As America and the rest of the world grapples with the escalating global coronavirus pandemic of 2020, healthcare providers are transitioning to remote patient care — often on the fly.
While hospitals are adopting emergency action plans, new federal rules have been enacted to allow providers to use telehealth tools for routine appointments without the burden of traditional barriers, such as reimbursement and privacy restrictions.
Meanwhile, big health insurance organizations have begun relaxing rules on early prescription refills and prior authorization requirements to allow patients to preorder and store medications and supplies. Pharmacists nationwide have urged this expanded access.
“We are all in this crisis together, and we need to bend some of the rules that we wouldn’t have before,” says Dr. Robert Gabbay, chief medical officer and senior vice president of the Joslin Diabetes Center in Boston. “If there is any silver lining here, it’s that this has all really focused us on delivering and paying for care differently. Hopefully, some of this will go on past the current crisis and continue as the way to practice healthcare.”
On March 17, the Department of Health and Human Services (HHS) issued new rules allowing telehealth services to be offered more broadly than ever before — both related to COVID-19 testing and general healthcare. Part of that order involves loosening the HIPAA restrictions calling for stringent privacy protection. The federal agency notes it won’t be fully enforcing those requirements as long as providers are operating in good faith.
The new rules allow doctors to be reimbursed for telehealth and remote patient visits at the same Medicare rate as they would for in-person visits, a long-standing issue that has prevented many in the healthcare field and diabetes space from using remote care more widely.
The Centers for Medicare and Medicaid Services (CMS) confirms that reimbursement rates will be the same for telehealth and in-person office visits, but that virtual check-ins will be billed as shorter visits, so the rates will be lower.
“We are empowering medical providers to serve patients wherever they are during this national public health emergency. We are especially concerned about reaching those most at risk, including older persons and persons with disabilities,” the HHS Office for Civil Rights (OCR) said in a published statement.
Under the new provision, providers can now use remote audio or video communication products to provide telehealth care during this public health emergency. They can legally treat and assess all medical conditions — ranging from sprained ankles to dental consultations, to chronic conditions like diabetes.
They’re allowed to use any popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts, Skype, and Zoom. Some are using more privacy-protected services and platforms already in place, such as Zoom for Healthcare.
“Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications,” HHS OCR explained.
The COVID-19 “shelter in place” regulations keeping people at home are also set to be a boon for companies already offering diabetes-specific health coaching and virtual care — Glooko, OneDrop, Livongo Health, and Steady Health.
In a goodwill move, on March 19 Glooko announced that it will offer its remote patient monitoring platform for free to both patients and clinics.
Similarly, Steady Health announced an offer of an initial three months’ service for free to new members, for what is usually a $50 monthly subscription fee. The company notes that it is now “in network” with several health plans across California, including Aetna, Cigna, Anthem, Blue Cross Blue Shield, and HealthNet.
At OneDrop, founder and fellow type 1 Jeff Dachis says they’ve seen an uptick in demand for everything they’re offering with the OneDrop platform: meters and test strips, mobile app downloads, virtual coaching messages, and the company’s multi-condition wellness and care program for employers.
“Our app-based solution and delivery of testing supplies ensure that the needs of our users are met without requiring them to leave the security of their homes,” Dachis says. He highlights the community aspect of the OneDrop app, as staying connected during times of isolation via remote working and social distancing is important to mental health.
Livongo spokesperson Jake Mazanke echos those benefits talking about their product platform, adding that Livongo’s telecoaching app now also includes COVID-19-specific information that is vetted by the American Diabetes Association. Customers can also get free, unlimited glucose testing supplies shipped directly to their doorsteps, a service that’s in high demand in this time of public health emergency.
As Wired magazine stated in a recent telling headline: “Telemedicine Is a Safety Valve for a Strained Health Care System.”
“Particularly when it comes to type 1 diabetes care, there is little we can’t accomplish remotely,” says Gary Scheiner, a diabetes care and education specialist who runs a practice called Integrated Diabetes Services in the Philadelphia area. “Even without a pandemic forcing our hand, our clients prefer the remote/virtual appointments because it saves time and money and reduces potential health risks.”
When government and private health officials began pointing out that people with diabetes should have adequate medication and supplies on hand, up to 90 days’ worth, patients started to become… concerned. How will they possibly access these items?
Insurers aren’t turning a blind eye, fortunately. Many are putting measures into place to ease prescription refills.
Aetna, Humana, and Blue Cross Blue Shield plans are among those allowing early refills on medications before the typical 30-day requirement. We’re also hearing that big pharmacies like CVS and Walgreens are waiving home delivery charges on prescription items.
Most commercial insurers have agreed to waive COVID-19-related diagnostic lab test charges and even restrictive prior authorization requirements. But it’s still uncertain whether those relaxed rules on lab tests will extend beyond the current virus.
Here’s what we know about the measures big insurers have put in place so far:
Cigna (which owns Express Scripts) adopted measures that recommend patients who currently receive a 30-day supply should switch to a 90-day supply. They’re also offering free home delivery of up to 90-day supplies for prescription “maintenance” medications (ongoing prescriptions) available through the Express Scripts mail-order pharmacy, along with 24/7 phone access to pharmacists there.
CVS Health Corp and Aetna are also encouraging patients who typically pick up a 30-day prescription to consider changing that to 90 days. They are also allowing for earlier refills on medications such as insulin. This will help ensure people have what they need during shelter in place or full quarantine orders.
Blue Cross Blue Shield (BCBS) announced in a news release that they will waive early medication refill limits on 30-day prescription maintenance medications (consistent with a member’s benefit plan) and/or encourage members to use their 90-day mail order benefit. They’re also expanding access to telehealth and nurse/provider hotlines.
UnitedHealthcare (UHC) is following roughly the same steps on prescription access, per this announcement. They’re expanding telehealth policies for all members, but especially for those at highest risk of COVID-19 infection.
Their new interactive platform “provides up-to-date information about prevention, coverage, care and allows members to schedule an in person or a telehealth visit with their provider, talk to a nurse, refill or schedule home delivery for prescriptions, and to access emotional support 24 hours a day.” They’re also adding a symptom checker that can help members quickly surmise their own health status.
Most notably, UHC has established a “navigation support program” that will provide members with a dedicated customer service professional to guide them through the isolation process and help coordinate access to medications, supplies, food, and appropriate care.
Members can access all of this by calling the customer care number located on the back of their ID card and indicating that their provider has prescribed self-isolation.
Beyond these insurance-specific measures, there are some other resources available for people with diabetes to access medications and supplies in times of need.
Stories being shared across social media shed light on the realities of our “new normal.”
Longtime type 1 Russ Smith in Austin, Texas, shared that he had his first endocrinologist appointment since the COVID-19 pandemic began, at a multi-office clinic in that town. He drove to the clinic, but wasn’t allowed inside.
“The clinic doors were locked, but I was able to pass my pump through the door so it could be downloaded,” Smith told DiabetesMine. “I sat in my car for a phone conference with my doctor afterward, as we discussed the data and she walked me through making a small change to a basal rate. I guess this is the new reality.”
D-Mom Maria Cangemi-Graziano in Palo Alto, California, says her endo also switched her teenage daughter’s routine appointment at the Lucille Packard Children’s Hospital to a telecom visit. They were given two options: “reschedule after this craziness is over” or go online. They chose the latter.
“Most of our counties (in the Bay Area) have “shelter in place orders” aimed at limiting person-to-person contact, so that is what we chose to do,” she said.
Another D-Mom in Iowa, Charity Serna, offered her insight from the healthcare professional perspective, as she works in a clinic connected to a hospital.
“I spent the day canceling all non-emergency appointments for the next two weeks,” she shared online on March 18. “The idea is to minimize exposure for people who aren’t sick (routine visits) and we are becoming an overflow ‘non-sick’ walk-in, as the hospital is overwhelmed right now with people. Our docs are making exceptions for refills, etc. at this time and will go ahead and call them in. They are also attempting to contact many of the patients via phone, and address concerns that way if at all possible.”
At Stanford Diabetes Research Center in Palo Alto, director Dr. David Maahs tells us they’re ramping up their remote care options to connect providers in the clinic to the patient/family in their home. Other clinics around the Bay Area say they’re working to put those procedures in place this week as well.
In Boston, the renowned Joslin Diabetes Center is also scrambling to establish best practices for providing remote care. For now, their remote policy includes:
- Patients should not come into Joslin unless confirmed by their provider as an emergency.
- Providers are still available for prescriptions and prior authorizations, to ensure patient access to medications and supplies.
- Patients may receive a phone call or text message “canceling” appointments, which refer to in-person visits. If a patient confirmed a remote visit, please assume that is not canceled.
- Patients are urged to call Joslin with urgent matters during the day whenever possible and the on-call provider overnight and on weekends.
One of the biggest challenges, according to Joslin’s Dr. Gabbay, is getting access to the data generated by diabetes devices like insulin pumps, glucose meters, and CGMs. They are encouraging patients to download data remotely, and use whatever means possible to share the data electronically.
“This is an area we’ve all been following closely and have been shifting towards remote care, but there’s nothing like a crisis to focus everyone’s attention and accelerate the process of systematic change,” Gabbay says. “The barriers of the past have been about payment and access, and those are being removed… which is a start. All of this is evolving quickly and our mantra is one day at a time.”
They are using their Joslin website as an information hub for patients, especially since situations are changing so rapidly.
The non-profit data accessibility organization Tidepool is also helping clinicians use their data platform with a telemedicine in mind, creating the diabetestelemedicine.org site with resources and tip-sheets for clinicians and patients. Some of this include downloadable PDFs on using patient portals and downloading data before a virtual appointment, and also billing code specifics for clinicians to use in getting reimbursed for these patient services.
This is quite handy, especially with more than a dozen different diabetes devices able to be connected to Tidepool’s platform, allowing patients and clinicians to see all of that information in one place from various glucose meters, CGMs, and insulin pumps.
Personally, I had an appointment in mid-March scheduled locally in Metro Detroit with Dr. George Grunberger, an internationally known endo here who started the Grunberger Diabetes Institute nearly two decades ago. I opted to cancel my in-person visit the week before, as the COVID-19 pandemic was escalating. Within a few days, Dr. Grunberger’s office informed patients that all in-person appointments would be rescheduled or transitioned to telehealth, at least through March 31. We were instructed to use a web portal to schedule a remote visit using Zoom for Healthcare. Getting this set up quickly was apparently quite the challenge.
“None of us slept much last night, but we did manage to launch this morning,” Grunberger told DiabetesMine on March 18. “Not an easy or simple undertaking, and the service providers were totally overwhelmed as other offices flooded them with their issues at the same time.”
I will also be determining whether to keep a first consultation visit with a retinologist in late March, due to two microaneurysms from diabetic retinopathy in my left eye, possibly needing injection treatments. I am unsure whether that’s considered an “emergency” or not, as long as I’m not about to go blind.
Welcome to the new normal, Diabetes Friends, at least for the short term.