Last week, CMS announced that PTs—along with OTs and SLPs—are eligible to provide telehealth services to Medicare beneficiaries for the duration of this emergency, which is huge. Rehab therapists have been advocating hard for this move since well before the pandemic struck, and now that this change is on the books, there’s the possibility that it could stay there well after the threat of COVID-19 is behind us. That means rehab therapists may be able to expand their reach to serve more patients in the long term, while also increasing revenue streams to potentially offset the dramatic losses incurred over the past few months.
But, is telehealth truly the golden goose that the industry has been waiting for? While it has its benefits, it also comes with some pretty serious challenges—something every practice leader should consider before adopting a telehealth model. Here’s what Guy Welch, PT, of Welch Physical Therapy (in business for 24 years) had to share about the biggest telehealth challenges his clinic has faced:
1. Regulatory changes are simultaneously happening too fast—and not fast enough.
One of the biggest telehealth implementation challenges Welch pointed out was that this option was “thrust upon” providers so quickly that “no one [was] prepared.” And he said providers weren’t the only ones caught off guard; when the APTA first began suggesting that PTs adopt telehealth as a supplemental service, some states (Arizona, for example) still had bylaws on the books that prevented therapy providers from legally doing so. Weeks later, once those bylaws were finally modified, it still wasn’t clear which payers were willing to actually pay for the services—and even those that were reimbursing for telehealth weren’t able to provide clear guidance on how to perform or properly bill for remote care services. Information on copays and deductibles was also nearly impossible to track down. As a result, everyone was more or less flying blind. And even now, weeks later, that lack of clarity still persists for some providers.
According to Welch, how providers handled this confusion was mixed: while some of his peers threw caution to wind and began offering these services to patients without fully understanding the rules of the game, others (including Welch) spent an inordinate amount of time reading industry publications, checking regulatory updates, questioning their professional organizations and networks, and listening to webinars to gain whatever clarity they could on how to move forward—all the while losing valuable time and money.
And even news that sounded great at first turned out to be fraught with limitations. For example, Arizona Governor Doug Ducey signed an “executive order that required insurance companies in the state…to cover telehealth at the same reimbursement rates as onsite visits,” which felt like a huge win. However, it soon became clear that most insurance companies are federally (as opposed to state-) regulated, which means they don’t fall “under the jurisdiction of [the] AZ state government” and thus “were not bound by the order” or even “on the same page,” Welch said.
2. The financial benefits aren’t yet known.
According to Welch, the financial benefits of offering telehealth were (and largely still are) unknown, and the time and effort required to research, develop, and implement these services didn’t make up for the cost. In essence, he and his team were trying to establish a brand-new service offering without the tools, knowledge, instruction, or permissions necessary to do so effectively.
As Welch put it, “time is a valuable commodity,” and the cost of investing so much time into something that didn’t have a clear payout seemed “astronomical,” especially in an environment where he was “trying to hold onto every dime [he] had.” According to Welch, it felt like “trying to fill up a jug of water that had holes in it.” Everytime he set out with a plan, the rules changed and he had to start again.
With reimbursement data still lacking, it’s difficult for practice owners to perform an accurate return on investment (ROI) analysis for telehealth services—which may deter them from taking the telehealth plunge. Furthermore, we don’t yet know the extent to which temporary telehealth provisions—like those that have expanded opportunities for rehab therapists to deliver telehealth services—will evolve into permanent statute. That makes investing in telehealth even more of a risk for therapy providers (and, as we’ll discuss in upcoming WebPT Blog posts, gives PTs, OTs, and SLPs even more reason to continue advocating for themselves and their patients).
3. The telehealth technology available isn’t ideal—and patients aren’t always comfortable using it.
On top of all the other learning curves that go along with implementing telehealth in the midst of the current pandemic, there’s also the issue of technology. Even in non-crisis times, adopting, implementing, and training staff and patients on a new tool is challenging; in the current climate, it can be downright taxing. In Welch’s case, he wasn’t comfortable taking on the expense of a videoconferencing platform designed for telehealth without knowing that he would be able to recoup that cost. So, per the Office for Civil Rights (OCR) relaxation on guidelines for suitable tools, the team began using a popular online meeting software to conduct telehealth appointments. While that platform did the job, it had its flaws. Many patients had trouble logging in and staying connected. The team created patient instruction documents to email patients prior to their scheduled appointments, but even that wasn’t enough. Often, the team had to call patients on the phone to walk them through connecting to the platform on their computer, thus costing them even more time (and patience).
4. PT patients want—and expect—hands-on treatment.
Many patients seek out physical therapy because they want to receive hands-on treatment modalities. In line with that expectation, the team at Welch Physical Therapy have branded themselves on the exceptional hands-on modalities they provide—things like “dry needling, scraping, cupping, muscle energy techniques, spinal adjustments, and a ton of other manual treatments.”
According to Welch, patients come to the clinic because they can obtain these services. In fact, the team makes a focused effort to train their patients on the benefits of these services and the importance of showing up to appointments consistently in order to experience the maximum benefit of physical therapy treatment. That was all in line with prior regulatory and practice guidelines supporting the importance of in-person physical therapy, Welch explained. “It was impossible to un-train them,” he added—especially in the span of only a couple months. Despite encouraging patients to schedule telehealth visits, most opted to either brave it in-clinic or wait it out until they felt it was safe to return.
Welch’s Solution: A Combination Method
So, how has Welch responded to these challenges? His team focused their telehealth efforts on cash-pay patients and those involved in motor vehicle accidents working under an attorney lien (with advanced attorney approval). That way, his team knew for sure they would receive some form of reimbursement for their efforts. While Welch’s cash-pay patients weren’t willing to try telehealth, five of the clinic’s motor vehicle patients were.
In order to facilitate the sessions, the team shipped patients physical therapy equipment, such as foam rollers, TENS units, and therapy bands. Given that even Amazon was operating on a significant shipping delay, this step proved difficult, and several patients didn’t receive their equipment prior to their appointments. That said, according to Welch, the appointments went well. “We have provided exercises, reviewed proper technique, [and] instructed them in the use of TENS units and home exercise equipment,” he said. “We feel that the patients are receiving benefits.” He noted, though, that they’re “having difficulty progressing patients in the telehealth environment. Physical therapy without manual treatment/touch is a difficult thing. Our hands are our tools. When we are not able to use them, patients seem to see a diminished value in our profession.” To help offset this, even telehealth patients are encouraged to have occasional in-person sessions.
Beyond that, the team at Welch doubled down on in-clinic practices to support those patients who still wanted to come in. Instead of having their front-office staff share the benefits of telehealth—which wasn’t proving very fruitful—the team switched over to communicating their safety best practices and hypervigilant cleanliness: “We have [patients] enter the office, take their temperature, usher them to a private room, assess them, and treat them,” Welch shared.
While the situation is far from ideal, Welch and his team are doing the best they can, acknowledging the unique reality in which they’re currently operating. According to Welch, their referring providers were seeing fewer patients, not performing surgeries, and trying to navigate changes themselves: “The last thing they were concerned about was referring patients to physical therapy,” he said. “New patients were almost nonexistent. Patients were afraid that social distancing in our facility was not possible. Masks were impossible to procure. Everyone was in a heightened sense of awareness.”
Frankly, everyone was scared—and so were Welch and his team. They lost 40-50% of scheduled visits in two weeks. “We were decreasing our employees’ work time by 40-50% to stay afloat,” he said. “We had to prioritize our efforts to what we knew, and where we knew that we would receive reimbursement—not towards something completely new.” After all, Welch knew for certain the cost of providing in-person treatment and the amount of reimbursement he would receive from payers. He was able to calculate the visit cost ratio to the dollar and adjust his schedule to the best of his ability. Right now, the goal at Welch Physical Therapy is to merely “keep afloat and survive until [they] can get back to normal,” a sentiment that likely resonates with many other clinic leaders.
It would be a flat-out lie to say that anything associated with the COVID-19 crisis has been easy. Providers and patients were (and still are) faced with incredibly difficult choices about how to navigate a situation no one was prepared for—all in a matter of days, and all while juggling questions about business solvency and patient and employee safety. While telehealth represents a huge opportunity for rehab therapists to reach more patients and generate crucial cash flow when in-person visits aren’t possible—even beyond the pandemic—it’s not perfect. In the rehab therapy world, telehealth comes with some pretty big hurdles—hurdles that become giant obstacles during a global crisis. So, what can we do?
Recognize the benefits and limitations of telehealth.
Acknowledge the current limitations of telehealth, while recognizing its potential. The industry’s introduction to telehealth was nothing short of trial by fire. But, things are starting to change for the better: providers and patients are learning the ropes, and payers are beginning to recognize the benefit of enabling PTs to provide this type of care. Will there continue to be a learning curve? Absolutely. Is telehealth right for every practice out there? No. But there are definite benefits to having this option available to you and your patients. And for some practices, this may be the difference between keeping the lights on and shuttering for good.
Advocate to ensure rehab therapists always have telehealth as an option—even beyond the pandemic.
Whether or not you choose to adopt this treatment method in your practice now, retaining the option is imperative for the industry—and that means providers must advocate for payers like Medicare to keep rehab therapy telehealth on the books permanently. After all, wouldn’t it be great to already have a backup option in place should we need it again? By establishing supportive legislation in advance, we can ease the burden on everyone down the road and ensure we’re not scrambling for action and regulatory clarity in the midst of chaos. As WebPT Co-founder and Chief Clinical Officer Heidi Jannenga has discussed previously, it’s high-time we start acting proactively (otherwise, we’re operating in a constant state of reactivity). And there is no better example to demonstrate how problematic that kind of pattern can be than the present situation.