By Julie Appleby, Kaiser Health News When the pandemic sidelined in-office visits at his practice, Dr. Dael Waxman “wasn’t exactly thrilled with being at home.” But he quickly shifted gears to video and telephone appointments. Now, he finds, there are good reasons to keep these options open even as in-office visits have resumed and many parts of the country have sharply loosened coronavirus restrictions. One is that some patients “have to overcome a lot of obstacles to get to me,” said Waxman, a family physician with Atrium Health in Charlotte, North Carolina. “I have lots of single mothers. They have to leave work, get their kids out of school and then take two buses. Why would they want to do that if they don’t have to?” Telehealth served as a lifeline for many during the pandemic, ramping up from a minority share of office visits to a majority, at least for a while. Still, it cannot replace hands-on care for some conditions, and for those not blessed with speedy broadband internet service or smart devices it can be difficult or impossible to use. As things head toward a new normal, lawmakers and insurers, including Medicare, are debating how to proceed, the biggest question being whether to continue reimbursing providers at the same payment rate as for in-person coverage once the covid public health emergency ends. While that debate rages — one side pointing to the costs associated with setting up such services, the other arguing that payment rates should decline because telehealth services are cheaper to provide — patients are left to decide if such visits meet their needs. KHN put such questions to physicians, who gave tips on the types of concerns that are best handled in person, and when video visits are most useful. Not surprisingly, they recommended that patients ask their provider which type of visit is most appropriate for their particular circumstance. Four additional things we learned: 1. Some things just need to be done in person. Chest pains, new shortness of breath, abdominal pain, new or increased swelling in the legs — all those things point to the need for an in-person visit. And, of course, blood tests, vaccinations and imaging scans must be done in person. “If your blood pressure is really high or you have some symptoms of concern like chest pain, one needs to go to the office,” said Dr. Ada Stewart, president of the American Academy of Family Physicians, which posted an online guide for telemedicine visits. If patients are concerned enough about the situation that they are considering going to an urgent care clinic or even an emergency room, “they should be seen,” said Waxman. And that would occur in person. If a condition, even something seemingly simple, hasn’t resolved in a reasonable time, go to the office. Waxman recalled a patient with an eye issue who went to urgent care and received antibiotics, but the eye was still irritated after treatment. “Because it had not resolved, I was worried about shingles of the eye,” he said. It turned out not to be shingles, but a different problem, Waxman learned after referring the patient to an ophthalmologist. In-person visits can also prove more productive because a physician gains visual clues to what might be wrong by watching how a patient walks, sits or speaks. While video visits are wonderful, said Dr. David Anderson, a cardiologist affiliated with Stanford Health Care in Oakland, California, sometimes things come up in person that might not over video. “I can’t say how many times I sit with a patient and I think we’re done — then the thing that’s really the problem gets brought up and we spend the next 45 minutes on it,” he said. Finally, a good reason to go in is, simply, if that’s what you prefer. “I had a patient the other day who said he could have done a phone visit but was old-school and just preferred being in the office,” Waxman said. 2. Sometimes a televisit is better. It’s not always necessary to trek into a medical office or clinic. Stewart, at the family physician group, said check-ins for chronic conditions, such as diabetes or hypertension, “that are basically under control” can easily be handled remotely. Cardiologist Anderson concurred, especially for periodic assessments or checking how a patient is handling a new medication. “If I have a [stable] 82-year-old patient and her daughter needs to miss work and come from 30 miles away to bring Mom in for us to sit there for 15 minutes to chat, that’s something where the efficiency of a video visit is good,” he said. But if that same patient complains that “when they take a morning walk, they are short of breath and they were not before, that person I would want to see face to face.” And, sometimes, video follow-ups for stable patients with chronic illnesses are preferable. “On the phone or by video, I found there to be a lot more non-distracted time for education,” he said. It is helpful if patients can monitor their blood sugar or blood pressure at home and then report their statistics during the televisit. But some patients cannot afford a home blood pressure monitor, so that can be a limitation, Waxman cautioned. And even those who have a monitor should initially take it into the office to make sure it is accurate, he said. Some dermatologic conditions — think rashes and such — can be handled by video, so long as the patient is comfortable using the camera on their smartphone or computer tablet and can get a good picture of the problem area. While 70% to 80% of skin issues can start with a video visit, he estimated, the rest require in-person evaluation, perhaps even a biopsy. 3. Everything works better when both sides prepare. Both patients and providers can get the most out of a video visit if they first take a few simple steps, the experts said. Find a quiet place without distractions. Turn off the TV. Have a family member present if you want a second set of ears, but choose a private setting if you don’t. “ You will not believe the circumstances where people Zoom in to me,” said Anderson. Some are in their cars, “maybe because that’s the best place where they get internet service,” or they’re in their pajamas, just finishing breakfast. “There’s a whole lack of preparation and seriousness that occurs,” he said. Have a list of medications you’re taking and write down the problem or symptoms you wish to discuss, as well as specific questions you have, to make the most out of the time available, advised Stewart. Providers, too, need to take steps. Anderson said they should read patients’ medical records ahead of time and focus because there are fewer cues to a patient’s concerns over video than in person. Physicians “have to be doubly vigilant,” Anderson said, pay attention to all their suspicions and be extra thorough because “it would be much easier to miss something important.” 4. What might happen next? Some advocates say insurers should make sure that their reimbursement policies don’t favor one type of visit over another and that no patient feels pressured into a televisit. During the covid emergency, Congress and the agency that oversees Medicare temporarily made it easier for beneficiaries to use telehealth — for instance, by removing geographic restrictions and allowing audio-only visits in some circumstances. Medicare also began reimbursing providers equally for telehealth and in-person care. Many private insurers followed Medicare’s lead; some also voluntarily waived cost-sharing requirements for telehealth patients. Many expect Medicare Advantage plans to keep covering televisits once the emergency is officially over, and traditional Medicare could follow suit. The Medicare Payment Advisory Commission, a nonpartisan agency that advises Congress, has recommended temporarily continuing to cover some services while the agency gathers data about a wide range of effects, including concerns that telehealth raises spending and the advantages it may offer. That data is important, said Fred Riccardi, president of the Medicare Rights Center. The expansion has helped many Medicare beneficiaries, he added, but “has left some communities behind,” including the oldest adults, those with disabilities and those in areas with spotty internet service. And future policies should ensure that patients who prefer in-person visits can continue them, he said. Anderson, the cardiologist, agreed that televisits “have a wonderful place” in the range of options, but he warned against cost-saving measures by insurers that might require patients to have a video visit before being granted coverage for an office visit. “I would see that as an unfortunate delay in care,” he said.