Which patients can be managed with teleurology?
While not all urology patients are appropriate candidates for televisits, certain diseases processes lend themselves well for virtual encounters. Examples of patient visits appropriate for teleurology may include symptom checks for men with BPH or ED, patients with OAB and incontinence, discussions regarding elevated PSA, uncomplicated UTI treatment, hypoandrogenism follow-up, and prescription refills (eg, alpha-blockers, phosphodiesterase type-5 inhibitors, anticholinergics, or pentosan polysulfate sodium [Elmiron]). (For a graphic showing a typical teleurology work flow, see figure 1.)
Other patients that may be considered for teleurology include postoperative patients, those living in rural areas with limited access to urologic care, patients managed with indwelling catheter exchanged by home health providers, and those on active surveillance/watchful waiting for prostate cancer. Further areas of opportunity amenable to teleurology might include home sterility testing in post-vasectomy patients, bladder cancer follow-up, and infertility evaluations.
Let’s look at a hypothetical scenario of a patient followed by teleurology. A 65-year-old man has BPH and ED. His digital rectal exam is normal and his PSA has been <1.0 ng/mL for 3 years. He has a history of elevated cholesterol and hypertension. His medications include sildenafil, tamsulosin, and telmisartan. There have been no changes in his lower tract urinary symptoms and the sildenafil is helpful for his ED.
The patient uses an app to monitor his blood pressure and flow rate. He goes to his local laboratory for PSA and cholesterol testing, and the results are sent to his primary care doctor and urologist. He completes an online health questionnaire, AUA Symptom Score, and a voiding diary, all of which show no changes in the past year. He has been refilling his sildenafil and tamsulosin prescriptions online for the past 2 years and receives a daily Apple Watch reminder to take his medication.
Under these circumstances, it would be appropriate for the urologist to review the blood work and AUA Symptom Score, and have a 5-minute teleurology visit at a time convenient for doctor and patient. The urologist would be compensated by the insurance company or out of pocket by the patient for the visit. This scenario benefits the patient by reducing lost travel time and the hassle for some patients of an office visit but also benefits the doctor by promoting efficiency, the practice by potentially reducing overhead, and the payer by more efficiently managing the patient’s various health issues—a win all around!
Regulation and reimbursement
Today’s patients, especially millennials, are looking for access and convenience, making telemedicine an attractive patient care option. Patients are joining higher-deductible plans with higher co-pays and increased out-of-pocket costs. Previously, the idea of charging patients out of pocket would have been laughable. For those with insurance, coverage was broad and copays were minimal or nonexistent. Now, however, there is an ongoing shift toward higher deductibles, more coinsurance, and increased out-of-pocket costs.
In the current climate, a typical copay for a primary care visit ranges from $20 to $40, while the copay for a specialist visit can be $30 to $50 and $30-$80 for a urology visit, according to Investopedia (bit.ly/copayarticle). With that in mind, if you can make teleurology services available for between $40 and $80 per encounter, you will become an attractive option to a large segment of patients who can avoid their insurance by paying the equivalent of a copay in a single out-of-pocket payment. If you can conduct three to five teleurology visits per hour, implementing teleurology may be in the best fiscal interest of your practice.
Additionally, while you may not be seeing Medicaid patients currently, new Medicaid laws and initiatives might mean that adding these patients to your practice via a virtual platform may be fiscally advantageous. This strategy can also rid practices of the paperwork and bureaucracy of dealing with insurance companies over reimbursement claims, providing tangible monetary benefits. Lastly, practices offering such a service may be attractive to uninsured patients who depend on transparent and reasonable service pricing.
Reimbursement currently varies among payers and states (figure 2). An excellent resource is provided by a national telehealth policy resource center, The Center for Connected Health Policy (bit.ly/CCHPresource), a nonprofit, nonpartisan organization working to maximize telehealth’s ability to improve health outcomes, care delivery and cost effectiveness.
It is critical to check with payers in your catchment area to be certain they will compensate you for conducting a teleurology service.
Private insurers. In the current climate, more than half of all states have telemedicine “parity” laws in place. According to the American Telemedicine Association, parity laws require insurers to reimburse a telemedicine service as they would a face-to-face visit. It is crucial to understand your states parity law prior to determining which patients might benefit from a teleurology visit.
Medicare. Historically, Medicare telemedicine reimbursement policies have been stifling at best. Unless seeing patients living in rural areas at a designated telehealth location for a select list of services, you would almost certainly not be collecting money from Medicare for telemedicine. This will be changing, at least in part, with a new CMS rule expanding telehealth coverage to Medicare Advantage patients. Beginning in 2020, virtual visits will be a core benefit covered by CMS. This will significantly expand the number of patients who have coverage for televisits, as 34% of Medicare patients are enrolled in Medicare advantage, according to the 2019 Kaiser Family Foundation Analysis of CMS State/Country Market Penetration Files, 2019.
Medicaid. Medicaid programs, on the other hand, have historically been more progressive. The American Telemedicine Association and Center for Connected Health Policy publish state-specific Medicaid coverage. On the whole, 48 states provide some type of Medicaid coverage for telemedicine. While details vary by jurisdiction, policies are typically more permissive than those of Medicare; 36 state Medicaid programs, for instance, permit patients to participate in telemedicine visits from their homes.