Telemedicine: A New Way of Health Care Delivery in Alabama

Alabama has been a leader in a national health care trend driven by the ongoing virus crisis, thanks to quick action by Blue Cross and Blue Shield of Alabama.

Dr. Eric Wallace, UAB Medicine medical director of telemedicine

Among those predicting things will never again be normal after the virus crisis, one of their expectations is a permanent change to telemedicine — doctor visits by telephone and other remote technology.

Alabama has been a leader in this trend from as early as March, thanks to quick action by Blue Cross and Blue Shield of Alabama, which covered the costs of this type of practice.

And many Alabama health customers might welcome a permanent change in this direction, whatever their beliefs about a new normal. They welcome it for convenience, not necessity.

Rather than taking off from work and sitting in a doctor’s waiting room, patients can consult with their doctor over cell phones, get what they need and be fully covered by their insurance.

On March 12, BCBSA announced its decision to cover in full and without co-payments all telephonic consultations by its network of more than 10,000 physicians. And it has gone without a hitch. Doctors are compensated at the same rate as they are for conventional office visits.

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“It was very easy for us to do. We told every one of our physicians in the state — 10,000 including behavioral health providers — that we were opening it up and they can do it now,” says Dr. Darrell Weaver, BCBSA vice president of Healthcare Networks Services.

Dr. Darrell Weaver, BCBSA vice president of Healthcare Networks Services

“It was something that could be done very quickly, telephonic care, and we said,  ‘You can do it to certain levels of care. There are levels of care from 1 to 5 established by the AMA, and when we started, we said we would cap it at level 3 and see how it went. Since then we have included up through level 4,” says Weaver.

Prior to the virus crisis, BCBSA was averaging approximately 2,000 telehealth claims a week. By mid-March, that rose to 14,000 claims per week. For April, there were about 70,000 claims a week; then, through May, there was a decline to steady number of 15,000 to 20,000 claims weekly in late June.

“We’ve been rolling out other specializations that have been covered, such as physical therapy and occupational therapy. These did require a video component, but an iPhone can work.”

Nor has the paperwork been a problem, says Weaver. No need for special software of medical practice management systems.

“It didn’t require specialized equipment or fancy billing. Billing is done the same as you do in the place of service, whether an emergency room or a doctor’s office.”

Of course, patients may need to have blood pressure monitors and other home medical equipment to provide information to their doctors.

Doctors were more than happy with the change, especially under the circumstances, says Weaver.

“People were staying away from doctor’s offices, as they should. And this was a way for providers to put money back into their pockets,” says Weaver.

To make sure that there were no hitches because of doctors having to check co-payment requirements, BCBSA dispensed with copayments during the changeover.

“We didn’t want to throw copayments into it when physicians might be working from home with no way to check,” Weaver says.

BCBS has continued with its telephonic coverage through August and updates its policy after monthly reviews.

As of press time, BCBS continued its telephonic coverage through July 31, with plans to review the policy monthly.

UAB a Leader in Telemedicine

The swift adaptation of the Alabama health care system to telemedicine during the virus crisis has been “nothing short of a miracle,” says Dr. Eric Wallace, UAB medical director of telemedicine. “We have seen a massive growth that has decentralized the health care system in a six-week period,” he said in late April.

Most recently, UAB, on July 8, was awarded a $1 million grant from the Federal Communications Commission to further facilitate the massive telehealth initiatives, including the purchase of iPads, webcams and remote patient monitoring devices.

The UAB Medical Center used to conduct only three visits by telemedicine out of a total of 5,700, says Wallace, and “UAB is now doing 59 percent of its ambulatory care this way. We are up to about 1,300 video visits a day and about 1,200 phone visits.

The number of video visits continues to increase, as providers have started to get to know the software better and the process continues to be refined.”

The virus and home sheltering drove the change, but it also required changes in attitude, mostly on the part of doctors, as well as the changes in insurance coverage.

Less of a hurdle was any reluctance on the part of patients. Rather, doctors had to change from thinking, “You as a patient need to come in to see me to personally reassure you,” says Wallace. Many doctors would rather see their patients, but all else being equal, “that decision should be patient-driven and not physician-driven,” says Wallace. “Giving patients the choice: That’s where the system needs to go.”

Wallace says UAB has measured patient satisfaction with their telemedicine experience at 90 percent.

More Problematic Specializations

Of course, telemedicine is not ideal for all doctor consultations. But even in one of the more problematic specializations for remote visits, obstetrics, the benefits were welcomed during the period before May 4, when the state of Alabama again opened doctor offices to nonemergency practice.

“Obviously, the situation in the world has mandated changes in the way we practice medicine. Some will continue in the future and some not,” said Birmingham OBYGN Dr. David McKee, shortly following the reopening of his practice, which includes seven other obstetricians.

“A lot of routine visits we have been able to do on telehealth — getting blood pressure, weight, heart rate documented. They are able to buy a home blood pressure cuff, a home Doppler device, and everybody has a scale at home. Then, if they need a vaccine or a glucose tolerance test or have bleeding and pain, you see them in person.”

A variety of electronic devices have been developed for remote monitoring of heart rate, though the degree of sanction by medical authorities varies. Monitoring of fetal heat rate, notes McKee, is one of the procedures that require a conventional visit to the doctor’s office — a quick visit arranged to reduce risk infection by contagion.

McKee says he always prefers to see patients in person but expects to concede to patient preferences in cases of minor issues that can be handled over a telephone. “From their standpoint, it’s ideal. They don’t have to travel or wait on us in the office, wait in line to make payments. From the patient standpoint, it’s pretty ideal.”

But sometimes the preference is not one of convenience, he notes.

“I’ve had elderly patients who absolutely don’t want to come into the office. Last week I had one who I had to talk with twice over the phone to insist she come in to the office at the hospital, and she literally cried, she was so afraid of a risk of infection. Most of my time on the phone was alleviating her concern about becoming sick.”

But will he continue to accede to those other patients who prefer the convenience of telemedicine?

“We’ll probably do that, if they want to be treated over the phone,” he says. “We’ll certainly make that offer.”

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