By Victoria Stern

The coronavirus pandemic has transformed the use of telemedicine. Before COVID-19 hit, many surgeons did not consider remote visits an option because of poor reimbursement and concerns about HIPAA compliance.

But shortly after the U.S. surgeon general and Centers for Medicare & Medicaid Services asked hospitals and health systems to postpone nonessential surgical procedures in mid-March, many surgeons found themselves in a difficult situation.

“No one had much warning about COVID-19 or much time to prepare in an intentional way,” said Catherine Ann Matthews, MD, FACS, FACOG, a professor of urogynecology and pelvic reconstructive surgery at Wake Forest Baptist Health, in Winston-Salem, N.C.

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Recent data from the Commonwealth Fund found that surgical specialties saw a 66% drop in outpatient visits and a similar decline in revenue.

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“We knew if we didn’t introduce a radical new way of doing business, it would jeopardize access to patient care and employment for staff,” Dr. Matthews said.

In late March, a different way of doing business became possible when the federal government eased HIPAA restrictions and increased funding and reimbursement for telehealth. As part of the first package of the coronavirus aid bill, Congress set aside $200 million to fund telehealth and included $100 billion to expand reimbursement options so health care providers could cover medical expenses or lost revenue from COVID-19.

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Several institutions—including the universities of Arizona, Michigan and Pittsburgh Medical Center—were able to lean on their existing telemedicine programs to continue providing patient care remotely.

But many surgeons were looking to telemedicine for the first time, with no road map to guide them.

“When faced with immediate stay-at-home orders in North Carolina, we quickly made an executive decision to convert all in-person visits to telemedicine visits,” Dr. Matthews said. “But when we tried to look for guidance about how to do this, nothing existed.”

Dr. Matthews and her colleagues formed a working group to get telemedicine up and running, which involved teaching patients how to download and use audio-visual platforms, figuring out billing and patient flow, and educating the office staff on how to engage with patients in this new environment.

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After building their platform, Dr. Matthews’ team published a tool kit to help other practices convert to telemedicine more easily (J Am Coll Surg 2020 Apr 30. [Epub ahead of print]). The tool kit walks providers through eight key factors for adoption, which also include how to integrate telemedicine visits into existing electronic health records and teaching patients how remote visits work.

Elements of a Telemedicine Program
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Adapted from Smith WR et al. J Am Coll Surg 2020 Apr 30. Epub ahead of print.
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“Through trial and error and teamwork, we’ve come up with a way to make this process efficient and engage the whole office staff, and we want to share that with others,” she said.

Since launching telemedicine, Dr. Matthews’ department has done 638 visits over a month. Dr. Matthews said translates to about 15 to 20 visits per day for her, compared with about 30 in-person visits before the crisis. A few patients still come to the clinic, which has remained open with a skeleton staff in case of emergencies.

Although telemedicine doesn’t allow for the same patient volume, Dr. Matthews said telemedicine has allowed her team to stay connected to patients and schedule operations several months in advance to avoid a backlog and long delays in care.

“Certain patients are much better off with telemedicine, including those with limited mobility and who live far away or need family members to accompany them,” she said. “I have an 85-year-old patient whose son has to take five hours of his day to transport her to and from my office for a 30-minute visit that we could do just as well over the phone or video.”

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Expanding Telemedicine

Before the pandemic, Neil Floch, MD, had a booming bariatric surgery practice. After the coronavirus hit, his patient volume dropped to zero.

Like many surgeons, Dr. Floch had never really considered telemedicine before, but very quickly it became his only option for seeing patients and keeping his business afloat.

“We all realized we weren’t going to be able to see patients because they are scared to come in, and we also don’t want them to come into the office right now,” said Dr. Floch, who runs Fairfield County Bariatrics, a four-surgeon private practice in Connecticut. “Suddenly, the only way to see patients and to bill was through telemedicine.”

After adopting telemedicine and using the platform for a few weeks, Dr. Floch has been able to ramp up remote visits and see 15 patients each day—two-thirds of his normal patient load before COVID-19.

For Dr. Floch, the ability to see patients remotely has been a lifesaver.

“What we used to do with an in-person visit, we can now do over the phone or video wherever they are in a HIPAA-compliant way, which has been incredible,” he said. “Working remotely has saved patients time and money, eliminates waiting times and a lot of overhead costs for private practice physicians; plus it has allowed me to work from 9 to 5 and to bill at my normal in-office rates.”

For Elizabeth Dovec, MD, the benefits of telemedicine in surgery come as no surprise. Although she did not do traditional telemedicine visits before COVID-19, she has been using a digital education platform as an essential part of her bariatric practice for over two years. The digital program, which is available to patients online and through a mobile app, substitutes for the typical in-person visits patients need before surgery.

“We thought about this long before COVID-19 and have virtually eliminated in-person supervised weight loss visits prior to surgery for the past few years,” said Dr. Dovec, the medical director of GBMC’s Bariatric Surgery and Comprehensive Obesity Management Program, a three-surgeon bariatric surgery practice that’s part of a larger 342-bed medical center just north of Baltimore in Towson, Md.

The reason: Bariatric surgery involves a lengthy preoperative education process. “It’s challenging to keep people engaged for several consecutive months before surgery, and there’s typically a lot of attrition during this process,” Dr. Dovec said.

To improve retention, Dr. Dovec developed a comprehensive digital program that allows patients to do consultations with her months before they have surgery. The idea is for patients to learn about diet and exercise from the comfort of their homes and to make care more efficient.

After initial online consultations in which Dr. Dovec explains insurance requirements and what patients need to do before surgery, the patients embark on a 12-week online education program that includes diet and exercise, as well as strategies to make long-term lifestyle changes. To stay on track, patients take quizzes and log food, exercise and weight through an app. After patients complete this process, Dr. Dovec checks in to determine whether they are ready for surgery.

The digital program made her practice worlds more efficient. Since going digital in February 2018, she and her colleagues are able to perform hundreds more bariatric procedures each year.

As for reimbursement for these visits, “we may or may not collect copays. We may or may not get paid from insurance for these visits, and the average reimbursement is less than $5.00 total,” Dr. Dovec said.

But these visits are essential because preoperative education is crucial from an outcomes standpoint and required by insurance to get the operations approved.

“Expansion of telehealth has vastly improved access to care, retention rates and patients’ experience, and has allowed us to continue our digital services uninterrupted during the pandemic,” Dr. Dovec said.

Will Telemedicine Persist Post-Pandemic?

Recently, some hospitals have begun preparing to bring patients back for elective or nonessential procedures.

The American College of Surgeons, American Hospital Association, American Society of Anesthesiologists and Association of periOperative Registered Nurses issued guidelines for how and when surgeons can start doing elective procedures again (www.generalsurgerynews.com/ COVID-19/ Article/ 05-20/ Return-to-Elective-Surgery- A-Road-Map-/58319).

North Carolina, for instance, lifted its stay-at-home order on May 8. Dr. Matthews said Wake Forest Baptist Health reopened its outpatient surgery center on May 11 and plans to ramp up to pre-COVID-19 volumes by June 8.

But social distancing protocols will still be in place, she said, and all patients will be screened for COVID-19 before surgery. Patients will do temperature checks a week before coming in for elective surgery and will be screened when they arrive at the hospital or clinic. Office visits will be spaced out to allow patients to practice social distancing in waiting areas.

“We’re also using enhanced recovery pathways to discharge patients more quickly and are expanding our hours to help make up for the backlog of cases,” Dr. Matthews said.

Even as some practices ease back into business as usual, Drs. Dovec, Floch and Matthews hope that the changes to telemedicine are here to stay.

“Relaxing billing and coding guidelines for telehealth is one of the best things that will come out of these times, and will change medicine in incredible ways,” Dr. Dovec said.