Neurologists with expertise in telemedicine and medical economics discuss how the COVID-19 pandemic will lead to changes in health care delivery, medical licensure, payment parity, and the neurology exam.

Just a few months ago, a telehealth neurology practice was considered a rarity, relegated largely to a handful of private practitioners seeking flexible employment from telemedicine corporations, and to academic stroke centers delivering care to patients at smaller, regional hospitals. Today, it has become the norm, with almost every practicing neurologist in the nation now set up to deliver care virtually. Sweeping changes in insurance reimbursement, regulatory mandates, state and federal legislation, and a remarkable spirit of cooperation have led many experts to predict that medical practice, as we once knew it, will be no more.

Neurology Today asked several telemedicine and medical economics experts to consider the role of the coronavirus pandemic as the catalyst to health care delivery reform, and to share their vision of neurology practice in five years to come. What follows are their propitious predictions as a tonic for these dystopian times.

We are in the midst of the greatest social transformation of American medicine in a century; the way we cared for patients fundamentally shifted from clinics to telemedicine in a matter of a month.
E. Ray Dorsey, MD, MBA, the David M. Levy professor of neurology and director of the Center for Health + Technology at the University of Rochester Medical Center.

Dr. Dorsey estimates that the number of telemedicine visits has increased from 100- to even 1000-fold in some medical centers and accounted for the majority of the outpatient visits in neurology at centers across the country during the first few months of the pandemic.

Many patients will question the need to return to a clinic after realizing the advantages of convenience and flexibility for the first time, Dr. Dorsey said. He also envisions that more frequent, shorter visits, from a wide range of clinicians—dieticians to occupational therapists to pharmacists—are more likely.

So too will medical credentialing requirements change. Bruce H. Cohen, MD, FAAN, director of the NeuroDevelopmental Science Center and interim vice-president and medical director of the Research Institute at Akron Children's Hospital, noted that the 2020 HHS 1135 waiver allowed state medical boards and departments of health to waive the need for a medical license at the site of service temporarily. Until that time, it had been both costly and cumbersome for physicians to apply for multiple state licenses routinely.

But over the next five years it is likely that physicians will carry an active license in the state in which they see patients face-to-face, and a restricted license or other valid credential for telemedicine services only which requires a minimal background check. Moreover, the advent of block chain credentialing services will make obtaining those additional state licenses as easy as sharing a private key with the licensing agency. Every credentialing statement will become the property of the physician and need only be authenticated once. The blockchain technology would also allow all state requirements for ongoing licensure to be pushed to the doctor in real time and intrastate reciprocity for educational requirements would be commonplace.
Bruce H. Cohen

The pandemic period motivated regulators to allow payment parity regardless of the visit site.

“It will not take long for insurers to permanently eliminate originating site of service rules as they are too burdensome and only in their removal can telehealth truly advance. Telehealth has been shown to be cost-effective, efficient, and equal in therapeutic value to face-to-face encounters, and quality studies will reveal that its value is commensurate with face-to-face visits, and in some cases, superior in better addressing the social determinants of health. Moreover, health disparity and access to care, a concern that applies to those with limited technology and mobility, will be addressed through acceptance of audio-only visits with reasonable reimbursement to effectively promote access to care and reduce disparities.
David E. Evans, MBA, chair of the AAN Health Policy Subcommittee.

With payment parity in place, it will be cost-feasible to employ telehealth broadly. Evans envisions that the process of valuing a televisit vs. an in-person visit will be an arduous process for the RVS Update Committee (RUC), which is tasked with establishing RVU values for CPT codes, but ultimately, the value proposition will drive appropriate valuation.

Patient smartphone apps and accessories will help with all aspects of the teleneurology encounter, including history, physical exam, medical decision-making, and treatment. With appropriate security and privacy measures in place, the data from these apps will be used for machine learning and artificial intelligence to increase our ability to diagnose and treat.
Neil A. Busis, MD, FAAN, associate chair of Technology and Innovation in the department of neurology at NYU Langone Health.

He believes that patients will record relevant aspects of their clinical course at home and share it with their physician before or during the encounter. The information will accommodate patient preferences to take the form of a text, audio, or video format.

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