Who You Gonna Call? COVID-19 and the Future of Telemedicine

Like many privileged Manhattan residents, my family was lucky to escape from New York City as the number of cases of COVID-19 was on its steepest rise.  It helped that we had to vacate our apartment by the end of March anyway. So, we stored our belongings in a warehouse in New Jersey en route to Union Dale, Pennsylvania. Susquehanna County—about 40 miles north of Joe Biden’s hometown, Scranton—was bespeckled with signs telling New Yorkers to go home. Local residents were understandably worried that people like us would spread the virus from its US epicenter. In fact, Trump had been talking about cordoning off the greater New York metro area. We felt relieved to have gotten out “in time,” but I nonetheless was nervous driving my family in the rental van with New York license plates.

So much for the best laid plans: Almost three weeks after our arrival, I fell ill.  During the first night of pain and vomiting, I figured that I had eaten some contaminated lettuce. But when my aches and pains didn’t abate after another couple of days, I worried that I might have become infected with the novel coronavirus. I called my primary care physician in New York, and discovered that he had died. (I never found out whether it was from COVID-19.) So there I was, a good 40 minutes from the nearest health care. Here was my crash-course introduction to telemedicine.

I am fortunate enough to know a lot of medical doctors. I texted a friend who is a urologist. He told me to immediately isolate myself from the rest of my family. I had figured that if I had food poisoning, it wasn’t contagious, but if I had COVID-19, it would be futile to prevent infecting the rest of the household. At the moment I received his text, I was sharing a glass of water with my one-year-old. But my friend quoted a study from Wuhan suggesting that within-household transmission rates were only 15-20%.

On his orders, I put on a mask and spent the next month in a room alone with a fever that hovered between 102 and 105 degrees, depending on time of day and when I had last taken Tylenol. At that time, in Pennsylvania, there was no testing available for people under 65 who were not front-line medical workers. Luckily, I had brought an oximeter with me. Based on when I experienced chills, I got good at predicting when my blood oxygen saturation was dropping into the 80s.

It turned out that I was again lucky in my medical social capital: Another doctor friend was conducting a longitudinal study on Covid-19, so he enrolled me and sent a collection kit for a mail-box test, which came back positive for me, but negative for the rest of my family—much to our surprise. After two weeks, my fever rose close to 105 and my oxygen was consistently in the low 90s. “I don’t give a [expletive] about your fever,” my urologist friend told me, “All I care about is your oxygen.” He told me it was time to go to the emergency room.

At the local county hospital, the nurse took my name and my vital signs. She asked: “In the last month have you been out of the country, or come into direct contact with someone who has been abroad?” I answered no. Then she asked whether I had been in New York during the past 30 days. Luckily, by then it had been more than a month since I had fled, so I was relieved to answer “no” to the question of being a carpetbagger vector.^[1] I was then given Tylenol, an x-ray (which confirmed pneumonia in my right lung), and another swab test. The attending physician told me that they don’t admit patients unless one’s oxygen saturation was below 85%, so he instructed me to call my wife to pick me up.

That night my fever eased, but my oxygen did not recover. I started antibiotics prophylactically, and I saw a tele-doctor through a service provided by my employer—another privilege of my social position. But after another week, I still had sharp chest pain and low oxygen. During my follow-up appointment with the same tele-doctor, she told me to leave and go back to New York, where I would indeed receive treatment for an oxygen level in the low 90s. Meanwhile, my researcher friend offered to get me enrolled in a trial for remdesivir in New York. I demurred both entreaties since it was not logistically feasible for us to return to the city. After another two weeks, the feeling of broken ribs that accompanied my low oxygen slowly ebbed, day-by-day.

Though it has been around since 1905, telemedicine historically was  championed primarily as a solution for underserved urban and, especially, rural communities. It would seem, though, with broadband and mobile coverage reaching saturation^[2] and 5G mobile technology imminent, the only thing holding back telemedicine was the culture of doctors, insurance companies, and regulators. The exigencies of the novel coronavirus pandemic seems to have finally provided the tipping point nudge for system-wide transformational change.

Indeed, in addition to being talked through my COVID-19 bout in the last month, I had my prescriptions refilled by my allergist via email, my son was diagnosed with Lyme disease via Zoom (confirmed by a blood test), and my daughter had a skin condition treated remotely, as well. The ability to interact with specialists from far away is exactly what visionaries had imagined when advocating for the expansion of telehealth services.

During the pandemic, federal regulators relaxed reimbursement regulations for Medicare and Medicaid and interpreted HIPAA privacy regulations to allow for synchronous and asynchronous communication of sensitive data over electronic communications media that are not “public facing” (i.e., Facebook is not allowed). States, too, allowed interactions that they previously deemed ineligible. But, as with many policies in our federalist system, there is incredible variation across the United States.

In most states, text message exchanges of the sort the urologist and I had would not be reimbursable. But, in Pennsylvania, it turns out that even my teleconference with a doctor in New York would not be legitimately billable had it not been for a temporary suspension of in-state licensure requirements.^[3] Had I lived in Texas, though, I could consult any doctor in the nation, regardless of their licensure status in Texas. It seems time, then, to systematically think about what kind of telemedicine landscape we want as a country.

One vision would allow patients to function as free agents in a national—if not global—marketplace for telehealth. For example, a patient might speak with a urologist in another country, a dermatologist in their own county, and a cardiologist in a different state. While this would improve access to specialist care more than a system that allowed restrictions for providers to be licensed in the patient’s state, it might also lead to the emergence of new health disparities on the patient side and winner-take-all markets on the health provider side.

I leveraged a large stock of social and cultural capital in arranging for my care, including seeking advice from close friends.  Indeed, a study in Sweden found that when there was a doctor in the family, the health behaviors, health, and life expectancy of family members all improved. Estimations based on timing of medical education and medical school admissions lotteries suggest that these are “real” causal effects and may explain 18% of the income and health gradient. Must we be prepared to accept—as in the case of most domains where digital technology rears its head—that certain people will be better positioned to take advantage of the wider range of choices that the collapsing of geography provides along with the greater health inequalities that will result? Perhaps the solution is a geographic quota system for appointments—where geography also proxies economic status. If such a system were enacted, then telemedicine might indeed solve a lot of access problems for people who, for example, have mobility issues or face scheduling constraints due to inflexible employers. That is, doctors may provide more access during non-business hours when they can do it from the comfort of their own homes.

On the supply side, will a totally scale-free approach to care provision result in a winner-take-all market for doctors, where certain star specialists are booked months in advance? Already, many specialties suffer from a star system, and collapsing space to allow unlimited access to the so-called “best” doctors might accelerate this trend. Of course, unlike recording artists, where the product can be duplicated ad infinitum for almost zero marginal cost, to the extent that doctors see patients in real time, even if remotely, they are more like barbers than rock stars: There is an inherent limit to the hours in their days; they are not infinitely duplicable. Moreover, the biggest inequalities emerge for medical services—like cosmetic dermatology, for instance—where the services are billable outside the constraints of insurance reimbursement frameworks.

We are experiencing a moment to rethink the delivery of medicine. Many doctors and other medical providers have now become accustomed to a new mode of service delivery, red tape has been trimmed, and patients themselves have long desired greater flexibility in the ways they interact with their providers. Let’s make sure that, when the pandemic recedes and these temporary orders expire, the right system remains in place to expand access and reduce disparities rather than one that exacerbates already steep gradients in health care and health. The goal should be to provide all US residents with as good telehealth care as I was able to receive on account of my social capital.

Notes

^[1] In fact, it remains a mystery as to how I contracted COVID-19.  Either I did indeed get infected in New York City where my neighbors came down with it a couple days after we left, in which case, I would have come close to setting a record for incubation time.  Or, I got it during our weekly trip to the supermarket, where I wore gloves and a mask—which seems almost equally improbable.

^[2] In 2020, over 80 percent of US residents use a smartphone (https://www.statista.com/statistics/201184/percentage-of-mobile-phone-users-who-use-a-smartphone-in-the-us/).  Meanwhile, 90 percent of the population uses the internet (https://www.statista.com/statistics/185700/percentage-of-adult-internet-users-in-the-united-states-since-2000/).

^[3] As of June 26, only one state and the District of Columbia had not waived some in-state licensure requirements; see https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf.

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