Among the many areas of telemedicine, a key opportunity exists for urologists in video visits, or “direct-to-consumer” telemedicine.
|Chad Ellimoottil, MD, MS||Dr. Ellimoottil|
Telemedicine is considered the fastest-growing segment of the health care market. Defined as the use of telecommunications software to diagnose and manage medical disease, telemedicine can be implemented through modalities such as video-conferencing software, mobile applications, and wearable devices. While telemedicine has been around for decades, a recent boom in utilization has occurred as physicians and health systems invest in the technology and payers increasingly provide reimbursement.
Among the many areas of telemedicine, a key opportunity exists for urologists in video visits, or “direct-to-consumer” telemedicine. Video visits (also called virtual visits, televisits, or evisits) have increasingly captured the attention of many physicians as an alternative to the traditional clinic visit. A video visit occurs when a physician conducts a medical interview or counseling session with a patient using video-conferencing software, such as Skype. At the University of Michigan, members of our faculty have used video visits as a way to expand capacity in our ambulatory care clinics without compromising quality of care.
While telemedicine has existed for decades, legislative and policy changes have facilitated the growth of video visits in a new way-directly from the patient’s home. Until recently, most commercial and government payers required that video visit patients be located in a health professional shortage area and that the visit be conducted from an approved medical facility. As one can imagine, these burdensome requirements once dampened the growth of video visits.
However, in the last several years, many of the nation’s largest commercial payers (eg, Blue Cross Blue Shield, Aetna, and UnitedHealthcare) have started to reimburse providers for conducting video visits with patients located at home. In addition, Medicare has waived some of the burdensome restrictions for physicians at health systems that participate in alternative payment models.
The Department of Veterans Affairs (VA) is widely recognized as a national leader in telemedicine. VA hospitals spent $1.2 billion and conducted two million telemedicine consultations in 2016 (Federal News Radio [May 8, 2017]; bit.ly/VAtelehealth). Investment in telemedicine at the VA has been supported by multiple studies that have demonstrated high levels of patient satisfaction and convenience (Urology 2015; 86:255–60).
Since April 2016, the urology department at the University of Michigan has implemented video visits in the outpatient urology clinic. Patients are scheduled for video visits using the same methods used for our standard clinic visits (eg, call center, front desk). At the time of scheduling, patients are given the educational packet that explains the requirements for the video visit. At our institution, the requirements are simple. The patient needs to use a smartphone and download a HIPAA-compliant application. Shortly after scheduling a video visit, patients will receive a phone call from our “patient engagement officer,” who reiterates the instructions given to the patient in the clinic and offers troubleshooting advice.
Providers who conduct video visits in our clinic will use an iPad that is mounted to our clinic desktop computer (figure). The iPad can be placed in any available clinic room, consult room, or even in the physician’s office. Once the clinical encounter is complete, the physician will take notes in the patient’s medical chart in the same way that he/she would document a standard clinical encounter.
Multiple urologists and a physician assistant are currently using video visits for encounters that involve postoperative care (especially after transurethral procedures), counseling (eg, metabolic workup results for kidney stone prevention), and follow-up for results.
Video visits offer benefits to both the physician and the patient. Physicians benefit from video visits in the clinic in several ways. First, turnover time between patients is minimal. This means that physicians can see more patients in clinics. For example, in some clinics at the University of Michigan, the mean appointment cycle time for a 15-minute appointment (ie, time the patient spends waiting, being placed in a room, seeing the doctor, and checking out) is approximately 70 minutes. In contrast, the average appointment cycle time is approximately 24 minutes for a video visit.
Second, video visits can be conducted without nursing and clerical staff. Accordingly, physicians can hold clinics after hours without paying for additional staff. Finally, the efficiency gained by utilizing video visits for low-complexity patients allows physicians to spend more in-person time with patients who have complex needs.
Video visits also have several obvious benefits to the patient. Patients avoid travel, traffic, and parking. They can avoid taking time off work or school. These benefits are equally important for caretakers who may be burdened with bringing their loved one to the clinic.
Regulations and reimbursement for video visits vary greatly from state to state. Physicians must be licensed in the state where the patient is located. In addition, some states have regulations on informed consent and on establishing a relationship with the patient prior to the video visit.
In the last several years, many large commercial payers have started to reimburse video visits from home. In most cases, the provider bills a standard office visit CPT code (99211-99215) and adds a GT modifier to the claim. Many states have telemedicine parity laws, which legally oblige commercial payers to reimburse video visits at the same level as face-to-face visits. However, Medicare does not currently reimburse for video visits conducted with patients from home. Medicaid reimbursement varies by state.
This author strongly believes that video visits will eventually become a natural extension of the physician’s clinic. With the rapid move toward digitalization and patient preference for on-demand services, it is possible that up to 50% of patients may be seen through video visits in the future. However, health systems will remain cautious in investing in video visits (and other telemedicine services) until Medicare begins to reimburse for such services. Fortunately, several active congressional bills are focused on liberalizing Medicare’s reimbursement requirements. The future of video visits, as with many things in medicine, will depend greatly on the potential for reimbursement and patients’ demand for the technology.
|Section Editor Steven A. Kaplan, MD||Dr. Hotaling|
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