HIV Specialist - March 2021 - 21

■	 Eliminating most geographic and originat-

ing site restrictions on the use of telehealth
and establishing the patient's home as an
eligible distant site so patients can receive
telehealth care at home and doctors can
still be reimbursed.
■	 Preventing a sudden loss of telehealth
services by authorizing the Centers for
Medicare and Medicaid Service (CMS) to
continue reimbursement for telehealth for
90 days beyond the end of the public health
emergency.
■	 Making permanent the disaster waiver
authority, enabling Health and Human
Services (HHS) to expand telehealth during
all future emergencies and disasters.
■	 Requiring a study on the use of telehealth
during COVID, including its costs, uptake
rates, measurable health outcomes, and
racial and geographic disparities.
Healthcare providers and patients alike
are becoming comfortable with telehealth and
voicing their desire to continue using virtual
care delivery. For example, a study published in
the American Journal of Managed Care looked
at how people living with HIV (PWH) felt
about using telehealth for HIV care instead of
face-to-face clinic visits.1 Of the 371 participants, 57 percent (n=211) reported a greater
likelihood of using telehealth versus one-onone in-person care if the former were offered.
Nearly 40 percent (n=137) reported they would
use telehealth more frequently, possibly always, instead of an in-person visit. The authors
noted a " positive attitude toward the use of
telehealth for HIV care among PWH. "
With seemingly positive movement on
both the state and federal level, and patient
and provider satisfaction with telehealth, this
all seems like good news, right? It is, mostly,
but sets up some potential administrative
challenges. Providers make care decisions
independent of insurance status. Ideally, that
leads to more egalitarian care. But we also
have concerns about direct billing patients for
services that insurance doesn't uniformly cover. Take my practice as an example. I think the
new Massachusetts law will guarantee I can
bill insurance for caring for an acne patient
but not a patient with a new changing mole.
We are not set up to parse patients in this way.
This is just one example of the betwixt and

between state we find ourselves in concerning
telehealth in this 'new normal.' There is no
doubt we are leaps and bounds ahead of where
we were at the beginning of last year, but there
is much critical work to be done in this next
phase. Much of this revolves around the change
in our healthcare delivery apparatus from a
one channel (everything in the office) system
to a two-channel or hybrid environment where
telehealth co-exists with in-person care.
Here are some priorities to consider:
We need to create new roles. In one-channel healthcare delivery, when a patient
requests an appointment with a provider, the
provider's office simply needs to find a time
in his or her schedule for the patient to come
to the office. The options offered by a hybrid
system require different decision making.
Is the patient appropriate for telehealth?
Should the choice be one of convenience for
the patient or guided by clinical criteria? I
would argue strongly for the latter (see the
use case discussion below). If so, the person
scheduling the appointment needs either
some clinical training and sound judgment
skills or a very well thought out flow diagram
to aid in decision making.
A second example is in my field of dermatology, where we ask patients to electronically submit images of their skin for review
before our telehealth visits (The resolution
of even HD video is not good enough for dermatologic diagnosis.). We currently employ
nurses to ensure that the images are of diagnostic quality. I would argue that a trained,
non-clinical person could do this.
We need to define clinical use cases
for telehealth. I see three broad categories-examples where telehealth is ideal
(e.g., behavioral health); examples where
in-person care is required (e.g., procedural
work) and examples that could fit in either
category depending on other variables (e.g.,
if the patient lives very far away, telehealth
becomes more attractive). Which scenarios
fit into these categories will vary by clinical
specialty, possibly by practice, and maybe
even at the individual practitioner level. I
had hoped that each of the specialty societies
would intuitively begin to work on this, but I
have seen only spotty evidence of any effort.

We need to rethink how we use our
brick-and-mortar facilities. I do my
telehealth sessions every Tuesday afternoon from the comfort of my home office. In
doing so, I consume much less institutional
overhead than I do when I go to the office to
see patients on Wednesdays. Most provider
organizations are now doing 15 percent to
25 percent of their ambulatory activity via
telehealth. The legislation noted above is an
example of a trend that will likely sustain
this mix. We need to rethink how we use our
physical clinical space and how we plan for
new facilities.
We need to tackle the disparities issue.
Beyond advocating for universal broadband
and continued reimbursement for audio-only
telehealth (The latter appears to be in peril.),
we need an industry-wide approach to this
glaring problem.
While the initial lockdown in early
March of last year was the stimulus that
catapulted telehealth into both providers'
and patients' everyday lexicon, it gave
people a sense that we could render all care
that way. That simplistic view has become
a disadvantage as we get into the groove of
two-channel delivery. Our best estimate is
that telehealth usage will calibrate to around
15 percent to 20 percent of care delivery,
striking an appropriate balance of in-person
and virtual care. Now it is time to make telehealth a legitimate care delivery channel for
the long haul by tackling policy, reimbursement, and implementation challenges in the
new year. HIV
DR. JOSEPH C. KVEDAR is chair of
the Board of the American Telemedicine
Association, professor of dermatology at
Harvard Medical School, and editor-inchief of npj Digital Medicine. He is also
co-chair the American Medical Association's (AMA)
Digital Medicine Payment Advisory Group (DMPAG),
and a member of the AAMC's (Association of
American Medical Colleges) telehealth committee. He
is the author of two books on digital health.

REFERENCE
1.	 Dandachi D, Dang B, Giordano TG. The attitude of patients
with HIV about telehealth for their HIV care. Presented at:
ID Week; October 21-25, 2020. Poster 1042. https://www.
ajmc.com/view/how-might-telehealth-benefit-persons-living-with-hiv-

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HIV Specialist - March 2021

Table of Contents for the Digital Edition of HIV Specialist - March 2021

HIV Specialist - March 2021 - Cover1
HIV Specialist - March 2021 - Cover2
HIV Specialist - March 2021 - 1
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