm as my third-grade teacher tried to explain what we had just seen on the classroom television screen and asked us to discuss it with our parents after we got home.

I watch my kids now taking online classes and doing their 500th loops around the cul-de-sac on their bikes, and I know that they understand enough about what is going on because of coronavirus disease 2019 (COVID-19) to realize that the world is not normal right now. That amazes me because what they are absorbing is largely in the abstract. They cannot see it. There is no military or scandal a plane flying into a building or a tragedy in space. There is only what looks like a dramatic episode of ER, Grey’s Anatomy, or New Amsterdam on the evening news. A lot of people talk about the new normal, but no one really knows what that means right now.

PRACTICES WITHOUT CORPORATE PROVIDERS HAVE BEEN RAVAGED

What we do know: Our economy has grinded to a halt in a way never seen before. Even the environment has taken notice, with clear skies over Beijing, China, for example. Whether we are talking about the Bronx, New York, or Grand Island, Nebraska, this virus has changed our lives and will change how pharmacists practice and how we all view essential health care infrastructure.

In my work with community pharmacies, things changed rapidly the day Commissioner Adam Silver shut down the National Basketball Association and likely saved at least tens of thousands of lives by giving us all a “time to sit up straight” moment. My first meeting after Silver’s decision and actor Tom Hanks’ announcement that he and his wife and fellow actor, Rita Wilson, had tested positive for COVID-19 was with a group of primary care physicians.

Toward the end of the meeting, the round-robin assessments eventually came to me, and I rightly said, “Well, job No. 1 for us has to be pharmacy workforce protection. If we lose 20% to 30% of pharmacies to closure owed to quarantine or worse, that’s a public health crisis.” I followed that assessment with one of the most naïve, poorly thought-out statements I have ever uttered: “I need to know from all our primary-care providers what you want the pharmacies doing when you become overwhelmed from the influx of patients seeking help.”

The opposite occurred. Suddenly, as pharmacists put in some of the busiest days of their careers, primary care offices found themselves with empty waiting rooms. Most patients observed stay-at-home orders and chose to forgo regularly scheduled evaluations and monitoring or elected to self-treat rashes.

The Los Angeles Times reported recently that in-person patient visits dropped up to 75% in March,¹ and 8 in 10 practices are now under severe or nearly severe financial strain resulting from the COVID-19 pandemic, with just a third reporting that they have enough cash to make it for another 4 weeks.² The irony is both astounding and sad that a health care crisis would have this effect, with many practices likely to go out of business unless they can access small-business loans under the Paycheck Protection Program.

LOCAL TELEMEDICINE STEPS IN TO FILL THE VOID

What do health care providers do when temporarily separated from patients? They find a way meet online.

If necessity is the mother of invention, it may also be the sister of practice transformation. Over the past decade, despite the hundreds of billions of dollars of rightfully made investments in population management, chronic care management workflows, and changes in how health care providers get paid, evolution has been excruciatingly slow. It took a pandemic to speed up change.

The Primary Care Collaborative (PCC) polled primary practices in real time for a few weeks in March, with eye-opening results. By the end of that month, more than half the nation’s primary-care office visits were conducted by telephone, with parking lot, texting, and video visits growing dramatically over the previous 4 weeks. Most patient visits now take place outside the office but with a local provider. One respondent shared the following experience: “We have had awesome system response, set up a triage line with 1500 patient calls per day, switched to virtual visits within 1 week, etc.”³

On March 6, Congress passed the first coronavirus response bill, and it was signed into law quickly, temporarily waiving many telehealth rules regarding the originating site and established relationship requirements. However, the reimbursement codes, visit requirements, and amounts of reimbursement remain incommensurate with the type of remote care in demand. I give credit to my home state and the North Carolina Department of Health and Human Services for responding so quickly to our colleagues in primary care. Almost immediately following that fateful first week of dramatic change, codes were opened up and reimbursement bolstered to provide telemedicine services to Medicaid recipients, even allowing the same for pharmacists having collaborative practice agreements in that setting. The department also doubled the per-member per-month payments for care and panel management and preventive care activities, recognizing all the changes and efforts not related to traditional visits but, rather, ensuring the health of populations.

As Ann Greiner, PCC’s president and chief executive officer, put it: “Next is to get financial relief to practices that are going under water and to move primary care much more rapidly to adequate prospective payment. Practices under such arrangements can weather these storms and provide higher-value care.”⁴

NEW MODEL FOR TELELOCAL EMERGES

The COVID-19 pandemic is not only forcing change in how providers interact with patients in a local health care ecosystem but also stimulating changes in how that gets paid. Telemedicine has until now been used to get a snap diagnosis of erectile dysfunction, obtain convenience care for a cough or cold, or quickly procure oral contraceptives from a provider whom the patient has not met and may never see again. The coronavirus response is an altogether different evolution. Over the course of a month, millions of online visits occurred with established patients, treating chronic conditions and changing physician workflow. The telelocal health care system took root in a matter of weeks, with payment reform trailing close behind. No health reform policy has ever had such an impact.

WAITPHARMACIES HAVE DONE TELEEVERYTHING UNPAID FOR DECADES

Telepharmacy (as broadly defined, beyond prescription checking) has been part of everyday community pharmacy practice since telephones were first installed in the 20th century. Call any pharmacy in the country and ask to talk with a licensed pharmacist and one will likely get on the phone within a minute. That has never been the case with other health care providers. The problem is, a pharmacist can have a 15 to 20 minute conversation, dispensing important health information, but receive exactly $0 in reimbursement. The caller might use another pharmacy or even mail order for prescription purchases. This must change. The drug product buy-sell no longer supports this ubiquitous service. We need different models of care and reimbursement for pharmacy, too.

AS OUR WORLD CHANGES, HOW WILL PHARMACY RESPOND?

Pharmacies have been providing telelocal for decades without policy changes. The past few weeks have shown that crisis necessitates change. Pharmacy’s long-term crisis is a dependence on an outdated and outmoded product-based reimbursement model that led us down the same path that cursed primary care, which is being changed forever by COVID-19. What events will necessitate our clarion call? And will we answer?

Troy Trygstad, PharmD, PhD, MBA, is vice president of pharmacy programs for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

REFERENCES

• Leavey NN. Coronavirus already changing medical care in the U.S. Los Angeles Times. April 10, 2020. Accessed April 30, 2020. https://www.latimes.com/politics/ story/2020-04-10/coronavirus-lasting-changes-healthcare
• Survey of primary care clinicians shows practices strained in response to coronavirus. Primary Care Collaborative. April 2, 2020. Accessed April 30, 2020. https:// www.pcpcc.org/2020/04/02/survey-primary-care-clinicians-shows-practices-strainedresponse- coronavirus
• Primary care & COVID-19: week 3 survey. Primary Care Collaborative. April 1, 2020. Accessed April 30, 2020. https://www.pcpcc.org/2020/04/01/primarycare- covid-19-week-3-survey
• Survey of primary care clinicians shows practices strained in response to coronavirus. Primary Care Collaborative. April 2, 2020. Accessed April 30, 2020. https://www. pcpcc.org/2020/04/02/survey-primary-care-clinicians-shows-practices-strained-response- coronavirus