After reaching historically high adoption rates during the height of the COVID-19 pandemic, the use of telehealth services has plummeted since the beginning of the year.
Experts say that places the healthcare industry at a fork in the road, where providers, payors, and tech companies must choose whether to embrace an effective and convenient healthcare medium or be left behind as telehealth marches forward.
The road toward adoption of telehealth — the use of electronic communications to provide care and other services — has been long. Before the COVID-19 pandemic took hold in 2020, the adoption rate in the US, nearly 60 years after telehealth technology was first introduced, was just 0.9% of outpatient visits.
In first few weeks of the pandemic, however, the percentage of virtual healthcare visits jumped to 52%, according to Mark Gilbert, senior director analyst for Healthcare Strategy at research firm Gartner. “In that five weeks, there was no time for strategic planning or business cases; there were no time for [requests for proposals], or any of that stuff that goes into normal procurement process of a technology platform,” Gilbert said. “It was just, ‘Get it done. Make it happen.’”
The US government has continued to fund efforts to establish telehealth as a more efficient supplement and, in many cases, alternative to in-person visits. Changes to government regulations of telehealth systems, most notably the expansion of insurance reimbursement by the Centers for Medicare & Medicaid Services (CMS) to cover telehealth appointments enabled rapid adoption. And HIPAA data privacy rules were relaxed to enable the use of consumer video apps such Apple’s FaceTime and Microsoft’s Skype as a temporary means of connecting doctors and patients.
After making significant gains during the pandemic, however, telehealth use has significantly receded in the past year; the number of Americans using electronic devices to interact with healthcare providers dropping precipitously, according to Gartner.
“Over time, we hit a steady state of 12%,” Gilbert said. "Some regions were higher. In California, we’re at a 20% steady state. In the Bay Area, it is 25%."
The decline in telehealth happened for several reasons, but mainly because patients understood as the pandemic eased they could once again go to a physical office to see their primary care physician, specialist, behavioral health therapist, or other medical provider.
Tracking telehealth use from January 2020 through March 2022 shows that although there was a sharp rise in spring 2020, use has declined since, according to Fair Health, a non-profit organization that tracks telehealth use. A study by Fair Health, titled "The Evolution of Telehealth during the COVID-19 Pandemic," revealed there may have been many telehealth use fluctuations over the past two years, but those were often related to the course of the pandemic. For example, in spring and summer 2021, telehealth claim lines dropped as vaccination levels increased. In fall and winter 2021, however, telehealth utilization rose again as the Delta and Omicron variants led to increased COVID-19 cases.
Further, even though there has been a decline since the peak months of 2020, telehealth utilization has remained much higher than before the pandemic. In December 2021, for example, telehealth claims accounted for 4.9% of medical claims nationally, compared to 0.2 percent in December 2019.
As COVID-19 fell out of the top five telehealth diagnoses nationally, other diagnoses rose; substance use disorders, for example, reentered the top five nationally in the Midwest and moved from fourth to second place in the Northeast.
“All that said, 1% to 12% is a heck of a jump,” Gilbert said. “Many organizations recognize the adoption of telehealth broke through a number of glass barriers — financial reimbursement, clinical adoption, and consumer adoption. Clinicians realized improved clinical efficacy. They saw the clinical outcomes. We also broke through many regulatory barriers.”
Can pandemic-era changes last?
During the height of the pandemic, providers and insurance companies introduced a variety of changes to improve payment mechanisms for telehealth. Now, government and healthcare insurance payers should look to ensure those changes remain in place, according to Daniel Ruppar, consulting director for healthcare and life sciences at business consultancy Frost & Sullivan.
“The main goal now is to not retract, but to further enable the use of telehealth by us as the patients and consumers of healthcare in the US,” Ruppar said.
That means health systems and physician practices need to look further at what they did in 2020 to ensure their approach to telehealth meets long-term organizational and digital transformation goals. Many likely pivoted to solutions that helped short term, but might not be ideal in the long term.
They might not, for instance, have been created for highly complex workflows or to integrate with existing self-scheduling and EHR systems, Gilbert said. “I’ve got two systems up while talking to a patient – my EHR and video conferencing system. It’s kludgy from a physician perspective.”
Some clinical specialties had better staying power after the pandemic wound down, according to Gilbert. For example, telehealth psychiatric care remains at high levels. “In Florida, for example, 61% of all psychiatry interactions are virtual,” he said.
Throughout the pandemic, mental health conditions have been the most common telehealth diagnosis nationally, according to Fair Health. Consistent with that finding, in January 2022, "social worker" was the provider specialty rendering the most telehealth services (most commonly psychotherapy). Nationally, three of the top five provider specialties were related to mental health: social worker, psychiatrist and psychologist.
Another issue affecting the healthcare industry involved insurance companies that chose to reimburse providers at a higher rate for in-person visits. As the pandemic waned, so did the incentives to continue telehealth.
Telehealth coverage and reimbursement continue to affect utilization, according to Natalie Schibell, vice president and research director at Forrester. “In the case of telepsychology coverage, reimbursement remains a concern, as states have different laws and mandates,” Schibell said. “Not all 50 states require reimbursement for teletherapy at parity with in-person visits.”
The staying power of teletherapy
For example, some insurers require that telehealth providers use proprietary technology platforms, which often require additional credentialing and fees. The American Psychological Association (APA) is pushing back by advocating for psychologists to be able to use any HIPAA-compliant platform. Health and Human Services offers a list of 10 vendors who claim to be HIPAA-compliant, including Zoom for Healthcare, Doxy.me, and thera-LINK.
Even before the pandemic, studies showed teletherapy was effective for many mental health issues, “but we know that is not the panacea,” Schibell said.
“We found that teletherapy is a useful and convenient tool, especially in times of emergency like COVID-19, but it does not replace face-to-face therapy,” she said. “The hybrid model reigns for optimal outcomes. The therapeutic presence is necessary for a patient to feel safe and understood. The use of body language is needed for patients and providers to better connect and build trust.”
The pandemic not only accelerated teletherapy, it also sped up the emergence of thousands of mental health apps, Schibell noted. The APA has said there are from 10,000 to 20,000 mental health apps, with Calm, Happify, and Headspace three of the major players in the teletherapy space. While the apps won’t replace therapists or a dedicated regimen of telehealth sessions, they serve as a doorway for seeking out a psychologist and getting needed care over the long-term, Schibell said.
Another challenge to telehealth adoption: more than half of consumers with employer-provided coverage have self-insured plans, according to Schibell. Those plans, covered by the Employee Retirement Income Security Act of 1974 (ERISA), aren’t required to cover telepsychology.
“The APA is also advocating for this to change as well as for states and payers to continue the current level of coverage for at least a year after the public health crisis ends,” Schibell said.
Telehealth as a permanent option?
With patients and consumers now more aware of telehealth as an option, the healthcare industry has reached a fork in the road. Going in one direction are organizations that understand the value of virtual care and are creating platforms that have integrated workflows, integrate into digital therapeutics, and can rearchitect the patient journey to reflect the value telehealthcare brings, according to Gilbert.
"The dichotomy exists between organizations that choose to become digital first healthcare providers — and those who do not recognize the transformative value," Gilbert said. “They’ve gone back to in-person visits and the way of doing things they always had. Perhaps they can’t invest in that transformation to virtual. So, for them, they’re tailing down. Maybe they’re at the 5% adoption [rate] and the leaders are at the 25% adoption rate.
The future of telehealth, Gilbert believes, will be a mix of virtual solutions and in-person physician visits.
“I firmly believe five years from now, [consumers are] going to assess the quality, capabilities and selection of a provider based on their ability to blend face to face interactions with to virtual and digital products and services within a hybrid patient journey,” Gilbert said.