HealthcareHospitals Scramble to Meet New Demand for Telemedicine but for Direct Care Physicians it’s Business-As-Usual

Telemedicine has been used by direct care doctors for years and now, under crisis, the rest of the healthcare industry is following suit.
April 2, 2020
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One of the numerous regulations Texas Governor Greg Abbott has temporarily suspended during the coronavirus pandemic limits the accessibility of telemedicine — the practice of meeting with a physician remotely over the phone or by video. 

Abbott’s executive order requires all state-regulated insurance plans to cover telemedicine services at the same reimbursement rate as in-person visits. With coronavirus spreading in Texas, the state wants to minimize in-person human interactions as much as possible, which includes doctor-patient face-to-face interactions.

Both out of coronavirus precaution and the improved reimbursement rate, typical doctor offices are more often using telemedicine to care for their patients. But telemedicine in Texas has long been used by direct care doctors to provide a more efficient and personal service to their patients.

Direct care is a physician model in which the middlemen — most often the insurance company and government — are cut out. This cuts costs and avoids the numerous regulatory and bureaucratic hoops through which insurance-based physicians must jump.

Modern telemedicine’s origin, at least partially, can be traced to North Texas to a company called Teladoc which began providing telemedicine services in 2002. Teladoc is currently facing a class-action lawsuit from its employees after its CFO was accused of an “inappropriate office relationship” with an employee and engaging in insider trading with that employee.

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But most direct care facilities operate as tiny pirate skiffs amidst a sea of behemoth warships, existing outside of the mainstream system. The best comparison for direct care facilities is really a modernized version of the healthcare system in place before the Great Depression — wherein doctors made house calls to their patients.

With telemedicine, those house calls can be done remotely which limits exposure of both the patient and doctor to diseases such as coronavirus.

John Chamberlain, former hospital CEO board chairman of Citizen Health whose mission it is “to build an affordable healthcare economy that puts people first and is sustainable for generations,” told The Texan direct care practices have “been at the forefront of telemedicine long before this pandemic.”

Citizen Health Board Chair John Chamberlain

Chamberlain pointed out that concierge care, which is similar to direct care but still uses insurance, also uses telemedicine but stops after giving out their cell number due to insurance reimbursement requirements (i.e. in-person visit requirements).

“Long before this pandemic, direct care doctors were doing telemedicine because it’s quick, convenient, included in the subscription price, and extremely effective from the patient’s viewpoint,” Chamberlain said.

For the doctor, Chamberlain added, the staff needs are reduced because “he doesn’t need to see 30 or 40 patients in a day nor deal with all the insurance paperwork that comes with it.”

The cost associated with taking government-run Medicare and Medicaid is an enormous burden too. Maintaining a perfect Merit-based Incentive Payment System (MIPS) score — which determines the reimbursement rate for physicians accepting Medicare and Medicaid — cost one physician $100,000 and countless man-hours just to keep up with all the required paperwork.

That’s time and money not being spent on care for their patients. 

About the pandemic-driven use of telemedicine, Chamberlain said, “Hospitals that own physician practices are closing them to in-person visits but still must take care of their patients and has thus driven the huge uptick in telemedicine use.”

He then queried, “But why shouldn’t they be able to do this normally?” 

One such reason, Chamberlain pointed out, is that HIPAA privacy regulations limit the telemedicine resources traditional physicians can use with their patients — requiring certain “certified” mediums, of which common products such as skype are not included.

Dr. Michael Garrett has operated a direct care practice in Austin since 2014 and has offered telemedicine since day one.

Garrett’s patients can reach him 24/7 by email, text, or phone call. “Providing that ability to our patients is a natural fit and they love it.” 

The convenience of the practice is only outdone by its necessity in this public health crisis. Like all healthcare workers, Garrett has had to adjust in order to ensure the safety, not only of his patients but of himself and his employees.

But due to the nature of his practice, he has found that transition to be rather smooth.

Doctors who break off from the traditional hospital/insurance-based model tend to do so after losing patience with the bureaucratic red tape within the traditional model that can inhibit the physician’s relationship with their patient. Direct care facilities get their competitive advantage from being leaner, more cost-efficient, and hands-on with their patients.

Dr. Michael Garrett (IJ.org)

In a traditional practice, more barriers exist such as requiring an in-person appointment to get a prescription even if the issue is regularly occurring and known between the patient and doctor.

“A doctor in a traditional practice often cannot bill the insurance unless an in-person visit is done, whereas we have the flexibility to say, ‘What’s best for the patient?’” The best interest of the patient is most easily determined between the doctor and patient themselves, and often only inhibited by the third party.

That’s not to say there is no basis for regulations such as in-person visit requirements, which are intended to prevent faulty diagnoses and prescription disbursements. But thanks to telemedicine’s innovations — or a simple video chat — the same information can be gathered as would be during an in-person visit.

But just because the option is there doesn’t mean Garrett and his patients only use that medium. Garrett and his patient decide together what is best, and for more serious situations an in-person visit is both necessary and prudent — but the flexibility improves rapport between the patient and their physician.

Operating outside the third-party model, there are fewer regulations constraining their ability to get creative with the care they provide patients. One of the numerous examples is telemedicine.

“Our ability to get a reimbursement is not dependent upon, or really even directly related to, how many patients we get in the office in a day,” Garrett added.

Another benefit of telemedicine is convenience. Time and money are saved by the patient not having to sit in traffic, waste away in the waiting room, and — if doctors like Garrett and San Antonio ophthalmologist Kris Held have their way, legalizing doctor dispense — avoiding the wait for the pharmacy to fill their prescription.

One of the most important aspects of telemedicine’s beneficial role in this crisis, Garrett says, is its minimized use of personal protective equipment (PPE). Supply chains all over the world are dangerously short on PPEs as the demand has skyrocketed and the supply has yet to catch up.

Limiting his use of PPEs is one, albeit small, load taken off the broader supply chain. But if all doctors began using telehealth more liberally — and were allowed to by regulation rollback’s such as Abbott’s — then even more burden would be lifted from the world’s stressed supply.

 “Any restrictions on telemedicine are harmful to doctors and patients in a time of crisis,” Garrett emphasized.

While many traditional healthcare outfits transition, as much as possible, to telemedicine, direct care physicians have long utilized it. Professionals like Garrett and Chamberlain wonder why it took a pandemic for the benefits of telemedicine to be fully realized by governments and insurance companies alike.

Once society returns to some semblance of normalcy — whenever that may be and whatever it constitutes — it’s fair to wonder if that realization will set in, sparking a change, or if the previous status quo will snap back into place.

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Brad Johnson

Brad Johnson

Brad Johnson is an Ohio native who graduated from the University of Cincinnati in 2017. He is an avid sports fan who most enjoys watching his favorite teams continue their title drought throughout his cognizant lifetime. In his free time, you may find Brad watching and quoting Monty Python productions.