In Depth: COVID-19 and Telemedicine in N.H.

May 18, 2020

Credit Joint Base Andrews

This week, The Exchange goes in-depth with a special series on the impact of COVID-19 on our healthcare system. On Tuesday, we discuss telemedicine.

In-person visits to doctors, dentists, and other providers are not permitted for most of the population, so providers are turning to telemedicine to treat patients via computers, mobile devices, and other technologies.

What has your experience been like? We explore the pros and cons of telemedicine and its potential lasting impact on patient care.

Air date: Tuesday, May 19, 2020. 


GUESTS:

  • Dr. Jonathan Ballard - Chief Medical Officer at the New Hampshire Department of Health and Human Services and a family medicine physician. 
  • Dr. Douglas Phelan - Attending Family and Preventive Medicine Physician at Elliot Family Medicine in Bedford. 
  • Alex Riccio - APRN at Equality Health Center in Concord. 
  • Dr. Joseph Insler - psychiatrist who works at the Counseling Center in Nashua. 
  • Transcript

      This is a machine generated transcript and may contain errors. 

    Laura Knoy: 

    From New Hampshire Public Radio, I'm Laura Knoy, and this is The Exchange. Due to the coronavirus pandemic, the use of telemedicine has soared and health care providers are grateful for that. Many have long wanted to expand their use of technology to assess patients either through video connections or an old fashioned phone call. But insurance coverage of these services was limited, so doctors offices limited their telehealth options as well. Now, those rules have changed, and many predict that telemedicine is here to stay. This hour on The Exchange, our in-depth series on COVID-19 and health care continues with telemedicine. Our guests are Dr. Jonathan Ballard, chief medical officer at the New Hampshire Department of Health and Human Services and a family medicine physician. Also with us, Dr. Douglas Phelan, attending family and preventive medicine physician at Elliott Family Medicine in Bedford. Welcome to both of you. And Dr. Phelan, let's start with you. How much were you seeing patients via telemedicine before the pandemic started?

Dr. Douglas Phelan:
That would be zero. It was something that I think a lot of health systems had been talking about, some had been starting to be more active than others. But due to a variety of limitations, I hadn't been doing any.

Laura Knoy:
And how much are you seeing patients via telemedicine now, Dr. Phelan?

Dr. Douglas Phelan:
Quite a lot. The news reports that you mentioned at the get go about this sort of taking off are true. We've combined a couple offices into one right now, and some people every day, every week, are seeing necessary visits in office. But everybody else is doing telemedicine. So there are some weeks where all I do is telemedicine.

Laura Knoy:
So walk us through, Dr. Phelan, a typical telemedicine appointment for those who haven't experienced this yet.

Dr. Douglas Phelan:
Sure, there'll be small differences from place to place, depending on the software that your provider uses. But basically the way that ours works is, you know, you get scheduled for a visit like you normally would. You talk to somebody, mention a problem or a concern and you get scheduled for a visit. We send you a link via text to a smartphone or through email to your computer or your tablet. As long as you have access and a camera and a microphone, we can send it to you. And then you enter a sort of virtual waiting room and you sort of customize there. And when we're ready to start the visit, you know, get done our previous visit. Just like in the office, then we come and start the visit. And it's like facetiming with somebody, if we're familiar with that. And you just need to have a face to face video exam. We can talk you through different aspects of a physical exam. We can just talk if it's more of a counselling and following up on labs and things like that. And it's what we call HIPAA-compliant. So as far as data safety, it meets criteria for that. And then once the call is done, it is, poof, gone, dissipated. And we keep our medical record, we write a note like we normally would write a note. And that's that.

Laura Knoy:
How do your patients feel about it, Dr. Phelan?

Dr. Douglas Phelan:
I would say patients, by and large, seem to be accepting of it. I think some folks are naturally wary of it. I think some providers are naturally wary of it. So patients aren't unique in that way. We want to make sure that what we're delivering is appropriate and good. But most folks, I think, have come on board for it because there are also some additional benefits for our patients as far as convenience, not needing to leave the home, not needing to leave their children or leave work.

Laura Knoy:
Right. A lot more convenient, you don't have to sit through traffic. You don't have to jump out of work. You don't have to find someone to stay with your child. If it's winter, you don't have to shovel out your car. So we are hearing that patients are more likely to stick with appointments when they are through telehealth. And we'll definitely talk about those instances when this does not work. But, Dr. Ballard, to you, what has surprised you most about this transition to telemedicine? It's been big.

Dr. Jonathan Ballard:
Yes, it has and we're pleasantly surprised at how important a tool it has been to prevent the spread of COVID-19. It was signed into law through emergency order number eight back on March 17th, a little over two months ago now as the expansion of access to telehealth, primarily to reduce the exposure persons had in the health care system itself had to the spread of COVID-19. And so the services really rapidly increased. We noted that from the state perspective, services were decreasing after the pandemic started to have effects in New Hampshire and then services had to increase in order to keep persons at home and to prevent a surge on hospital services, as one perspective was at the time. So we've been pleasantly surprised about how rooted and fast hold this is taking place.

Laura Knoy:
Yeah, we heard yesterday from two hospital executives who talked about how they are still struggling with the PPE, the personal protective equipment. And so telehealth for them, when appropriate, was a way to conserve PPE for those vital cases. What are you hearing, Dr. Ballard, about physicians and how they're feeling about this transition?

Dr. Jonathan Ballard:
Well, there's by and large part positive reaction to it. It's been able to allow pysicians to maintain connections with their patients and patients with their providers. The telehealth modes in New Hampshire, through the emergency order allow for both audio and video components, as well as just audio only and the audio only has been very helpful to many types of providers, especially providers who provide mental health care. They are able to reach patients in rural areas or who have only access to a phone. It may not be the ideal setting for a telehealth visit, but it's been providing access to those who would not have typically had it.

Laura Knoy:
You know, I'm glad you mentioned that, Dr. Ballard. And just remind us, you know, if someone hears telehealth, they may think, well, I don't have a laptop or I don't have the best smartphone in the world. Just remind us what this includes, because it doesn't have to be super high tech, Dr. Ballard.

Dr. Jonathan Ballard:
Not at this time. Prior to the pandemic and the federal government relaxing the rules around the types of equipment that is required for telehealth visits, it was previously specific types of equipment that were required. But currently in New Hampshire, reimbursement is provided to health care providers for all modes of telehealth, including audio or video, audio only, a telephone call. But in addition to that, using other types of electronic media, there are a couple of types of telehealth tools out there, one called remote patient monitoring and another one called store and board technology.

Laura Knoy:
So say that last part again, Dr. Ballard.

Dr. Jonathan Ballard:
Store and board. So this is the storage of health care types of data. For example, a patient who may have diabetes and records blood sugar levels and that information can be relayed to a health care provider who can view it, assess it, interpret it and provide recommendations to the patient about what they should do to better control their diabetes, as an example. That could be considered storing information or forwarding it to the provider.

Laura Knoy:
Well, in a few minutes, I want to ask both of you about other pieces of equipment that some patients might need, including patients with chronic conditions. And Meg wrote in. She says, My husband developed some troubling symptoms in mid-March and we got a phone appointment. We were both feeling reluctant, but the process was great. The first call began with a nurse taking a new patient screening (vital signs, history.) And then the doctor came on and asked a series of refining questions to understand the symptoms. Within a half an hour, she was pretty confident of a diagnosis and laid out a treatment plan. My husband has had two phone follow ups since then. It's been a great process during these sketchy times. I'm sure telemedicine doesn't work in all situations, but it was a great option in my husband's case. Meg, thank you very much for calling in. And Dr. Phelan, I myself had a telehealth appointment a couple weeks ago. I had just a minor eye condition and, you know, took some pictures of the eye and got on Zoom with the nurse and then with the doctor. And half an hour later, the medicine was called into the pharmacy. Previous eye appointments because of, you know, people being busy and the office being crowded and having to be checked in and so forth, my last appointment took two hours. This one took 30 minutes. So, yeah, I understand what Meg is saying. What kind of feedback you're getting from patients about this, Dr. Phelan?

Dr. Douglas Phelan:
I think while I'm very happy that both you and Meg have had, it sounds like pretty good experiences and that's definitely a plus. You know, in many ways, it's sort of a little virtual Marcus Welby. Right, that your family doc comes comes in and you get to talk with them. And there's not all of these other extraneous things that are necessary in our modern healthcare system. Right. Like, we've got to do some checking stuff, do some administrative stuff. But that doesn't have to be part of this visit. It can be sort of separate. So it's really dedicated nice time, consolidated time with you and the provider or you and the nurse and the provider. So that's definitely a nice thing. And I think what you've said about the timesaving is something that we do here a lot. To Meg's point, you mentioned, you know, as far as limitations there are still limitations to it. If there's a condition where I know I need to listen to your heart or I know that I could look at your leg, but it would be better if I did an exam and felt your leg. Then we can go from there and there's going to be a comfort level that will vary from provider provider about what they feel like they could adequately make the diagnosis via video as well. So we hope to do as much as we can. And the types of things you're talking about have probably been some of the, you know, Laura, you mentioned the eye has been one of the more longstanding examples going back a few years. That and dermatology and psychiatry have been telehealth standbys.

Laura Knoy:
Well, and I'd like to ask both of you about the types of conditions and the type of situations where this works less well. And so, Dr. Ballard, you first. In what types of situations does telehealth really not work? You need to get your hands on the patient. You need to listen to their lungs or their heart. Go ahead, Dr. Ballard.

Dr. Jonathan Ballard:
Yes, the human touch of medicine is a vital component. Now, using technology and having that humanness of medicine does not have to be at odds with most situations. Most visits, there are elements of the interaction that can be done through telemedicine. However, there are moments that Dr. Phelan mentioned where the human touch or listening to the heart, if you don't have appropriate technology or tools that provide for that, it can be a challenge. And this speaks to a little bit broader perspective of the practice of medicine. The father of modern medicine, Dr. William Osler, who started the first residency training program at Johns Hopkins Hospital, said the practice of medicine is an art based on science. And in that situation, it really was about bedside teaching, teaching the physical exam components. And so this shows how medicine really has changed in the modern world from that time period. But there are several elements that just cannot be ignored and that still hold true today about in-person visits can't completely be substituted.

Laura Knoy:
So give us a couple examples, Dr. Ballard, where you would absolutely say, no, you need to come in.

Dr. Jonathan Ballard:
Well, there are certain things that one has to physically come in for in some component or at least have a visiting nurse, for example, come to your home, including vaccinations. It's important to public health to promote healthy lifestyles and prevent and respond to infectious diseases. Other very important aspects of the visit besides vaccinations would be components like a physical exam component, such as listening to the heart. Picking up on arrhythmias that can be treatable. Oftentimes when I'm seeing patients just for a physical exam, preventive health checkup, I pick up on subtle clues, subtle subtleties of the physical exam that prevent a bad complication later on. So there is some fear that some of that may be missed in this era. But for the large part, for chronic diseases where you're managing a condition that is known, helping to adjust medication or lifestyle changes such as treating diabetes or obesity, telemedicine and telehealth has been remarkably successful.

Laura Knoy:
Let's go back to our listeners. And Stephanie is joining us from Portsmouth. Hi, Stephanie. You're on the air. Welcome. Go ahead.

Caller:
Good morning. Thanks so much for taking my call, Laura. This is Stephanie Sheheen and I am one of the co-founders of a company called Good Measures. And we've been providing telehealth services for people, mostly registered dietitian support and certified diabetes educators. And it's been amazing during this period where people's daily routine and lives have been really upended to help people think about the food they're eating, how to shop in the grocery store when food supply is upended and looks very different than it might have before, when they're not going out to restaurants as often and really focusing, frankly, on immune health and how using their own food pantry can help them feel better, stay healthier during this uncertain time.

Laura Knoy:
So for nutrition and for people with chronic conditions, Stephanie, this is really working. I'm curious. We talked about this earlier with the two doctors. I have read that again, one outcome of this is patients are much less likely to skip appointments, especially quick checkup appointments like how are you doing with your you know, management. What are you hearing about this, Stephanie? What have you seen?

Caller:
Absolutely. What we know in a traditional model, almost 60 percent of second appointments with registered dietitians are likely to be canceled.

Laura Knoy:
60 percent!

Caller:
Yeah. We think of how hard it is to get to the dentist, to get to the doctor, to come to, you know, add another appointment to see someone in person where you have to get in the car and drive some place and fit it into your work schedule. Here we're able to schedule phone calls over lunch breaks, you know, later in the evening. We have call time on weekends and people are really able to connect when they're available to connect, when it works for them, when and where they need it. So we've really focused on meeting people where they are and providing the reinforcement that they need. And it's interesting at this time when everyone's routines are disrupted, people are taking the time to say, how can I feel better? What can I do to protect myself? And they're reaching out in ways that they haven't before. And we're excited to be supporting them. And it's been interesting to see. And really, it's a transformative model because we're reaching people we wouldn't have otherwise otherwise been able to reach.

Laura Knoy:
Yeah, we're going to talk later with someone in the mental health field who's got some things to say about the ability to reach people. Last question for you, Stephanie. As a provider, then, are you going to continue with this once this pandemic is over?

Caller:
Yes, in fact, this has been our model from the very beginning. We do have the ability to see some people in person. But as you noted, it's much harder to get reimbursed for those non in-person visits until this reality struck, that we actually made more outbound calls and connected with more people in the month of April than we have at any other point in the company's history, because we're able to reach people where they are and they really want the support. And for a lot of people, our registered dietitians may be the first connection they've had to a clinician. And we are also helping screen, you know, helping identify whether there are reasons to be worried beyond just the day to day realities of getting through life.

Laura Knoy:
All right, Stephanie, thank you for calling in. We appreciate it.

Caller:
Thanks so much for the show. Really appreciate it.

Laura Knoy:
And after a break, we will talk with a provider of birth control and sexual health, how her organization is providing telemedicine in this time. We'll be right back.

Laura Knoy:
This is The Exchange, I'm Laura Knoy. Today, our in-depth series this week on COVID-19 and health care continues with telemedicine. Its use has soared since the pandemic began. And we're finding out how it works, when it works well and when it doesn't. We're talking with Dr. Jonathan Ballard, chief medical officer at the New Hampshire Department of Health and Human Services and a family medicine physician. Also, Dr. Douglas Phelan, attending family and preventive medicine physician at Elliott Family Medicine in Bedford. And joining us now is Alex Riccio, an advanced practice nurse at Equality Health Center in Concord, which provides birth control, sexual health and other related services. And Alex, welcome to The Exchange. Thanks for your time.

Alex Riccio:
Good morning, Laura. Thank you for having me.

Laura Knoy:
So how much of the care that you provide now, Alex, is done either online or over the phone? And how much is done in person? You don't need to give me exact numbers, but 50, 50, 60, 40. How much is telemedicine playing a part with your services today?

Alex Riccio:
Yeah, it's approximately 80 percent telemedicine. And we see about 20 percent of the patients in-house at this time.

Laura Knoy:
80 percent telemedicine. Wow. And what was that transition like for you, Alex?

Alex Riccio:
It was a pretty smooth transition the first couple of days. We were just trying to get used to the scheduling and sort of the virtual flow of patients going through the clinic from reception to me to, you know, closing the visit with billing and scheduling for future appointments. But once we sort of figured out the glitches and the flow of the schedule, it has been a really easy transition for everyone, even our patients.

Laura Knoy:
Well, any technical glitches, either on your end or on the patient and Alex?

Alex Riccio:
Sure. We use Doxy.me, which is our virtual video chat line that we use that most medical practices will use that because of HIPAA and privacy, security reasons. Some people don't always have a really good Internet connection. And when we are not able to connect through video, we'll just have the patients call us or I'll call them.

Laura Knoy:
Wow. So you are using just regular phones. And now, as we heard from our our doctors, that is covered. How does this change your daily schedule, Alex?

Alex Riccio:
Well, it seems that the visits, and I will concur with a lot of what the other physicians were talking about today, that the visits are much more concentrated and seem to be shorter and so we can sort of move through the day and our patients a lot more quickly. So we are seeing probably maybe even more patients than we would see if they actually came to the clinic.

Laura Knoy:
Wow. Tell me a little bit more about that, because you just can get through things more quickly?

Alex Riccio:
Yes. So the time that I spend with the patient is a lot more concentrated. You know, it is a conversation through video. There is no physical contact. So there's no exam that's occurring. There's just lots of questions and answers, conversation that the dialogue going on between me and the patient. You know, it's sometimes difficult to have, like, the awkward pause or silence. So it seems like whatever the patient has to say or whatever questions they have or concerns that they have, these questions can be answered directly and quickly. And there's no walking through the clinic, which also takes time and visiting with reception or a nurse. It's a much more quick visit, although, you know, a lot of the paperwork that has to be done is sort of done, you know, behind the scenes and is taken care of either before the patient actually speaks to me and then afterwards. So for the patient, it's actually very convenient for a very short amount of time.

Laura Knoy:
Are you worried, Alex, about something you might be missing? You know, an infection or, you know, just looking at people physically having your own eyes on something, a rash or whatever?

Alex Riccio:
Yeah, well, yeah. I mean, we ask those questions. You know, if patients are having any signs or symptoms of infection. So a lot of that is covered just through conversation. You know, we're not always looking at skin infections. But patients are usually reporting if they're having any, you know, concerning symptoms and if they are, we actually have them come into the clinic. Of course, we screen them for COVID and all of that. So it's a safe environment.

Laura Knoy:
Wow. What about testing? You know, lab work, Alex, if someone says, I think I have a urinary tract infection, you know, how do you even get that sample so that they can be tested and you can prescribe the appropriate medication?

Alex Riccio:
Sure, so what we're doing now with that kind of a visit is we'll have a consultation over the phone or on video. And if there is risk for some type of infection like a UTI, we will have them come in and just leave a sample.

Laura Knoy:
Ok. So are there barriers to care that have been removed for prospective patients, Alex, or has this in any way put up new barriers for patients?

Alex Riccio:
No, I actually think that it's removed quite a few barriers. I mean, we have a lot of patients that come from far and wide. Some patients will travel, one, maybe even up to two hours to come see us because we specialize in certain treatments like prep patients. Those are prophylaxis for HIV people who are at risk for contracting HIV. And so if they don't have to spend that time traveling in the car, if they don't have transportation or if it's bad weather, we're able to remove that particular obstacle for them so they can have their visit and get appropriate treatment.

Laura Knoy:
Wow. So because you provide some specialized services, as you mentioned, people will travel two hours to come to Concord to see you. That's a huge time savings for them.

Alex Riccio:
Huge time savings. I think that the telemedicine has not only remove those obstacles, but made these visits a lot more convenient for the patients. And, you know, keep them safer in a way, because they don't have to do all that traveling in inclement weather and also economically for them, you know, it's much more cost effective because they're not spending money on the travel.

Laura Knoy:
Yeah, that's half your day if you've got to travel two hours. I've read a lot about something, Alex, and I want to ask what you think. The idea of new patients versus patients who you know and you know, you can kind of quickly check in with them and ask how their particular condition is going. When this pandemic is over, do you think you'll sort of approach telemedicine differently depending on whether someone is a new patient or an established patient?

Alex Riccio:
Yeah, absolutely. We always want to develop some kind of good rapport with the patient when they're an initial patient. We love to see them in-house. You know, there's a lot that you can learn about a patient, not just from their voice on the phone, but certainly from their kinesthetic and, you know, reading their emotions and also their mental health is really vital to their medical history and intake. So I would hope that we would continue seeing initial patient at the very least in-house, because that's very important to have that contact with them.

Laura Knoy:
Yeah, well, sounds like you are hoping to continue using telemedicine, Alex. Once this is all over. Sounds like you guys are, this is working for you and you're gonna continue doing it.

Alex Riccio:
Yeah, I hope that we can. Absolutely.

Laura Knoy:
It's great to talk to you, Alex. Thank you very much.

Alex Riccio:
Thank you, Laura. Thanks for having me today.

Laura Knoy:
That's Alex Riccio. She's an advanced practice nurse at Equality Health Center in Concord. Again today on The Exchange, we're talking about telemedicine as our in-depth series on COVID-19 and health care this week continues. We're looking at how the use of telemedicine has gone up in a huge way since the pandemic began and how it might continue once the pandemic is over. And before we go back to our listeners, Dr. Ballard, any thoughts from what we heard from Alex Ricci? Pretty remarkable that she's able to see more patients and some of them don't have to take, you know, half a day off of work to come in and see her. What do you think, Dr. Ballard?

Dr. Jonathan Ballard:
It is remarkable. Just looking at some numbers, back in 2018, Medicaid total expenditures for telehealth was one hundred eighty three thousand dollars. That's what Medicaid spends, about one billion dollars per year. So very small amounts. The majority of that was billable for crisis stabilization for mental health visits to keep people from entering crisis or having to go to the emergency room. Today, I'm very interested in what those numbers should be. We plan to examine this very soon in New Hampshire.

Laura Knoy:
What is the plan at this point, Dr. Ballard, in terms of coverage for telemedicine? Again, Medicaid and other insurers have sort of, you know, lifted the rules during the pandemic. Is there talk about them restricting use of telemedicine or at least their coverage of telemedicine, once this is over?

Dr. Jonathan Ballard:
Coverage of telemedicine varies by insurance type. The federal government, the Centers for Medicare and Medicaid Services, relaxed many restrictions.

Laura Knoy:
And that made a big difference. Medicare and Medicaid. Yeah, go ahead.

Dr. Jonathan Ballard:
They relaxed the audio only restriction. Tricare did similar for those members of the armed services, the Veterans Administration, which is for vets. There was a family's first coronavirus response act. They did this for the employer sponsored self-insured plans. And in New Hampshire and in Medicaid, we expanded coverage for telehealth last year in 2019 with the passage of Senate Bill 258 and signed by Governor Sununu. That allows for telehealth coverage to be provided for all types of care, including primary care, which was previously not allowed for Medicaid. There are further bills that are pending before the legislature to further expand telemedicine after the current emergency order number eight expires at the end of the state of emergency. There's house bill sixteen twenty three from Representative Marsh. And Senate bill six forty seven from Senator Kahn expands telehealth for medication assisted treatment and medication assisted treatment to inmates in correctional facilities. There's also Senate Bill five fifty five from Senator Kahn that would say coverage parity for in-person versus telehealth payments to providers to encourage their continued use of it.

Laura Knoy:
So lots of people looking at this, in other words.

Dr. Jonathan Ballard:
There are many layers to this. And our health care system has regulations from different aspects of federal, state and also regulatory boards as well from the Office of Professional Life Insurance Certification. So just like the Board of Medicine.

Laura Knoy:
Ok, well, lots of e-mails that I'd love to share with you. Some people who are thrilled with telehealth and some who are feeling a little less thrilled. Tom in Exeter writes, I had a telehealth call with my doctor in late March and it was so convenient. Tom says there was no risk of contracting something from another patient, and I didn't have to idle away time in a waiting room. I highly recommend it. Tom, thank you. And everybody hates sitting in a waiting room for half an hour when you have other things to do. Allegra writes in, I have had a few nice telemedicine visits so far, and I think a mix of regular in-person and video visits is overdue in society. I had an orthopedic appointment in late March with a nurse practitioner and while I liked it and she took time with me, Allegra says it left me feeling frustrated because I needed a cortisone shot for a shoulder injury and from her watching me move it on the screen, she felt I could wait another six weeks. Even after I explained my pain level. So physical pain issues seem more difficult to gauge in this medium, I'd say. I'd rather she examined me in person and could closely inspect my shoulder. Thank you to Tom and thanks Allegra. And Dr. Phelan, what do you think about Allegra's comment? You know, a mix would be better. Go ahead, Dr. Phelan.

Dr. Douglas Phelan:
Yeah, absolutely. I think that's spot on. Personally, you know, we've already talked a little bit about there's certain parts of a physical exam and the power of human touch. You know, I'm family medicine. We love seeing our patients. It's sort of like in our bones. So that makes perfect sense. And I think the fact that there are conditions that require a more in-depth physical exam. There's a lot I can guide you through on a video and have you do. But there's a lot I can't yet. Or maybe we're yet to figure it out. But there's still a lot that we can't. And so that mix is right. Whether it's for acute things like a shoulder injury or for chronic things like diabetes management or COPD management, striking that mix, I think is going to be nice for patients as much of the benefits and convenience of telemedicine, but also making sure that they have the opportunity when they need to come in to come into the office.

Laura Knoy:
Well, Dr. Phelan, I wonder what you think about what Alex Riccio said about the difference between new patients and established patients and the importance of meeting that new patient face to face in your office that first time.

Laura Knoy:
Yeah, there's nothing like that in person interaction. I will say one thing that I find myself saying to almost everybody I've seen in office is almost the first words out of my mouth are, you know, normally I would shake your hand, but not today. So I do miss that because especially for a new person, you both want to show each other pieces of who you are. You've got to find the primary care physician or provider or the specialist who jives well with your sensibility. And so that first interaction is so key. That said, I've done some new patient visits now over telemedicine and a lot of people understand the situation going on right now and are appreciative because they didn't think that they'd be able to, quote, unquote, meet me for another few months.

Laura Knoy:
We've got a caller who couldn't stay on the phone, Wesley in Portsmouth, but he asks a good question. I'd like to throw it to you Dr. Ballard. Wesley is wondering whether the push for virtual appointments during the pandemic might make it harder to get in-person visits after the pandemic is over. Wesley says he's more comfortable with in-person visits and wonders if that might be less possible. That's interesting, Wesley. I had not thought about that. What about that, Dr. Ballard? Could we possibly go overboard with this? And if people want to come in again, once, it's really safe to do so, will they face doctors' offices saying, no, it takes too much time. You got to do it over Zoom.

Dr. Jonathan Ballard:
I don't believe so. It's a very good question. Dr. Phelan and myself did training in family medicine. The author Malcolm Gladwell, his book Outliers, describes that you can master any real topic when you have a passion based on skill level, but you have to put in time. In family medicine residency training, we put in about 2000 hours of work to learn how to be a family medicine physician. Most were learning how to treat patients like bedside, be in the exam room with patients, have that human touch. You connected in this physical exam. That's why many of us went into medicine, is that connection. So I just don't see that going away, even though we want to be accessible to patients to provide care to them through telemedicine when appropriate. I don't see that passion and that ability, desire to see our patients in person to go away after.

Laura Knoy:
I got an email here from Cynthia who says, I am a registered dietitian in private practice. I would like to hear more about challenges related to self-insured employer based health plans that are not required to comply with government mandates. In the Monadnock region where many employers have self-funded plans, not everyone is able to use their coverage for telehealth. Dr. Ballard, what can you tell us about different insurers and how open they have been to this? You mentioned earlier Medicare, Medicaid, the Veterans Administration and so forth. But it sounds like, from what our emailer is saying, not every insurer is on board. So what more can you tell us about that, Dr. Ballard?

Dr. Jonathan Ballard:
Self sponsored insurance plans are regulated by the federal government. There is a law called the Employee Retirement Income Security Act of 1974 that sets the minimum standards that employer sponsored health plans must meet. It's regulated by the U.S. Department of Labor IRS. In that, there has been actually some movement mentioned earlier, the Family First Coronavirus Response Act that does state that even these employer sponsored self-insured plans do have some requirements for payment around COVID-10 testing and visits associated with COVID-19 without additional co-pays, deductibles, coinsurance. And it also further goes on to allow health plans, if they wish to pay for telehealth and waive different co-pays and such. You could choose to do so. That is where we do see some variation, but for the large part in New Hampshire, most health plans seem to be supportive thus far of telehealth and the power that can hold for patients to prevent further disease and worsening of chronic conditions that may end up in potentially more expensive care like a hospital visit. Because of their condition may decline. Preventable surgery, potentially. So there is great value. There is a lot of researchers across the country, including in New Hampshire at Dartmouth, that are using health claims data and data from the Dartmouth Atlas that looks at Medicare claims and other data to look at what is the cost effectiveness and what is the human disease prevention value. So there's a lot to learn. It's evolving. And I think we have to learn about what is the essential benefit, but also how to actually do this better.

Laura Knoy:
Well, and it sounds like you're looking at the data and lots of people will be looking at the data to see, you know, when this works well for patients, when it doesn't to do it better moving forward. I want to talk to both of you a little bit more about populations that don't have good access to video conferencing and so forth. There is some concern about an emerging digital divide. Also coming up after a short break, a Nashua psychiatrist will give his perspective on the use of telemedicine in mental health. All that's coming up. We'll be back in a moment.

Laura Knoy:
This is The Exchange, I'm Laura Knoy. Today, our in-depth series on COVID-19 and health care continues with telemedicine. We're talking with Dr. Jonathan Ballard, chief medical officer at the New Hampshire Department of Health and Human Services and a family medicine physician. Also, Dr. Douglas Phelan, attending family and preventive medicine physician at Elliott Family Medicine in Bedford. And joining us now is Dr. Joseph Insler, a psychiatrist who works at the counseling center in Nashua. And Dr. Insler, welcome. It's really good to have you on.

Dr. Joseph Insler:
Hi. Thank you for having me.

Laura Knoy:
How much have you been seeing patients via telemedicine the last two months, Dr. Insler?

Dr. Joseph Insler:
Well, at the Nashua practice, we've totally switched over from in-person visits to telemedicine.

Laura Knoy:
Wow, one hundred percent. And what's been surprising to you about this? How did you feel about it when it started and how do you feel about it now?

Dr. Joseph Insler:
It's a blessing to have the opportunity to do it. I think it was coming and things just happened to get accelerated because of the pandemic. But it really is a nice opportunity to be able to see patients in a safe environment so that they can feel comfortable so that we can feel comfortable. And, you know, there were bumps along the way because so many people were transitioning so quickly to these platforms. But recently, it's gone pretty smooth.

Laura Knoy:
I got an email from Tom on the Seacoast, Doctor Insler, about his experience with telemedicine and psychiatry. And I want to run it by you. Tom says telemedicine was an acceptable substitute for face to face contact with my psychiatrist. I spoke much more freely than on the phone and he could read my face, which is very important. Tom says, however, my phone camera isn't good enough to show my eyes clearly. Eye contact is extremely important for reading me. I'm not an eye contact guy, but I always stare into his eyes so he can understand me better. Telemedicine is working, Tom says. But I look forward to in-person contact again. Tom, thank you for writing. That's really interesting. Dr. Insler, I just wonder what your insights are in terms of the way people look at each other and try to read each other over a video chat.

Dr. Joseph Insler:
Well, it's true. I mean, it's definitely better than the phone, but it is not as good as in-person. And I find that when I'm doing these visits with my patients, I actually will purposely try to look in the camera rather than at their eyes on the screen, so that at certain times, so that they can kind of get more of a feel for it being more of a intimate interaction. Because if you're looking at the screen you're clearly not looking directly at their eyes, that's kind of diverted. So it certainly is quite different. But you do what you can to try to reproduce that in-person interaction as much as possible so that people can be more comfortable.

Laura Knoy:
Do you have some patients who would just prefer to talk to you on the old-fashioned phone. They don't want the hassle and the distraction of setting up a video connection.

Dr. Joseph Insler:
Yes, certainly there's some patients who do, certainly I see a a wide age range and some of my older patients who maybe aren't as adept with technology say that they prefer to do it over the phone rather than through the computer. And for them, you know, we do what we can. For some of the younger patients, they they do really appreciate being able to use this platform. And, you know, it goes pretty smoothly with them.

Laura Knoy:
Well, and they know you, and it's probably nice for them just to see your face. We talked earlier with another provider about the importance of seeing new patients in person. This pandemic is not going to be over tomorrow, as everybody knows. And I wonder what your thoughts are, Dr. Insler, about new patient visits versus established patients using telemedicine.

Dr. Joseph Insler:
Well, I think it's, you know, this is a moving target, and I think what we maybe thought was once not acceptable can become acceptable. And I've seen this through many different issues that come up during this pandemic, use a mask, for example, mask weren't acceptable at some point. Now they're mandated. And I think people used to say, no, it's not acceptable to prescribe a controlled substance to somebody you haven't seen in person. And, you know, for good reason, there were certain concerns about that. But that was during a time where you were able to see people in person. And so when you have a virus come up, that carries with it significant risks. Now we need to reassess our opinions about things because we have new information. And so if you have patients that could benefit from certain treatment, certain medication, but they're not able to come in anymore because the risk isn't an acceptable risk to deal with. I think now you have to pivot and say, you know what, maybe it is now acceptable to see a new patient virtually or over the phone even, if, you know, something happens with the technology. And it is appropriate under specific circumstances to write a certain medication for a patient that previously wasn't permitted before.

Laura Knoy:
We got an e-mail from Linda, who also works in the field of mental health. Linda says, I'm a psychologist working in Dover and have been seeing all my patients via telehealth since mid-March. Initially, Linda says nearly everyone was happy that we could continue to meet virtually. At this point, though, Linda says, I'm noticing some people are looking forward to coming back to my office. With many types of therapy, the in-person interaction helps to create an alliance and also provides important information through non-verbal interactions. Linda says, I agree with the caller, who recommended a combination of in-person and telehealth. In case of bad weather, child care issues and just general life commitments, having the option of meeting virtually would provide for continuity of care. Linda, thank you very much for emailing and Dr. Insler, what are your thoughts on some of the points that Linda raises?

Dr. Joseph Insler:
Yeah, I agree. I think I think she raises good points. I think having the flexibility is great and I hope it continues to be an option in the future. I think doing all of just virtual visits in the future wouldn't be the same. I also heard what the other doctor was commenting about before. There's really something nice about being in person with the patient. It's certainly what we thought about when we chose to go to medical school to be able to be in the same room with our patients. And I think to totally replace it is not something that I would want to see happen. But I do really appreciate the ability to =have it, you know, the convenience that it offers. And in this circumstance, the safety that it offers, I think it's nice to have it available and at certain time periods.

Laura Knoy:
You know, I want to ask you a little bit about billing and insurance coverage, because that's come up a lot in our conversation today, Dr. Insler, and one therapist was quoted in an NHPR story saying she finds the insurance coverage information, quote, confusing, ever changing and hard to trust. This person said she fears that insurers will create so-called wiggle room or special categories that will lead to psychiatric services not being covered. Well, how are you finding the insurance coverage of this at this point, Dr. Insler? And do you have concerns that insurers down the line might create wiggle room for themselves to not cover what you do?

Dr. Joseph Insler:
It's a good question. It's not my expertise, you know, in terms of the managing or understanding the particulars about the insurance companies. I'm thrilled that they did allow this coverage for this type of service. And I think it was really needed. And so, you know, it's worked out well so far. I'm hoping that it does continue. But it is a concern that I worry about what will happen when hopefully things start to improve and people start to do the in-person visits. I'm really hoping that they do still allow for the virtual visits, that they still give coverage, because if they're not covering it, then nobody is going to do that. It's just not possible to do the virtual visits. I'm sure there will be some divergence among the particular insurance companies, but I hope there's some pressure on them to do the right thing and continue to allow these services to be available because they really can help patients.

Laura Knoy:
Dr. Insler, it's been really interesting to talk to you. Thank you very much.

Dr. Joseph Insler:
Oh, it was my pleasure. Thanks for having me.

Laura Knoy:
That's Dr. Joseph Insler, a psychiatrist who works at the counseling center in Nashua. And Dr. Ballard, Dr. Phelan, a couple more e-mails for you before we close out. Michelle in Manchester writes, I'm a nurse practitioner working in endocrinology. Although I see a value in telehealth, it does present some added responsibilities for patients. Michelle says many of our patients have diabetes and we need their blood sugars. They are used to handing us their glucose monitor or device to download in the office. Many of them are unable to access their data at home. She says this is affecting our ability to provide the best care possible for our patients. And Michelle says unless patients can accept these responsibilities, we will need to continue to see them in the office. Michelle, I'm so glad you wrote, because Dr. Phelan, you talked earlier about how most people can get telehealth, you know, over some kind of video connection or over the phone. But some people do need tests, measurements, checks. What do you think about what Michelle says, Dr. Phelan?

Dr. Douglas Phelan:
I think it's a real challenge. You know, with every passing day and every passing week that this is going on, we're finding new benefits, but we're finding new challenges. And this is definitely one of them. Now, one would hope that as this becomes something that's more enshrined in how we are able to work, that this becomes something that's a guaranteed ability for us to do in health care, that there will be companies, technology companies that rise to the challenge to meet those needs. And we might not have that right now. So they might need to find a way to come in to download information in that particular event and do that in a safe manner. And then do they just come to drop it off or do they come to drop it off and stay for a visit? There's lots of wrinkles that will need to be done there. I would say, you know, we've seen the saying floating around regarding a lot of stuff that, you know, will return to normal. What's return to normal? Well, the old normal was kind of broken. And so one would hope that we can build a new normal where there is this combination where you can do what you can through the telemedicine, but understand that there are still instances in the status quo such as that, where somebody is going to have to come in maybe.

Laura Knoy:
Broken in what way, Dr. Phelan, in that people had to drive long distances, sit in the office for half an hour, do a long, extensive check in that maybe wasn't necessary? I'm interested in what you mean by that.

Dr. Douglas Phelan:
Yeah, it's all of that. You know, health care is always, like many things, it's always going to be an evolving service, an evolving care experience. And there were things that we certainly didn't love about how traditional sit in the waiting room, drive, miss a day of work medicine had to work. But it's what we created. We created what we could within the constraints that we had. And now we've got this new tool. So one hopes that we can achieve a new normal. It's going to involve this new tool. It's not a replacement. It's part of the new armament. It's another, you know, another tool in the toolbox. And you can help alleviate some of those things that you just said, which were part of what was not great about the patient care experience. So that for instances where you need to come in or where it's beneficial for you to come in for your physical or your mental health that you still can. But for instances where you can do it through telemedicine and it's better for you to come in for telemedicine, that you can.

Laura Knoy:
And it might lead to more people actually showing up for their appointments if they don't have to do all those things. We heard earlier from Alex who talked about the large number of patients who would just not show up. I have a neighbor who's a dermatologist. He says you can't believe the number of no shows for appointments, which is a waste of time and energy for the staff at the doctor's office for sure. Last question for both of you. And Dr. Ballard, I think I know what you're gonna say, but how much do you think telemedicine is going to continue in the future? Is this a culture shift in American health care? Dr. Ballard, go ahead.

Dr. Jonathan Ballard:
Laura, I think it's here to stay. What Dr. Phelan discussed was disruptive innovation and that we will have a new normal. It's a huge new tool that we can use to combat issues that have long persisted. Former Surgeon General Vivek Murthy under President Obama has talked about loneliness, health outcomes that are bad as a result of loneliness. We hope that this will be a great tool to combat that. It will never replace the in-person visit totally. But some combination can be a new normal that helps us provide better care for patients and improve the health of all Granite Staters.

Laura Knoy:
Dr. Phelan, and what do you think? Here to stay?

Dr. Douglas Phelan:
We've got to hope so. You know, from the patient care standpoint, from a health equity standpoint, it's proving itself beneficial. We've got some wrinkles to work out. But I'm looking forward to it.

Laura Knoy:
All right. Both of you, thank you very much for taking the time with me. Dr. Ballard, thanks a lot for being with us today on the air. We appreciate it.

Dr. Jonathan Ballard:
Thank you.

Laura Knoy:
That's Dr. Jonathan Ballard, chief medical officer at the New Hampshire Department of Health and Human Services, and a family medicine physician. Dr. Phelan, it was good to talk to you, too. Thank you.

Dr. Douglas Phelan:
Thank you so much.

Laura Knoy:
That's Dr. Douglas Phelan, attending family and preventive medicine physician at Elliott Family Medicine in Bedford. Thanks for being with us. I'm Laura Knoy.