key: cord-0050703-h9dakd3n
authors: Fero, Katherine E.; Bergman, Jonathan
title: EDITORIAL COMMENT
date: 2020-09-26
journal: Urology
DOI: 10.1016/j.urology.2020.05.082
sha: 36d56def9747293133fccdccaa2f074ce73bc937
doc_id: 50703
cord_uid: h9dakd3n

nan

In the United States, specialty care has traditionally been delivered through a familiar structure: a patient sees his primary care provider and, if the provider believes input from a specialist would be helpful, she refers the patient to a specialist, who then sees the patient in a face-to-face visit. This flow has endured mostly through inertia, with room for improvement of specialists' ability to manage populations of patients. 1 Innovative alternative models have shown a more nuanced way to deliver specialty care that meets the needs of patients and populations. 2 The emergence of COVID-19 served as a natural experiment in reimagining care delivery. Sweeping efforts were undertaken to preserve resources and prevent nosocomial spread of COVID-19 as many healthcare providers dramatically decreased in-person clinic operations and, in concert, rapidly implemented telemedicine services. These services, including video and telephone patient-physician visits, have existed for decades, however widespread adoption has been hindered by regulatory policies regarding geography, privacy and reimbursement. The unique context of the viral pandemic resulted in immediate policy modifications that have enabled the brisk adoption of telemedicine, including in urology practice.

Although data exists regarding telemedicine feasibility, convenience and provider and patient satisfaction, there remains a critical knowledge gap pertaining to what exact purpose these visits are serving. Are they an additional step that serves as a prelude to in-person evaluation, ultimately increasing health-care utilization overall? Or can a subsequent in-person visit be safely avoided to the benefit of patients and healthcare systems alike? In this issue of UROLOGY, Andino et al present an important evaluation of video visits as substitutes for in-person visits at a large tertiary academic center. The authors report that, prior to the emergence of COVID-19 in the US, the proportion of patients who required a return visit within 30 days of a video visit was no higher than those who were initially seen in-person, suggesting that for appropriately screened patients a video visit can substitute for an in-person visit. This may reduce burdens on socio-demographically and physically disadvantaged patients, who often pay a high price to physically come to clinic.

While COVID-19 will likely prove to serve as the tipping point for broad adoption of telemedicine, the work to be done is in getting these services to the appropriate patients with efficiency, quality and accessibility. Caution must be taken that in overcoming a barrier to access as it relates to geography, or travel time, we do not ignore barriers to access due to lack of devices, internet or language services. This will require rigorous implementation and delivery science to define strategies tailored to each unique and vulnerable population, including the elderly, non-English speakers, and those with lower socioeconomic status. Promise and perils abound. 

All patients in our study were previously established with and examined by a urologist. Over 80% had commercial insurance, resulting in reimbursement comparable to clinic encounters due to Michigan's favorable telehealth parity laws. 1,2 The regulatory landscape limited which patients could be seen from their homes and how clinics were reimbursed for video visits. It is possible that new patients who have never seen a urologist, the elderly, and those whose socioeconomic status qualify them for Medicaid stand to benefit the most from reduced travel time and the convenience of performing these visits from their home or work.

However, the policies that previously provided only sub-sets of our patients with the ability to use telehealth have all changed. COVID-19 resulted in unprecedented and rapid changes in the reimbursement and regulation of telehealth after the pandemic was declared a national emergency on March 17, 2020. 3 Since then, the disproportionate impact of COVID-19 on minority populations 4 in the United States has brought discussions about health disparities to the forefront of medical and public discourse. We find ourselves at a pivotal moment for thoughtfully designing the future of care delivery in the United States. Physicians must advocate to prevent a return to the status quo. For the coming years, we need to work within the COVID-19 reimbursement and regulatory environment to rigorously evaluate telehealth. How do new patient encounters impact access to specialty care? How do Medicare and Medicaid beneficiaries use telehealth to connect with their providers? Is the availability and use of telehealth affected by racial, ethnic, or cultural characteristics? Like much of medicine, there is no silver bullet that will meet the needs of our diverse populations. Rather we should leverage different forms of telehealth, from e-consults to telephone encounters and video visits, in order to bring specialty care to our patients. Rather than expecting them to show up at our doorsteps.

Projecting the urology workforce over the next 20 years

Development and implementation of expected practices to reduce inappropriate variations in clinical practice

State of the States Report: Coverage and Reimbursement

The impact of video visits on measures of clinical efficiency and reimbursement

Medicare Telemedicine Health Care Provider Fact Sheet

COVID-19 and racial/ethnic disparities