The neurologist will you see now, virtually

NYU Langone’s neurology practice got lucky as the pandemic shut down in-person visits in March 2020. The department was already planning on rolling out telehealth visits for patients slowly that year, expanding upon a pilot program that targeted urgent care patients.

Dr. Neil Busis, a neurologist associate chair of technology and innovation of academic medical center’s neurology department, said all they had to do was use the same platform that merged the patient portal, the patient’s chart and a video visit for their neurology patients.

“The IT part was already set up and that’s why we could go fully virtual, literally with a flip of a switch,” Busis said, who is also the chair of the American Academy of Neurology Telehealth subcommittee. “The exam [in neurology] is not all that different when a doctor does it from when you instruct the patient to do it themselves, as long as they’re able to think and see and hear.”

NYU Langone, along with countless health systems, moved fast to allow patients to stay home and maintain care. A portion of visits have stayed virtual even with providers moving to in-person appointments again, according to a new report from Vizient.

The healthcare performance improvement company analyzed over 26 million visits between April 2020 and January 2021, which came from 96,500 providers and 18,000 locations. In January, 40% of neurology visits were still conducted using telehealth, second only to behavioral health, which had 68% of visits over telehealth that month.

Vizient group senior vice president of advanced analytics and product management David Levine said they were surprised by the finding.

“Neurology is sort of an interesting as a hybrid; you wouldn’t expect the amount of visits to be as high because there’s an element of neurology that is dependent on the physical exam,” Levine said. “But in other cases, chronic neurological conditions like migraine headaches or control of seizure disorders, where it’s more checking in and adjusting patient’s medication and less dependent on the physical exam at every visit, are very amenable to telehealth.”

Busis believes that neurology was and still remains ripe for virtual care because of the foundation of evidence that was already built around telestroke care. A little over ten years ago, the National Institutes of Health stroke scale was shown to produce robust and accurate results, just as accurate as if a person had a stroke exam in person.

NYU Langone, along with the Mayo Clinic and the University of Rochester, quickly came out with models for how to conduct neurological exams over telehealth. It turned out that 91% of the standard exam can be done just as well over telehealth, according to NYU Langone’s model.

Dr. Ray Dorsey, director of University of Rochester Medical Center’s Center for Health Technology , said there are a lot of chronic conditions — like Parkinson’s disease, Alzheimer’s, multiple sclerosis and ALS — that are well-monitored and treated following initial diagnosis.

“Because neurologists care for a lot of people with chronic conditions — as opposed to an orthopedist, who sees someone with a sprained ankle or a broken wrist — the ability, especially once relationships been established, to provide ongoing care is very attractive,” Dorsey said.

Neurologists can have patients hold out their hands, stand up, walk around and observe their movements to gauge disease progress. And if they can’t tell what’s going on, they will see the patient in-person.

Neurological disorders also are ripe for telehealth visits because many are associated with impaired mobility, ability to drive and cognition.

“The least-friendly environment is one that you have to drive into an urban center that requires considerable mobility and cognitive ability to navigate,” Dorsey said. “So, I think patients have found in the setting of COVID-19 that this is a great way of receiving care; patient satisfaction in almost always high in telemedicine studies.”

The University of Rochester Medical Center has done telehealth for neurology patients for a long time, but historically relied on study grants to fund visits. With Medicare opening up restrictions due to the pandemic, now providers can bill CMS, and other insurers have taken Medicare’s lead.

But it will take an act of Congress to keep this expansion — Medicare said it doesn’t have statutory authority to do so. CMS traditionally restricts telehealth to patients living in health professional shortage areas. Patients had to go to a local doctor’s office or clinic rather than conduct the visit from home. Numerous bills have been introduced this legislative session.

However, Busis said CMS can relax restrictions on four other parts of telemedicine, including phone visits, remote monitoring, digital evaluation and physician consultations.

“This is great, and streamlines things tremendously,” he said.

Organizations like the American Medical Association are developing reimbursement rates for virtual video visits, Busis said. For a standard neurology visit, a clinician is paid about $100, and the health system facility is also paid $100. Medicare has kept that payment during the pandemic.

“Maybe you don’t pay the rent and the heat on a bunch of exam rooms, but you have to pay for an IT infrastructure, appointments, equipment, the electronic medical record, the answering service and the staff and having people on call,” Busis said. “It’s a different kind of facility fee.”

Greg Esper, the associate chief medical officer at Emory Healthcare and a neurologist who leads Emory’s telehealth initiatives, said it’s important to remember that telehealth is a tool, and it’s not clear what percentage of neurology visits ideally would be done virtually.

“It should be used appropriately to improve quality, improve access, and lower the cost of care for the patients,” Esper said. “If this happens, there will probably be minimal barriers to appropriate reimbursement.”

Dorsey at the University of Rochester Medical Center said he thinks new entrants will drive adoption of telehealth because hospitals will want to hang on to the revenue from facility fees.

“Hospitals will still want to see patients in-person because they love that facility fee, they’re like addicted to it: to pay a receptionist $30,000 a year and get $100 check every time someone steps in the door, that’s too good to be true,” Dorsey said.

And insurers like Cigna have entered the game with their recent acquisition of virtual care provider MD Live.

“You can imagine that they might do this as a lower cost basis, because insurers don’t like paying facility fees,” Dorsey said.

Vizient found that only 0.3% of ambulatory visits overall were via telehealth prior to March 2020. By the next month, 65% of visits were done over telehealth, but that has since shaken out to about 22% overall in January.

Ahead of neurology, behavioral health remains the highest utilizer of the delivery method in Jan. 2021, followed by adult primary care (24%), cardiology (17%), oncology (17%) and surgery (15%). Large health systems with over 1,000 providers had slightly higher rates of telehealth use, and patients with commercial and Medicare insurance had similar rates of usage, at 25% and 22%, respectively.


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