Challenges and Opportunities in Telehealth: A Q&A With the Experts
Telehealth is in the news lately, as state and federal lawmakers debate the necessity and logistics of remote patient care and payment, including the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019. The bill, which APTA supports, would expand the use of telehealth services and ease restrictions on telehealth coverage under Medicare, as well as encourage the Center for Medicare and Medicaid Innovation to identify which services delivered via telehealth can result in cost-effective and positive patient outcomes.
#PTTransforms Blog spoke to APTA members Sarah Gallagher, PT, DPT, and Alan Lee, PT, DPT, PhD, about the possibilities, challenges, and current use of telehealth across health care professions. Gallagher is the owner of South Valley Physical Therapy, a Colorado private practice specializing in neurologic and vestibular physical therapy that began providing telehealth services to solve an access to specialty care problem. Lee is the telehealth lead for the APTA Frontiers in Rehabilitation Science and Technology (FiRST) Council and vice president of the Technology in Physical Therapy Special Interest Group of HPA The Catalyst, APTA's section on health policy and administration.
#PTTRANSFORMS: How is telehealth being used already, both inside and outside the physical therapy profession?
Gallagher: In my practice, we primarily treat vestibular conditions. Outside of assessments and adapted interventions, we can educate patients and family members, learn about how the person interacts with their native environment and make recommendations, make the person independent in their home exercise program, help them problem solve where and how to do the exercises they were taught in the clinic, progress activity recommendations, evaluate performance on home exercise equipment, and make recommendations for office environments and ergonomics.
Lee: Within physical therapy, telehealth is used synchronously with live audio and video sessions and asynchronously with remote biometric and imaging sessions, as well as remote monitoring. Telehealth inside and outside of physical therapy is used in large federal health systems such as the Department of Veterans Affairs, as well as large private health systems such as Kaiser Permanente. Some corporate telemedicine firms contract with health care plans to provide additional telemedicine services.
Physical therapy telehealth services are emerging in pediatrics, geriatrics, women's health, oncology, wound management, orthopedics, neurology, cardiac and pulmonary rehabilitation, and home health care. Obviously, any physical therapy services that require hands-on care are not provided via telehealth. Screening out patients that require in-office care is key to appropriate use of telehealth. Telehealth is just a tool to facilitating best practice and care in physical therapy and should not duplicate any unwarranted services. If telehealth services are not improving the quality of care or improving patient outcomes, they should not be used.
#PTTRANSFORMS: Is telehealth a potential business opportunity for small practices?
Gallagher: Absolutely. A practice can expand its physical reach and offer specialty services to a broader geographical audience.
Lee: This has been a point of contention on social media. Yes, telehealth physical therapy can be an opportunity, but it is more complex than just a simple video chat. Offering telehealth services is the same as establishing professional in-office care. You will need risk mitigation with attorneys, insurance, billing and coding, documentation, and competencies for staff and yourself in policies and procedures for emergencies and handling all situations. Some helpful resources include APTA's telehealth webpage, the APTA FiRST Council, the Federation of State Boards of Physical Therapy (FSBPT), HPSO's telemedicine risk management (.pdf), and APTA's Private Practice Section.
#PTTRANSFORMS: Are services for telehealth being reimbursed differently from those delivered in person?
Gallagher: Our clinic is being paid by insurance at the same rate as for our in-clinic sessions, but it depends on the state legislation regarding payment parity.
Lee: It can be different in some situations where insurance parity is not the law, or if the payers deem that telehealth services will be paid at a lower level. This is where your advocacy, as well as sharing direct patient testimonials from your telehealth services, can be helpful to all stakeholders to educate and deliver high-level care with appropriate payment.
Again, telehealth is just a tool to enhance the patient-provider relationship and engagement, and thus it should be paid at the same level as in-person services. There is evidence of Medicaid telehealth physical therapy services being paid according to CPT codes, when they were deemed medically necessary and there were no in-person services accessible to patients. And, there are private payer examples in Colorado and Minnesota for vestibular physical therapy care, with private practice physical therapists engaging with payers for parity in payment for services.
#PTTRANSFORMS: What licensure or regulatory issues need to be considered?
Gallagher: PTs must know their state practice act to be sure there are no legal restrictions on telehealth, for example, with regard to direct access and scope of practice. The patient must be located in the state in which the PT is licensed during the telehealth session. If your patient vacations in a state in which you are not licensed, you cannot treat them at that time. PTs also need to be aware of any other state telehealth legislation, such as regulations for informed consent language.
Lee: The key is to maintain your license in the state where the patient is located. Currently 18 states issue interstate practice privileges under the Physical Therapy Compact, while eight others have enacted legislation to allow participation. Providers must stay current on licensure compact issues and individual physical therapy practice acts, since some states do have specific telehealth physical therapy language. As of November 2019, 16 state practice acts explicitly state that telerehabilitation is within the physical therapist's scope of practice: Alaska, Connecticut, Delaware, Florida, Georgia, Illinois, Kentucky, Louisiana, Montana, New Mexico, North Dakota, Ohio, Oregon, Tennessee, Washington, and Wyoming. Additionally, two other states, Iowa and Rhode Island, contain open language in their state practice act suggesting that telerehabilitation may be within a physical therapist's scope of practice.
#PTTRANSFORMS: What would you say to skeptics, including PTs, who are concerned about the level of care provided via telehealth?
Gallagher: Competence is key. Telehealth does not have a large body of evidence for clinicians to refer to for best practice; therefore, advanced clinical decision making is a requisite to determine how to best and safely adapt practice via video. In addition, practice to gain competency is important. Telehealth should be used as a means to solving a problem, such as a patient's inability to commute to the clinic, and should not be used simply for the convenience of the PT or because of the novelty of technology. It should be thought of as a mode of delivery of PT services, but delivering the same standards of care.
Lee: If telehealth is low quality and just a simple audio or video chat, this perspective seems true to me as well. Telehealth is not just a quick audio or video chat. The level of care must be similar to or the same as in-office care.
The profession should develop formal competencies for telehealth practitioners, and those discussions are beginning. When we are teaching students, we need to train our students to see differently, to use their eyes and ears as well as their hands. These skills are helpful in the office or in telehealth treatment.
Both patients and providers should be wary of social media telehealth promotion and avoid closed telehealth Facebook groups. These forms of interaction have neither filters nor checks and balances for vulnerable providers and patients seeking best care and education on telehealth. Always check the source for potential bias or for a history of putting out poor or biased information on social media. Always verify the provider's licensure and credentials with FSBPT, including any issues with the physical therapy provider's license.
There are physical therapists doing great work in telehealth; seek them out in person at APTA conferences to learn more about telehealth physical therapy.
Also, the November 2019 issue of PT in Motion featured an article on strategies for use of technology and best ethical and legal practice.
#PTTRANSFORMS: What is the future of telehealth?
Lee: I believe the future of telehealth in physical therapy will depend on rehabilitation providers' advocacy, future research in practice with telehealth for cost savings, high quality of care, and improved access to care. Our profession is not alone; we must collaborate with other telemedicine providers to improve societal needs and address patient preferences in the digital age.
Gallagher: I agree. I also feel there is a short-term need for developing continuing education and training to ensure that we are providing the best standard of care possible. Because the mode of delivery is relatively new and not widespread, telehealth practitioners are mostly self-taught. As more practitioners want to add telehealth to their services, training would help ensure ethical and high-quality care.
Telehealth and other digital practice experts will share their experiences and expertise at CSM 2020 sessions in February, including:
Register today for CSM!