In our debut podcast episode, Vin DiCianni & Jerry Coyne explain the future of telemedicine and home healthcare during a pandemic and beyond.
Brenda Morris 00:00:05
Hello, and welcome to Integrity Through Compliance: AMI’s Business Success Series. My name is Brenda Morris and I’m a managing director of corporate compliance and business oversight. This podcast was created by seasoned compliance experts at Affiliated Monitors to speak practically to your business needs. During this series you will hear from AMI’s experts in corporate compliance, healthcare, government contracts, antitrust, manufacturing, education, and more, who will provide their observations on industry trends, geared to raise your awareness and to protect your brand. So grab a cup of coffee and join us as we guide you and your business to integrity through compliance.
Vin DiCianni 00:00:53
Good morning, everyone. This is Vin DiCianni at Affiliated Monitors, and I’m here with Jerry Coyne. We’re going to be talking today about the impact of COVID on telemedicine in healthcare and home health care. And it’s going to come from the perspective of Affiliated Monitors’ independent monitoring perspective. So a little bit about Affiliated. We were started about 17 years ago to provide independent monitoring for healthcare providers and others. And our approach is very remedial. And so in the work that we do in terms of our oversight and remediation, we’re always looking to help entities improve their practices, improve their compliance with regulatory schemes, with laws that are applicable to their particular industry. So today, we’ll spend some time talking about how telemedicine has been so impactful during COVID. So let me turn it over to Jerry to say hi, and then we’ll get started.
Jerry Coyne 00:02:03
Good morning. My name is Jerry Coyne. I’ve been with Affiliated Monitors now for about two years. I joined Affiliated after a career in the Rhode Island attorney general’s office, where I came to know Affiliated Monitors as a customer we had in my office approved two hospital mergers. And when we approved those mergers, we imposed multiple conditions on the parties. Soon thereafter, we realized we had no way to monitor those conditions, and we ended up retaining Affiliated Monitors, which monitored both of those transactions and monitored the compliance with the conditions. And it drove home to me just how critical of a tool monitoring can be for a public entity, like an attorney general’s office, because we weren’t staffed and we didn’t have the expertise to do what Affiliated Monitors did. So that sold me on the value of monitoring, and when I retired from the attorney general’s office, I joined Affiliated. And like I said, now I’m in my second year.
Vin DiCianni 00:03:07
So let’s start by talking a little bit about telemedicine and where we are with telemedicine. So before we go much further, Jerry, could you define what telemedicine is?
Jerry Coyne 00:03:19
You know, I can try to define telemedicine, but defining telemedicine is like the Supreme Court trying to define pornography: You know it when you see it. Because there is no single definition of telemedicine that covers all the different jurisdictions. The most general — and probably best definition— comes from the Institute of medicine. They say that “telemedicine is the use of electronic information and communications technology to provide and support healthcare when the distance separates participants.” So basically, it’s the delivery of medical services when the provider and the patient are in separate locations.
Vin DiCianni 00:04:01
So there’s sort of been a change in how the world views and uses telemedicine since COVID. So before we go to the COVID circumstances, talk about telemedicine, and how it was used prior to COVID.
Jerry Coyne 00:04:15
Well, you know, telemedicine is not a new concept, but for the people that were really advocates of telemedicine pre-COVID, there was a lot of, I think, even frustration about the fact that telemedicine hadn’t caught on the way that its advocates felt it should. Telemedicine has been used for a long time by the armed forces, by the Veterans Administration and by other healthcare delivery services where people had to try to reach patients in areas where there just weren’t a lot of doctors. So CMS had adopted some pretty comprehensive rules for telemedicine, but the requirements focused on the delivery of services having to be to patients in what they defined as rural areas. And the patient, in fact, could not be in their home. They actually had to go to a different facility where there would be remote devices available where those remote monitoring devices could link the patient and the doctor. That’s the way that telemedicine existed before March of 2020.
Vin DiCianni 00:05:26
So what was sort of the hesitancy, do you think, to have a wider use for telemedicine?
Jerry Coyne 00:05:34
I think part of it is just the hesitation for change. People went to their doctors, they were comfortable going to their doctors, and so much of the talk about telemedicine today and its future focuses on making sure that patients get comfortable with the use of telemedicine. COVID changed all that because COVID didn’t give you a choice. You had to become comfortable with it. Until COVID, it was a different world.
Vin DiCianni 00:06:01
Yeah. So in a little while, I’ll talk a little bit about some of the cases that we’re working on with home health and how impactful telemedicine and telehealth have been in providing those services. But let’s talk now about the impact that COVID has had on medicine, because it’s really changed, right? In terms of the use in a variety of settings…
Jerry Coyne 00:06:26
It’s been a dramatic change, and it was a change that was really forced upon the medical field. It was forced upon patients because of the fact that COVID was such a highly contagious disease. Patients who needed medical treatment and who needed to be seen by doctors could not be brought into doctor’s offices because of the risk of spreading an infection. In that kind of a scenario, it was almost as if you had to design a way to address that and to provide medical services, you probably would have designed a system like telemedicine, because telemedicine is tailor made for situations like that.
Vin DiCianni 00:07:06
So with COVID, CMS and a lot of states, you know, implemented new guidance that accepted telemedicine and paid for it, right? But through Medicaid, Medicare, and different networks, let’s take the impact that telemedicine has had on the world of medicine from a couple of different vantage points. And I know you wrote an article relatively recently that was published, I believe, might be American Health Lawyers Association, on the change in telemedicine.
Jerry Coyne 00:07:39
Yes. You know we took a look at telemedicine to try to examine how it had been impacted by COVID. And one of the big changes that we noticed first was that traditional telemedicine, like I mentioned to you briefly, required a patient to have access to remote patient monitoring devices. And when I refer to a remote patient monitoring device, it’s really a remarkable type of instrument where a patient can be hundreds of miles away from the physician. But through that device, the physician can have real time monitoring of blood pressure; can have real-time monitoring through a stethoscope of different heartbeats, and you can take different types of tests. However, with COVID, that was just simply not always going to be possible. So when they expanded telemedicine under COVID, they removed that specific requirement simply because in order to get telemedicine to the number of people that needed it, they needed to go and find a way to do it without requiring the patients to leave their home. And that level of monitoring wasn’t always going to be necessary.
Vin DiCianni 00:08:56
Right. So let’s take it from the understanding that now patients are staying in their home right now. The delivery of telemedicine is in their home. Give us, you know, what you have learned. What’s the practitioner’s viewpoint? And obviously it’s not going to be universal, but what are you seeing, in terms of the practitioner’s viewpoint of telemedicine in the time of COVID?
Jerry Coyne 00:09:21
Well, for one thing, it has allowed practitioners to have real-time communication with all of their existing patients. And the one limitation on telemedicine — no matter how it’s delivered — has been that it’s very difficult through telemedicine to either make a diagnosis or deliver treatment that requires the physician to touch the patient…to have hands-on contact. However, for the purposes of COVID, that hasn’t necessarily been required. And what telemedicine has done is not only allowed physicians to maintain contact with patients who may be potentially suffering from COVID, but more importantly, one of the real concerns that’s been expressed by many, many health care providers is that because of this focus that we have (for many good reasons) had on COVID, many patients have neglected to seek treatment for other things for which they should be seeking treatment. And they’ve also neglected to go and perhaps get things like annual physicals. Telemedicine has allowed practitioners to maintain contact with patients so that they could address not just COVID related issues, but all sorts of other health-related issues that they should be seeing patients for. Anyway, that’s it.
Vin DiCianni 00:10:47
So with new technologies, I’m getting this understanding that they will be able to do things like heart monitoring at home, and other kinds of testing. That’s going to give more of that intimate kind of doctor office visit, right?
Jerry Coyne 00:11:03
Absolutely. This has forced telemedicine to become much more of a mainstream practice. And I think we can all expect that in the next few years, both physicians and patients are going to become much more comfortable with the use of telemedicine on a widespread level.
Vin DiCianni 00:11:21
Tell us about the government’s perspective. I mean, again, government was reluctant to accept telemedicine. I know I was at many medical board hearings where telemedicine companies would come in and say, “we can do this, we can do that”, but there was this hesitancy to ever accept it, and then COVID hit. And so now we have this whole different viewpoint where you want people to stay home. You don’t want them going to hospitals or having to be at a clinic because of potential exposure. So how has that viewpoint changed, from the government’s perspective?
Jerry Coyne 00:11:54
Well, you know, I think telemedicine has certainly, as a practice, stepped up and shown not only its legitimacy, but its value to government regulators. And what we’re seeing now is a lot of different regulatory agencies really seeking to spend a lot of focus on updating their telemedicine regulations, making them more practical. The Commonwealth of Massachusetts just implemented extensive regulations that were effective January 1st. Many other states are doing the same thing. And right now what I think the challenge is going to be, and what other people have noted, is that almost every change that the government has made, has been done through emergency regulation. We have had government by executive order across the country for better or for worse. And the challenge will be, now, trying to pick out the best parts of those regulations and enact them through legislation in order to make the positive changes permanent.
Vin DiCianni 00:12:52
And the other perspective that I think is very important and it’s gotta be a consideration is the patient’s perspective: instead of being in a rehab center, being at home, right? Give me some sense of what you are learning about the patient’s perspective of telemedicine, and again, at the time of COVID.
Jerry Coyne 00:13:14
Well I think, you know, most people would tell you that the response has been mixed. It has, without question, allowed that contact with doctors. But I think one of the complaints that some people have expressed is that, particularly for the types of contact, whether it’s not the remote patient monitoring patients have felt that that is not as perhaps beneficial to them, for things like physical exams and different things that they have been used to over the years. So one of the issues that people have mentioned over and over again is that once COVID ends and the crisis growth for telemedicine ends, one of the challenges is going to be to make sure that the form, the telemedicine takes is one that patients feel comfortable with. There’s a lot of surveys that show that patients will leave their practitioner or leave the provider that they’re with, for a place where they view it as more convenient. And I think people just need to be comfortable with it.
Vin DiCianni 00:14:19
So where are we going? What’s the future?
Jerry Coyne 00:14:23
Well, I think it’s here to stay. But where it has really shown its value, and in a way that I think people anticipated but underestimated, was in the delivery of behavioral health and primary care, particularly, you know, behavioral health, mental health counseling. Telemedicine in that area has been widely, widely praised — universally praised through the COVID crisis. And I think that telemedicine is here to stay generally, but telemedicine for behavioral health is going to be an area where we see it more and more and more.
Vin DiCianni 00:14:59
So there’s really been some concern about the lack of oversight by government regulators of telemedicine. Right? And as you said, it was sort of an emergency…just put in place because it had to be. Where does Medicaid, Medicare go in looking at potential areas of fraud or abuse, with regard to telemedicine?
Jerry Coyne 00:15:25
Well, you know, one of the areas is the same type of fraud that you encounter for any other type of healthcare service, which is: have services been properly coded. Have they been properly billed? People have focused on telemedicine, particularly for the need to maintain security over the transfer of healthcare information, to make sure that that remains a secure process. And another one that I had not anticipated, but that people have mentioned a lot is that, you know, it doesn’t take fraudsters long to follow when there’s an opportunity out there. And that there have been instances where people have called people and said they were calling in regard to a telemedicine visit and ask you to give you their billing information or healthcare information. And the person just assumes that it’s a legitimate call. So, you know, where opportunity exists, fraud follows in a lot of cases. Telemedicine presents some opportunities that we had not necessarily anticipated.
Vin DiCianni 00:16:27
And so you and I have talked a lot about the use of sanctions, right, In certain instances? One of them of course, from our perspective is, you know, monitoring. But I think before we can get there, I do say if we need some kind of regulatory schemes related to the providing of telemedicine and telehealth, which is probably not too far down the road, right?
Jerry Coyne 00:16:53
And I think one of the things you’ve really got to keep in mind is that there is so much change going on in the field of telemedicine and telehealth right now, in terms of things just like billing. There’s got to be attention paid to make sure that a physician’s mistake is not necessarily viewed as fraud. And that’s where I think the regulatory process has to take a close look and make sure that if somebody is not doing something properly, there may be a need to retrain that person, maybe a need to implement better controls. And that’s where something like monitoring can really help, because the physicians that are using telemedicine are really doing it to deliver a critical service, and it doesn’t serve anyone well to just cut them off from that service.
Vin DiCianni 00:17:38
So we’ve been working on multiple home health monitoring matters. Right? And home health is intimately linked, obviously, with telemedicine. So I wanted to spend a little bit of time, before we end, talking about home health, but then the impact of telemedicine on home health care. Right?
Jerry Coyne 00:18:05
You know Vin, when you talk about home health, you know, I said, it’s tough to define telemedicine. When I hear a term like “home health”, what exactly do you mean when you refer to home health?
Vin DiCianni 00:18:15
Yeah, it’s again, a wide ranging answer, right? So Medicare, you know, looks at home health more along the lines of healthcare services that can be given in your home for an injury or illness, a disability. And so home health, as I think has been recognized, is quite less expensive than an individual being hospitalized or being at a rehab nursing home. When they can stay at home, you’re saving, you know, really significant funds. And so on the Medicare side, a lot of it is related to actual health care. Medicaid on the other hand, has different programs. And each state has a variety of different types of programs that expand home health to things like safety; maybe food and helping an individual shower, going shopping for them, doing some light healthcare…providing like maybe taking a blood pressure and stuff like that — making sure that medications have been delivered, and those kinds of things. But it’s much broader reach into the home health world. So again, it’s a very wide ranging level of services that are being undertaken when you talk about home health, and each state has little nuances. They have various programs where you get a waiver and you don’t have to stay in a nursing home, and you can go home. But it’s very complicated, and it’s going to vary state by state.
Jerry Coyne 00:19:50
You mentioned the benefit of potentially, the lower costs, but what are the other benefits that people would look at home health care and identify as a benefit of that program?
Vin DiCianni 00:20:00
I mean, the most obvious is that somebody gets to stay in their house, you know? And I’ve got a personal situation now, where my mother-in-law has been in a rehab center, and just couldn’t wait to go home. And now, she’s going to have home health come in and help her. She can’t get around just, she’s not very mobile. She’s going to need help showering and shopping, and all of those kinds of things. That’s probably the most significant benefit: just, people want to be in their home. They’re secure there. With COVID, they really want to be in their home. They don’t want exposure to a lot of people, you know? So there’s a comfort to being at home and for, you know, homebound individuals who’ve been there for a long time, a lot of the home care providers sort of become a social outlet. That might be the only person they talk to in a week is their home health provider! You know, so there’s many benefits, but it really is focused on the patient. Right?
Jerry Coyne 00:21:01
Yeah. I mean, I do think when you talk about the desire to stay in the home, having had two elderly parents, that was their desire: how long could they stay at home? And maybe it’s a generational thing, but I think everybody can identify with that. What are the concerns about it though. What does government look at in terms of the hesitation about it? What are their concerns?
Vin DiCianni 00:21:25
So, a lot of times it surrounds the issues of fraud, false claims, you know, all the home health workers really going when they say they’re going to be there? Are they really doing what they say they’re supposed to be doing? Again, it’s hard to measure those things in terms of quality of care, how well they’re doing. You know, are they abusing the people in their house? Are they qualified to provide the services? Are they appropriately documenting? So some of the things that we’re seeing, and again, this is an ongoing thing prior to COVID and with COVID: false claims. Accurate billing is an issue. Kickbacks for referrals to physicians to get to that home. Quality of care is an issue. And then just the unscrupulous business practices of, you know, the elderly, and trying to sell your services to the elderly so that they could stay in their home.
Jerry Coyne 00:22:19
You know, you mentioned the idea of people coming in the home. And one of the concerns that I’ve heard over the years has been, just as you say, you’re inviting somebody into your home. You don’t necessarily know who that person is. How regulated is the field of home health care today?
Vin DiCianni 00:22:36
Oh it’s pretty heavily regulated. I know that attorney generals’ offices and the IG for HHS, CMS have focused on home health and all of the things that I mentioned, because there’s a lot of action and activity there by state agencies. So that’s half of it, and there’s also licensing issues. You know, one of the things that we’re seeing, and I wanted to just move into this as we sort of wrap up is the notion of mental home health, right? And because I think that’s a very significant and very beneficial element to what’s going on now. Because we’re monitoring a company right now that provides mental health for people to stay in their homes. And, you know, for the people in their homes, this is what we’re hearing: they’re very comfortable talking to their mental health provider by video conference and telephone, even in ways that are more open than when they visit their house. And I don’t know what that you know is you know, tied to, it’s just amazing. People are comfortable with now using Zoom and, and what have you. But that’s a significant change, where people are actually being more open, receptive to hearing the mental health counselors. So I think that that’s a place that is going to be, again I think, more heavily used. I think of the benefits instead of being in a mental health facility, staying at home and being treated and getting regular care. So I think that that’s going to be a very significant benefit. You know, again, I think that there’s going to be a lot more activity on the telehealth side of things and, and home health, and it should be, but you know, this is a necessary service and I think it’s going to get a lot more attention and hopefully this podcast is going to bring the attention to the benefits of home health and telehealth. Jerry, let’s wrap up with a couple of thoughts. Give me a couple of things that you would say are the major takeaways that you want people to get from your presentation.
Jerry Coyne 00:24:41
I would say that telemedicine is rapidly growing — It’s here to stay — but that as the process matures, we need to make sure that we have a regulatory process and a regulatory structure that works for both the healthcare provider and the patient.
Vin DiCianni 00:24:59
Yeah, I think those are terrific. And from my perspective on home health and telemedicine, I think that it’s a great assistance to folks that are stay-at-home, and for the elderly, and for the disabled and what have you. I think there’s still no substitute, however, for the types of services like showering and buying groceries. I mean, they’re still going to have to go in that house. That’s not going to change greatly, but sometimes there are these multidisciplinary practices where you’re getting nursing care, you’re getting meds, and then the home health care. And I think for the nursing care, where it’s moved to telemedicine, I think it’s been very effective. So I think that that’s another takeaway. So thank you so much, Jerry. And everyone, thank you for listening. And if you have any questions, just contact us, and we’ll give you the information in a minute. Thanks everyone.
Jerry Coyne 00:25:56
Thank you very much.
Brenda Morris 00:25:59
Thank you for joining Affiliated Monitors podcast, Integrity Through Compliance: AMI’s Business Success Series. Today’s segment is just a sample of the subject matter expertise captured by AMI’s compliance professionals. Go to our website at www.affiliatedmonitors.com to view the comprehensive list of industry and in-house talent AMI has available to enhance professional and business integrity programs and controls. Also, connect with us on LinkedIn to receive updates and trends in the areas of enforcement and compliance. If you have any questions about today’s podcast or would like to learn more, please contact us at firstname.lastname@example.org. Our Affiliated Monitors podcast production team of Deloris Saad, our compliance associate, Dan Barton, our editor and podcast music composer, and me, Brenda Morris, Managing Director for Compliance and Business Oversight look forward to you joining us again for our next installment of Integrity Through Compliance: AMI’s Business Success Series.
“The Expansion of Telemedicine During COVID-19 and Prospects for its Continued Use” by Gerald Coyne in Health Law Weekly (July 31, 2020)