A few years ago, officials at Cheshire Medical Center in Keene began to examine how much time it took for patients to be seen for a routine care visit.
They started tracking from the time a patient left home, factoring in the drive to the office, the hunt for parking, waiting in the check-in line and waiting room, until they were finally seen by a physician.
The results confirmed what doctors suspected. Patients were spending an average of two hours to get to their 30-minute medical consultation.
Cheshire Medical wasn’t the only establishment examining accessibility to medical care in New Hampshire. Long before the start of the COVID-19 pandemic, New Hampshire was already considering telehealth.
“Our policy makers, the governor and Legislature, wanted to start thinking innovatively, to increase access to care in rural areas,” said D.J. Bettencourt, deputy commissioner of the N.H. Department of Insurance. “Telehealth could be a tremendous help in breaking down barriers that restrict access to care. By the time the pandemic hit, New Hampshire was in a better position than a lot of other states.”
Two and a half years later, telehealth has become an integral part of medical care for many New Hampshire residents. The service has been particularly useful for rural residents, as well as those who need to travel for care or just lead busy lives. New legislation passed in August expanded eligible services and added to the list of medical professionals permitted to provide online care, making it clear that telehealth is here to stay.
“It has changed the way patients and doctors thought about providing health care. People started to like it.” said Dr. Andrew Tremblay, chair of family medicine at Cheshire Medical Center. “It means they don’t have to take off from work. It means they don’t have to miss an appointment. And providers are also seeing a benefit to that, too.”
What is telehealth and who is it right for?
Telehealth, or telemedicine, allows doctors and patients to visit online via video chat and to send messages via email or another secure messaging system. While telehealth visits are not appropriate for all types of care, it can be beneficial for managing chronic conditions, assessing behavioral health, engaging with people who avoid doctor’s visits, and reaching rural residents, Tremblay said.
“If you were my patient and you had diabetes and I said, ‘You know, I think you’re doing a fantastic job. Your vital signs are stable. You have nothing acute going on at this time. We know we need to see each other twice a year’— that would be a good candidate for telehealth,” he said. “And for people who don’t typically go to the doctor, if it is telehealth, they are all in.”
Many people with mental health concerns tend to be more comfortable talking from home, Tremblay added.
Additionally, seeing patients in their home space can be revealing.
“I’ve seen some pretty amazing things, like people who are listed in our system as non-smokers, but when we do our visit, they’re smoking while I’m talking to them,” he said.
What happened before and during the pandemic?
Prior to the pandemic, telehealth was not widely used in New Hampshire, Tremblay said. Patients tended to want to do what they had always done — come in and see their provider.
Dr. Michael McLeod, who practices at Concord Hospital, found using telehealth challenging prior to the pandemic because of state restrictions on where patients were located.
One patient, he recalled, lived in Hillsborough County — which residents would describe as rural, but isn’t officially deemed so by Medicaid. This means the telehealth visit wouldn’t be covered at that time, McLeod said.
Everything changed in March 2020.
Gov. Chris Sununu declared a public health emergency and issued a series of executive orders regarding the use of telehealth services for medical care. The state temporarily allowed insurance coverage for all types of technologies, including audio-only phone calls, and allowed out-of-state providers to deliver telehealth services — a significant change for the many people who temporarily moved to new locations during the shutdown.
The state also required Medicaid and private insurers to provide reimbursement for telehealth services, on par with in-office visits.
“The pandemic really removed restrictions to say if you are a licensed provider you can do telehealth visits with anybody, regardless of where they are located,” McLeod said.
Anthem Blue Cross and Blue Shield, the largest insurance provider in New Hampshire, reported a 25 percent increase statewide in telehealth in January and February 2020 over the previous year. And those numbers jumped more than 6,000 percent in March, to a peak of 24,000 percent in April, according to Stephanie DuBois, company spokesperson.
What did doctors see?
In the early days of the pandemic, Tremblay said, efforts went toward getting information to patients and rescheduling their appointments.
“If we all remember, we had no idea how long this would last,” he said. “It was really just reaching out, seeing if anybody needed anything, seeing how people were doing and refilling medicine so there were no lapses in care.”
Once telehealth systems were put in place, doctors and patients had to get comfortable with the new approach to care, which evolved to include home health visits with a video component. The collaboration allowed doctors to assess an injury and collect vital signs. It worked so well that some patients preferred the home visits, even after the practice began to bring people back into the examination room.
Cancellations dropped where telehealth was available, Bettencourt said, particularly for patients receiving mental health services.
“For some people, getting out, going to the provider, sitting down, can be overwhelming,” he said. “Because they are able to access medical providers from home, the missed appointment rate is incredibly small. It was a very encouraging development.”
Where are things now?
Telehealth changed the way patients and doctors thought about providing health care, and it is now a permanent feature of New Hampshire’s health care system.
In August, the state Legislature expanded the definition of telehealth to include texting or emailing a therapist in order to make it more accessible to rural residents and those with poor Internet service. The law requires any state-regulated insurance carrier to cover these expanded services to meet standards for treatment.
In addition to doctors, the new law includes nurses, midwives, psychologists, dentists, community mental health providers, addiction treatment professionals, dietitians and others certified by the National Behavior Analyst Certification Board. If they cover in-person treatment, they have to allow telehealth as well.
As COVID-19 transitions from pandemic to endemic status — meaning the virus is consistently present in an area, making its spread more predictable — the numbers of those seeking telehealth services are evolving.
DuBois said telehealth visits have decreased over the past year, but visits for behavioral health services have remained steady and now represent the majority of telehealth visits.
McLeod added this is part of the evolution of telehealth and its ongoing role.
“In-person evaluations will always be a necessity,” he said, “but it will help meet patients’ needs in the busy lives we all have.”